Assignment: Therapy for Clients With Personality Disorders- Narcissistic Personality Disorder – 1 page Briefly describe narcissistic personality disorder,

Assignment: Therapy for Clients With Personality Disorders- Narcissistic Personality Disorder – 1 page Briefly describe narcissistic personality disorder,

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  • 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 admiration,
harbor fantasies of success and ideal love, exploit

the others, and lack empathy. These features are
typical of the so-called overt type (Gabbard, 1989).
Instead, the literature has consistently noted that
many patientsfeature the different picture of covert
or vulnerable narcissism (Gabbard, 1989). This
personality type’s inner life is quite different from
that depicted in DSM–5. Persons are consumed by
shame, guilt, inferiority and envy (Ritter et al.,
2014), experience emptiness, loneliness, separate-
ness and alienation, and have little trust that others
can help instead of exploiting them (Kealy et al.,
2015).
PN,withitsbroaderspectrum,embracespersons

with a combination of both overt and covert
aspects. The very same individual may present as
arrogant and boastful at one moment, and at others
conceals himself because of his deep-seated feel-
ings of guilt, shame and inferiority (Caligor &
Stern, 2020; Crisp & Gabbard, 2020; Dimaggio
et al., 2002; Kealy et al., 2015; Kohut, 1977). Evi-
dence shows that grandiose narcissism tends to

Giancarlo Dimaggio https://orcid.org/0000-0002-9289-
8756

Correspondence concerning this article should be
addressed to Giancarlo Dimaggio, Centro di Terapia
Metacognitiva Interpersonale, Piazza dei Martiri di Belfiore
4, 00151 Rome, Italy. Email: gdimaje@gmail.com

1

Journal of Psychotherapy Integration
© 2021 American Psychological Association
ISSN: 1573-3696 https://doi.org/10.1037/int0000263

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swing between grandiose and vulnerable states,
while the vulnerable type has more stable levels of
negative experiences and rarely expresses grandi-
osity(Edershile&Wright,2020).
PN is highly comorbid with symptom and

behavioral disorders, for example, anxiety and
depression (Kealy et al., 2020; Pincus et al., 2014),
alcoholanddrugabuse(Stinsonetal.,2008),eating
disorders(Gordon&Dombeck,2010)andrisk-tak-
ing behaviors, especially if these are socially disap-
proved (Leder et al., 2020). Thinking in terms of
PN helps make sense of why patients with more
prominent global suffering and personality dys-
functions and poorer real-world functioning are
associated with a suboptimal psychotherapy pro-
cess, while patients with higher levels of narcissis-
tic traits, low sense of control over action, and
higher real-world functioning have better therapy
responses(Krameretal.,2020).
In sum, these persons’ livesare filled with symp-

toms and loneliness but are difficult to deal with
interpersonally. There is therefore a need for per-
sonalized and empirically validated treatments.
The problem is that, as of today, there are none, in
spite of NPD’s wide prevalence, for example,
8.5%-20% in outpatient independent practice
(Weinberg&Ronningstam,2020).
As noted by Yakeley (2018) and Weinberg and

Ronningstam (2020), some approaches have been
tailored or adapted to PN and offer promises of
effectiveness. These include psychoanalytic psy-
chotherapy (Kernberg, 1975; Kohut, 1971; Ron-
ningstam & Maltsberger, 2007), Mentalization
Based Treatment (Drozek & Unruh, 2020), Trans-
ference Focused Therapy (Diamond & Hersh,
2020), CBT (Beck et al., 2015), Schema-Therapy
(Young et al., 2003), Metacognitive Interpersonal
Therapy (Dimaggio & Attinà, 2012), and dialecti-
cal behavior therapy (Reed-Knight & Fisher,
2011),andanotherapproachadaptedtotreatingPN
is Clarification Oriented Psychotherapy (COP;
Sachse,2020).Theproblemisthatasoftoday,nota
single one has been tested in a randomized con-
trolledtrial(Ronningstam,2019;Weinberg&Ron-
ningstam, 2020). So, in an era where delivering
validated treatments is necessary, what does a ther-
apist do when treating PN? And, more specifically,
what does the integrative therapist, who cares more
about being effective than being faithful to a spe-
cific orientation, do? Should they give up their
ambitionsofdeliveringsomethingempiricallysup-
ported and resort to generic principles of change?
Orcantheyroottheiractioninstableground?

