• Briefly describe narcissistic personality disorder, including the DSM-5 diagnostic criteria.
  • Explain a therapeutic approach and a modality  to treat a client presenting with this disorder. Explain why  the approach and modality was selected, justifying their appropriateness.
  • Next, briefly explain what a therapeutic relationship is in psychiatry. Explain how to share your diagnosis of this disorder with the client in order to avoid damaging the therapeutic relationship. Compare the differences in how to share this diagnosis with an individual, a family, and in a group session.

Journal of Psychotherapy Integration
Treatment Principles for Pathological Narcissism and Narcissistic
Personality Disorder
Giancarlo Dimaggio
Online First Publication, September 2, 2021. http://dx.doi.org/10.1037/int0000263

CITATION
Dimaggio, G. (2021, September 2). Treatment Principles for Pathological Narcissism and Narcissistic Personality Disorder.
Journal of Psychotherapy Integration . Advance online publication. http://dx.doi.org/10.1037/int0000263

Treatment Principles for Pathological Narcissism and Narcissistic
Personality Disorder

Giancarlo Dimaggio
Centro di Terapia Metacognitiva Interpersonale, Rome, Italy

Pathological Narcissism (PN) is a challenge to clinicians, who have difficulties
dealing with clients relationally and forming and agreeing on a therapy contract. PN
sufferers easily fuel relational conflict or withdraw from relationships. In spite of its
severity and prevalence, there is no empirically supported treatment for this condition.
Given this, integrative therapists need to be offered a series of principles of good
clinical practice, that they can adopt irrespective of their preferred orientation. This
article focuses on 5 domains of PN, that is: (a) maladaptive self–other schemas, (b)
poor self-reflection and intellectualizing, (c) disturbed agency, (d) maladaptive coping
and defenses, and (e) poor theory of mind and empathy. With this background, I offer
specific treatment suggestions that can be applied in an integrative spirit and are
formulated in a way that lends them to empirical investigation. With this and other
recent efforts, the hope is to increase clinicians’ and researchers’ awareness of how
PN can be treated and possibly increase the amount of empirical studies aimed at
showing what principles of change are actually effective. Pathological Narcissism and
narcissistic personality disorder are prevalent and present with significant comorbidity
and create problems to self and others, but there is no empirically supported treatment
to date for these conditions. This article presents treatment suggestions that may pave
the way for addressing them and paving the way for empirical studies.

Keywords: Pathological Narcissism, narcissistic personality disorders, maladaptive
interpersonal schemas, metacognition, integrative psychotherapy

Clinicians facing clients with Pathological Nar-
cissism (PN) or narcissistic personality disorder
(NPD) need empirically supported treatments.
Suchclientspresentwithcharacteristics,bothatthe
level of inner experience and interpersonal func-
tioning, that make psychotherapy complicated.
ThroughoutthepaperIwillmostlyrefertoPN(Pin-
cus & Lukowitsky, 2010), as it describes a broader
range of phenomena than NPD as categorized in
the DSM–5 (American Psychiatric Association,
2013). The latter refers to persons who feature self-
enhancement and grandiosity, seek admirati

Personality Disorders: Theory, Research, and
Treatment
Delay Discounting and Narcissism: A Meta-Analysis With Implications for
Narcissistic Personality Disorder
Sulamunn R. M. Coleman, Anthony C. Oliver, Elias M. Klemperer, Michael J. DeSarno, Gary S. Atwood, and Stephen T.
Higgins
Online First Publication, January 6, 2022. http://dx.doi.org/10.1037/per0000528

CITATION
Coleman, S. R. M., Oliver, A. C., Klemperer, E. M., DeSarno, M. J., Atwood, G. S., & Higgins, S. T. (2022, January 6). Delay
Discounting and Narcissism: A Meta-Analysis With Implications for Narcissistic Personality Disorder. Personality Disorders:
Theory, Research, and Treatment. Advance online publication. http://dx.doi.org/10.1037/per0000528