PN poses serious challenges to the treating clini-
cian. Clients may involve therapists in different
maladaptive relational patterns, pushing them to
feel angry, devalued, helpless and inadequate and
to disengage from the therapy process (Colli et al.,
2014;Tanzillietal.,2020).Inthecaseofadolescent
PN,therapiststendtoreactwithangerandcriticism
or disengagement when facing the grandiose type
or with worry and feeling overwhelmed when fac-
ingthevulnerabletype(Tanzilli&Gualco,2020).
Compliance with tasks may be limited: Very of-

ten patients barely accept they are in treatment to
dealwiththeirveryownpersonalityissuesandonly
ask for symptom relief. This is one source of impo-
tence and frustration in therapists, who eventually
ask themselves: “Is this person really suffering?
Andifhedoes,ishewillingtobehelped?”
Therapists would better avoid being overconfi-

dent about their own generic therapeutic skills and
insteadadjusttothe specificneedsofthesepersons.
Clearly integrative therapists facing such a difficult
condition need to be guided, so not to remain either
prey to disturbing feelings or get trapped in rela-
tional problems, which end up in conflict, stale-
mates, and dropout (Crisp & Gabbard, 2020;
Ronningstam, 2020). In absence of empirically
supported solutions,one strategy isto offerintegra-
tive therapists a series of pragmatic ideas on how to
handlePN,irrespectiveoftheirorientation.
In the next section of the paper, I will summarize

some aspects of PN pathology and describe what
challenges they pose to the clinician. I will exclude
patients with antisocial features and malignant nar-
cissism,astheyrequirea differentapproach(Yake-
ley, 2018) beyond the scope of this work. After this
section, I will provide a series of therapeutic sug-
gestions on how to handle these problems and
illustrate them with clinical vignettes. These sug-
gestions are a working-out of principles identified
in two recent papers selecting the most suitable
approaches to treating PN and NPD (Yakeley,
2018; Weinberg & Ronningstam, 2020). My effort
is in line with the pragmatic “dos” and “don’ts” for
treating NPD offered by Weinberg and Ronning-
stam (2020). The main difference is that these
authors’ “principles were derived from clinical ex-
perience, not from a theory of NPD” (p. 138). My
workinsteadtriestoofferaseriesoftechniquesand
strategies tailored around a theoretical and empiri-
cal model of PN. Another specific aspect is the
inclusionofexperientialtechniques,suchasguided
imagery and rescripting, role-play, two-chairs, and
body work. This is necessary because among

2 DIMAGGIO

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current models for treating PN only Schema Ther-
apy (Young et al., 2003), Metacognitive Inter-
personal Therapy (Dimaggio et al., 2020), and
Clarification Oriented Psychotherapy (Sachse,
2020)includethemintheirrepertoire.Experiential
practices were not mentioned in the two recent
papers offering a perspective on current treatments
for narcissism (Yakeley, 2018; Weinberg & Ron-
ningstam,2020),whiletheycanaddasharperedge
topsychotherapyforthiscondition.

Narcissistic Psychopathology

Clearly there is a gap between current diagnostic
manuals of mental disorders and existing knowl-
edge about PN and NPD. In order to be clinically
useful, a diagnosis needs to be grounded on a con-
sistent model of psychopathology, which is hardly
provided by listing a set of mostly behavioral crite-
ria as in past editions of the DSM (see Sachse,
2020). The DSM–5 (American Psychiatric Associ-
ation, 2013) has made a step forward when adopt-
ing the level of personality functioning model,
which aims at describing personality disorders in
terms of their self and interpersonal functioning,
assessing aspects such as identity and capacity for
self-reflection—self-direction that is clearly con-
nected to a core PN problem, that is agency; empa-
thy, and capacityfor intimacy.The following list of
aspects may provide a comprehensive picture of
PN which could then be mapped on a formal, clini-
cally useful diagnosis of NPD in future editions of
DSM and also of ICD, which currently does not
allow for a diagnosis of NPD (see Sachse, 2020 for
similarobservations).
On the basis of such a rationale I will now (a) list

the core aspects of PN and NPD, then I will (b)
describe in details each of them and finally (c)
describe how the therapist can work in order to
tacklewiththeseelements.

PN and NPD Psychopathology

The aspects of PN and NPD psychopathology I
willanalyzeanddiscussare:
a) maladaptive representations of self and

others;
b) impaired self-reflective capacities and tend-

encytointellectualize;
c)agencydisturbances;
d)maladaptivecopingstrategiesanddefenses;
e)poortheoryofmindandempathy.

Maladaptive Representations of Self
and Others

Persons with PN are guided by crystallized and
maladaptive ideas of self and others (Caligor et al.,
2015; Diamond & Meehan, 2013; Dimaggio et al.,
2015; Young et al., 2003), which means that they
endorse: disturbed self-representations and dis-
turbed representations of others in the context of
trying to fulfill core wishes or needs. In simple
words,apersonwantstobeappreciatedandharbors
ideas of being inferior, which are, however, con-
cealed by explicit ideas of being superior; he imag-
ines others as either admiring or spiteful and,
according to how his ideas about the self and others
are combined, different affects emerge. For exam-
ple, if he thinks he is inferior and the other spiteful,
he will experience either anticipatory anxiety when
waiting for judgment or shame after receiving
criticism.
Maladaptive schemas in PN revolve around

some core wishes or needs. When driven by social
rank, as they often are, patients’ self-concept
swings from inferior to superior, and a dissociation
between explicit self-esteem (high) and an implicit
one (low) is present (Gregg & Sedikides, 2010;
Kunstetal.,2020).
In the attachment domain many problems arise.

PN patients usually adopt a dismissing attachment
style (Diamond et al., 2014), avoiding expressing
attachment needs because they anticipate others
will neglect them and being cold and controlling.
They can also display unresolved attachment,
anticipatingtheothermightbeverbally,physically,
and emotionally abusive (Drozek & Unruh, 2020;
Johnson et al., 2001). Resorting to self-soothing as
a means to avoid attachment was also observed
(Bamelisetal.,2011).
When driven by the wish for group inclusion,

PNs swing between the desire to belong to ideal
communities where they share special qualities, to
derogating groups and experiencing themselves as
different and superior (Dimaggio et al., 2007) or to
experiencing anxiety at the idea of being rejected
(De Panfilis et al., 2019) or pain when feeling
excluded and angry, even if at times they may deny
it (Cascio et al., 2015; Dimaggio et al., 2008;
Twenge&Campbell,2003).Thismeansthatwhat-
evertheirconsciousexpectationsare,patientsover-
reacttocriticism.Overall,whenthey,experienceor
anticipate negative reactions from others they eas-
ily resort to fight/flight strategies. They may first
attack, devaluate, or blame the others, but in the

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 3

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long run they resort to withdrawal, shutting them-
selves in an ivory tower or a in cocoon, entering
states of emptiness and emotional detachment, and
self-soothing (Dimaggio et al., 2007; Kohut, 1977;
Modell,1984;Youngetal.,2003).
Based on these schemas, PNs experience mental

states such as angerat being hurt or rejected, empti-
ness and alienation, guilt, envy, fear, anxiety, and a
sense of annihilation. Only at times do they enter
grandiosestatesofmindfilledwithglory,pride,sat-
isfaction, and self-fulfillment, but these states are
short-lived (Dimaggio et al., 2002; Kohut, 1977;
Kernberg, 1975; Modell, 1984; Ronningstam,
2009).