Delay Discounting and Narcissism: A Meta-Analysis With Implications for
Narcissistic Personality Disorder

Sulamunn R. M. Coleman1, 2, Anthony C. Oliver1, 2, Elias M. Klemperer1, 2, Michael J. DeSarno3,
Gary S. Atwood4, and Stephen T. Higgins1, 2

1 Vermont Center on Behavior and Health, University of Vermont
2 Department of Psychiatry, University of Vermont

3 Department of Medical Biostatistics, University of Vermont
4 Dana Medical Library, University of Vermont

Several psychiatric conditions (e.g., substance use, mood, and personality disorders) are characterized, in
part, by greater delay discounting (DD)—a decision-making bias in the direction of preferring smaller, more
immediate over larger, delayed rewards. Narcissistic personality disorder (NPD) is highly comorbid with
substance use, mood, and other personality disorders, suggesting that DD may be a process underpinning
risk for NPD as well. This meta-analysis examined associations between DD and theoretically distinct, clini-
cally relevant dimensions of narcissism (i.e., grandiosity, entitlement, and vulnerability). Literature searches
were conducted and articles were included if they were written in English, published in a peer-reviewed
journal, contained measures of DD and narcissism and reported their association, and used an adult sample.
Narcissism measures had to be systematically categorized according to clinically relevant dimensions
(Grijalva et al., 2015; Wright & Edershile, 2018). Seven studies met inclusion criteria (N = 2,705). DD was
positively associated with narcissism (r = .21; 95% confidence interval [.10, .32]), with this association
being largely attributable to measures of trait grandiosity that were used in each study (r = .24; 95% confi-
dence interval [.11, .37]). No studies included diagnostic NPD assessments. These findings provide empiri-
cal evidence that DD is related to trait narcissism and perhaps risk for NPD (e.g., grandiosity listed in
Criterion B of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, alternative model
of personality disorders). Considering the positive evidence from this review, and the

Missouridou et al. BMC Psychiatry (2022) 22:2
https://doi.org/10.1186/s12888-021-03607-2

R E S E A R C H

Containment and therapeutic relationships
in acute psychiatric care spaces: the symbolic
dimensions of doors
Evdokia Missouridou1*, Evangelos C. Fradelos2, Emmanouel Kritsiotakis1,3, Polyxeni Mangoulia1,4,
Eirini Segredou5 and Ioanna V. Papathanasiou2

Abstract
Background: There is an increasing trend of door locking practices in acute psychiatric care. The aim of the present
study was to illuminate the symbolic dimensions of doors in Greek mental health nurses’ experiences of open and
locked working spaces.

Results: A sequential mixed-method designexplored the experiences of nurses working in both open and locked
psychiatric acute care units. Participants experiences revealed four types of doors related to the quality of recovery-
oriented care: (a) the open door, (b) the invisible door, (c) the restraining door, and (d) the revolving door. Open doors
and permeable spacesgenerated trust and facilitated the diffusion of tension and the necessary perception of feeling
safe in order to be involved in therapeutic engagement. When the locked unit was experienced as a caring environ-
ment, the locked doors appeared to be “invisible”. The restraining doors symbolized loss of control, social distance and
stigma echoing the consequences of restrictingpeople’s crucial control over spaceduring the COVID-19 pandemicin
relation toviolence within families, groups and communities. The revolving door (service users’ abscondence/re-
admission) symbolised the rejection of the offered therapeutic environment and was a source of indignation and
compassion fatigue in both open and locked spaces attributed to internal structural acute care characteristics (limited
staffing levels, support, resources and activities for service users) as well as ‘locked doors’ in the community (limited or
no care continuity and stigma).

Conclusions: The impact of COVID-19 restrictions on people’s crucial control of space provides an impetus for erect-
ing barriers masked by the veil of habit and reconsidering the impact of the simple act of leaving the door open/
locked to allow both psychiatric acute care unit staff and service users to reach their potential.

Keywords: Acute psychiatric care, Open doors, Door locking practice, Nurses, Greece

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