Impaired Self-Reflective Capacities and
Tendency to Intellectualize

PNs are poor at describing their inner experien-
ces (Dimaggio et al., 2002; 2007; Krystal, 1998;
Pincus, 2020). They have difficulties labeling their
affects, in particular ones related to vulnerability
and fragility (Lowen, 1983). They can easily say
they are angry or refer to emotions related to self-
enhancement (Dimaggio et al., 2002; Drozek &
Unruh, 2020) but are much less likely to recognize
they feel sad (Bouizegarene & Lecours, 2017),
guilty, ashamed, or scared (Dimaggio et al., 2002).
As previously noted, they actually experience pain
due to feeling rejected but consciously deny it
(Cascio et al., 2015). Unaware as they are of their
vulnerabilities, they are not able to integrate these
aspects in their self-concept. This is a likely reason
for their liability to symptoms such as anxiety or
health-anxiety, that is they, when experiencing a
sense of fragility and fear, can hardly name it or
communicate it to others, so that they remain prey
to negative emotional arousal they then interpret as
asignalofimpendingdanger.
The other side of the coin of their diminished

capacity to report inner experiences is their
tendency to intellectualize (Dimaggio et al.,
2002). When trying to convey their inner life to
a listener, they resort to abstract theories and
intellectualizing; in other words, they pseudo-
mentalize (Ronningstam, 2020). It is as if they
were on stage delivering a TED talk, which pre-
vents listeners from promptly understanding
they are talking about something personal and,
most importantly, what it is about. These per-
sons often resort to intellectualizing more when
they have just experienced failure or rejection,

something clinicians discover later in therapy
(Dimaggio et al., 2002).

Agency Disturbances

In spite of the layperson idea that persons with
PN are goal-oriented and behave like bulldozers
when driven by a goal, their agency is frequently
impaired, ranging from the expected hyperagentiv-
ity to loss of agency (Ronningstam, 2009). When
these persons are neither pursuing grandiosity nor
fighting against someone they perceive as an obsta-
cle, they lack an inner source for goal-oriented,
self-initiatedaction(Dimaggioetal.,2007;Dimag-
gio & Attinà, 2012; Kohut, 1977; Modell, 1984).
Lack of agency is considered a central aspect of all
DSM–5 personality disorders (American Psychiat-
ric Association, 2013; see Dimaggio et al., 2009;
Links, 2015). In recent years, laboratory findings
have backed up clinical observations of agency
problemsinPN.Asregardsinflatedagency,partici-
pants in a laboratory study with moderate to high
(but not extreme) narcissistic traits had greater
agency than controls, meaning they were overcon-
fident of being in control of their actions (Hascalo-
vitz & Obhi, 2015). Commenting on the results of
Hascalovitz and Obhi, Dimaggio and Lysaker
(2015) speculated that sense of agency should be
weaker in vulnerable narcissism and stronger in the
grandiose type. Render and Jansen (2019) investi-
gated this hypothesis in a nonclinical sample and
found the vulnerable type was correlated with
diminished agency, while the grandiose type did
not display any increase in agency. The plausible
link with inflated sense of agency and grandiose
narcissism requires further exploration in samples
withclinicalPNlevels.
Indirect support for the presence of agency dys-

functions in PN comes from findings that depres-
sion (Obhi et al., 2013) and social exclusion
(Malik & Obhi, 2019), both present in many PNs,
have a detrimental effect on agency. This means
that poor agency in PN may have both trait-like
(Hascalovitz & Obhi, 2015; Render & Jansen,
2019) and state-like properties, that is it dimin-
ishes when these persons experience specific
states of mind such as depression or social rejec-
tion. Other indirect evidence for the agency prob-
lem is that narcissistic traits are related to reduced
entrepreneurship and self-efficacy (Wu et al.,
2019) and disengagement from academic activ-
ities(Robins& Beer,2001).Thesemaysignalthat

4 DIMAGGIO

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PNs feel they have less influence on the world,
which gets manifested in not sustaining long-term
activitiesrequiringprolongedeffort.

Poor Theory of Mind and Empathy

Poor capacity to understand the others and lack
of empathy are part of the core definition of NPD
(American Psychiatric Association, 2013; Kern-
berg, 1975). Many studies support the observation
that PNs are poor at understanding the others and
resonating with their inner experience (De Panfilis,
et al., 2019; Dimaggio et al., 2009; Leunissen et al.,
2017; Marissen et al., 2012; Ritter et al., 2011).
Poor empathy affects behavior, for example less
ability to take others’ perspective predicted lower
generosity in narcissism (Böckler et al., 2017).
Using a specific interview to assess mentalistic
capacities, NDs displayed significantly less
capacitythanpersonswithoutanyPDtounderstand
what passed through others’ minds and to see the
world from their perspective instead of an egocen-
tric one (Bilotta et al., 2018). There is debate about
whether PNs are poor mentalizers either because
they are unwilling to for self-serving purposes or
because they have context-dependent issues (Bas-
kin-Sommers et al., 2014). A meta-analysis by
Urbonaviciute and Hepper (2020) found that both
grandiose and vulnerable narcissism were associ-
ated with decreased empathy, assessed both with
self-reporting and behavioral measures, but it
appeared that their problem was motivational, that
is, they had the cognitive capacities to understand
othersbutwerenotmotivatedto.
This leads to the question: under what condi-

tions do PNs lose motivation to understand the
others? The hypotheses are that, for the most part,
failures in the capacity to understand the others
happen under the influence of either attachment
(Drozek & Unruh,2020) orsocial rank, in particu-
lar when persons experience defeat (Colle et al.,
2020) or the need to belong when facing social
rejection (Dimaggio et al., 2007). Analyzing the
first treatment sessions of 3 NPD patients, Dimag-
gio and colleagues (2009) found that during treat-
ment all 3 improved in their capacity to both
understand others and to reason about their inten-
tionsfrom a decentered perspective. This suggests
that this capacity is more state-like than trait-like
and depends on relational conditions. In light of
these observations, consistent with those of Bas-
kin-Sommers and colleagues (2014), therapists

need to pay attention to creating the conditions for
theory of mind and empathy to flourish, rather
than stigmatizing patients for something they are
thoughttobejustunwillingtodo.

Maladaptive Coping and Defenses

PNs do not just suffer because of their maladap-
tive schemas but also because of the consequences
of how they deal with their symptoms and frustra-
tion.The strategiespatientsuse forthispurpose,of-
ten automatically and unconsciously, are variously
termed maladaptive coping (Kealy et al., 2017) or
defenses (Caligor et al., 2015; Kernberg, 1975).
Beside differences in theory, both concepts refer to
behavioral and cognitive/affective strategies aimed
at minimizing or preventing psychological pain a
person thinks or feels he is unable to bear. Coping
anddefensesareenactedforself-protectivereasons
and stem from schemas, that is PNs think the other
will not give the desired responses to their wishes
and needs and so they automatically react in order
to prevent,reduce, orkeep at bay the negative emo-
tionsthatwouldfollow(Dimaggioetal.,2015).
PN has been described as a constant sense of

threat to the self (Westen, 1990). According to this
idea, narcissistic strategies can be conceived as
grounded in the most archaic defense system in
front of threat: fight/flight. Tendencies such as
attacking, blaming, belittling and dominating
others, and passive-aggression are aspects of the
fight system and have been consistently found in
PN (Mielimaka et al., 2018; Twenge & Cambpell,
2003).Conversely,similarwell-knownPNtenden-
cies toward isolation, withdrawal, emotional dis-
tancing, finding shelter in an ivory tower or cocoon
(Modell, 1984), disengaging from relationships,
and avoiding displaying vulnerabilities (Kohut,
1977) are aspects of the activation of the flight sys-
tem. More in general, the most typical narcissistic
coping strategy is self-enhancement (John & Rob-
ins, 1994), that is an ongoing effort to boost a vul-
nerable self-esteem by both striving for the
maintenance of an idealized self-image and pre-
senting oneself to others as grandiose. It is the most
investigated PN cognitive mechanism and is sup-
ported by a plethora of studies (Grijalva & Zhang,
2016). It mostly serves to protect from contact with
covertfragileself-esteem.
I offer now an example of the role of the malad-

aptive consequences of self-enhancement aimed at
protectingtheunderlyingvulnerableself-esteem.

TREATMENT PRINCIPLES FOR PATHOLOGICAL NARCISSISM 5

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Michele is a musician from Puglia in his early 40’s and
came to therapy in desperation. He said he had lost
meaning in all aspects of his life, after the ending of his
marriage with a rich and beautiful woman with whom
he had travelled the world and led a grand life. The
ending also involved a financial disaster for him, as
during his married years he spent all his money to
adjust his lifestyle to that of his wife. He realized that
he was always searching for something bigger, better,
and more beautiful and never had a sense of reaching
it. At the beginning of the therapy, he did not see any
way to restart his quest for grandiosity and felt his des-
tiny was just delivering music lessons to earn a few
bucks, a condition he wholeheartedly despised. It was
not difficult to get him to see that his aspiration to gran-
diosity was simply a mechanism. After a few sessions,
when he was dating a new woman and enjoying it, he
said: “Yes, things are fine but, well . . . you know. . .
she’s not Charlize Theron.” I answered that I was
pretty sure that if he had had a relationship with the
real Charlize Theron, he would have longed for a more
beautiful woman. He agreed that he would then have
desired to be with Scarlet Johansson or Nicole
Kidman. We laughed about this, and he realized that he
was prey to a relentless mechanism he now wanted to
stop.

When describing coping and defenses at a be-
havioral level, many manifestations appear. PNs
adopt perfectionism with the goal of fixing the
intolerable flaws they see in themselves (Dimaggio
et al., 2018), procrastinating (Weinberg & Ron-
ningstam, 2020) or lying in order to maintain a
grandiose and spotless presentation. Resorting to
omnipotence and denial of vulnerable aspects can
be the origin of risky behaviors such as having con-
domless sex, which has been found in women stu-
dents with grandiose narcissism (Coleman et al.,
2020), and gambling (Leder et al., 2020). In order
to avoid pain or boost self-esteem, PNs resort to
alcohol and drug abuse (Stinson et al., 2008)—for
example, cocaine—to restore their sense of grandi-
osity, problematic videogaming, which is typical
of vulnerable narcissism (Di Blasi et al., 2020), dis-
ordered eating in both grandiose and vulnerable
types (Gordon & Dombeck, 2010), cosmetic sur-
gery (Fitzpatrick et al., 2011), and overexercising
(Spano, 2001). Repetitive thinking, in the form of
rumination and worry, is a cognitive coping strat-
egy whose goal is to reduce suffering but with
counterproductive effects. Rumination has been
observed in PN (Dimaggio et al., 2020). It is corre-
lated with vulnerable narcissism and a predictor of
its comorbid depression (Kealy et al., 2020). Vul-
nerable narcissism is also associated with jealousy,
which triggers worry about a partner’s emotional
infidelity (Tortoriello & Hart, 2019). Repetitive
thoughts filled with anger and suspiciousness are

significant in PN and an important route toward
aggression (Krizan & Johar, 2015). Similarly, Fat-
fouta and colleagues (2015) found that a combina-
tion of anger and rumination is a path between
narcissisticrivalryandlackofforgiveness.

Principles for an Integrated Therapy Based
on Narcissistic Psychopathology

In light of the above-described aspects of psy-
chopathology, to be successful, therapy should aim
at:
a) increasing self-reflection and reducing

intellectualizing;
b) reducing the impact of maladaptive schemas

andforminghealthierandmoreflexibleideasabout
selfandothers;
c)supportingagency;
d) counteracting maladaptive coping and pro-

moting healthier ways of dealing with suffering;
e)promotingtheoryofmindandempathy.
Thesegoalscanbereachedbydifferentavenues,

including: working through the therapy relation-
ship—for example, psychodynamic therapies
(Kohut, 1971; Kernberg, 1975), Mentalization
Based Treatment (Drozek & Unruh, 2020), Trans-
ference Focused Therapy (Diamond & Hersh,
2020), Metacognitive Interpersonal Therapy
(Dimaggio et al., 2020), agreeing upon a therapy
contract (Diamond & Hersh, 2020), focusing on
affects instead of accepting intellectualizing, and
using behavioral experiments and experiential
techniques (CBT, Schema Therapy, DBT, Meta-
cognitiveInterpersonalTherapy).Thisproposalfor
an integrated treatment is built around a model
of PN; I …

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