Task 5 - Is It Me, Or Is It Him? PDF

Task 5 - "Is it me, or is it him?" Introductory chapters + material from PAID course General definition of personality disorders Personality disorder - stable and enduring patterns of thought, feeling, and behavior (i.e. personality traits) that emerge in...

Task 5 - "Is it me, or is it him?" Introductory chapters + material from PAID course General definition of personality disorders Personality disorder - stable and enduring patterns of thought, feeling, and behavior (i.e. personality traits) that emerge in adolescence or early adulthood, deviate from the norms of one's culture, are pervasive and inflexible across many aspects of one's life, and lead to distress or impa irment. To diagnose a personality disorder in someone younger than 18 years, the personality patterns must have been present for at least 1 year (except antisocial PD, which requires the age of 18). Personality disorders usually come with unusual ways of interpreting events, unpredictable mood swings, or impulsive behavior. In the DSM-5, the 10 personality disorders are grouped into 3 clusters based on their descriptive similarities. However, it also recognizes that this clustering system is limited, has not been validated, and fails to account for co- occurring personality disorders from different clusters. Cluster A: Odd-eccentric personality disorders Many researchers consider this group of personality disorders to be part of the schizophrenia spectrum, particularly schizoty pal personality disorder, though they are below the threshold for the diagnosis of a psychotic disorder. Paranoid personality disorder Paranoid personality disorder - a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. People diagnosed with this disorder believe that other people are chronically trying to deceive or exploit them, and they are preoccupied with concerns about being victimized or mistreated by others. They are hypervigilant for evidence confirming their suspicions. For example, they notice a slight grimace on the face of their boss or an apparently trivial slip of the tongue by their spouse that would go unnoticed by everyone else. Moreover, they consider these events to be highly meaningful and spend a great deal of time trying to decipher such clues to other people’s true intentions. They are also very sensitive and angrily reactive to real or perceived criticism and tend to bear grudges. These people are resistant to rational arguments against their suspicions and may consider the fact that another person is arguing with them as evidence that the person is part of the conspiracy against them. Some are secretive and withdraw from other people in an attempt to protect themselves, but others become hostile and argumentative, sure that their way of looking at the world is right and superior and that the best defense against the conspiring of others is a good offense. Comorbidities include major depression, anxiety disorders, substance abuse, and psychotic episodes. The prognosis generally is poor, with symptoms intensifying under stress, sometimes experiencing very brief psychotic episodes. Heritability of paranoid personality disorder is around 0.50. Cognitive theories view the disorder as a combination of an underlying belief that other people are malevolent/deceptive + a lack of self-confidence about being able to defend oneself against others. Exposure to discrimination, prejudice, childhood trauma, and low SES are risk factors. Treatment is quite difficult, because patients usually seek treatment for anxiety/depression during crisis, and are not willi ng to have their paranoia treated. To gain the trust of a paranoid person, the therapist must be calm, respectful and straightforward. Paranoid thinking cannot be confronted directly, but indirect questions about the client's typical way of interpreting situations can be raised. Full insight into one's problems is not achieved, but developing trust for the therapist may help to learn to trust others as well and somewhat improve interpersonal relationships. Cognitive therapy focuses on the sense of self-efficacy in dealing with difficult situations, this decreasing fear & hostility toward others. Schizoid personality disorder Schizoid personality disorder - involves an extreme degree of detachment from social relationships and a very limited expression of emotions in interpersonal settings. Schizoid individuals are not interested in family relationships, friendships, or sexual relationships, and instead prefer almost always to be alone. They are also emotionally detached - they express no affection for others and are indifferent to praise/criticism. While they tend to view relationships as unrewarding, messy, and intrusive, in those few situations in which they may temporarily feel comfortable talking about themselves, they may acknowledge having painful feelings, particularly related to social interactions. Psychopathology Page 1  about themselves, they may acknowledge having painful feelings, particularly related to social interactions. Even in the nonsocial settings they prefer, they feel little joy or pleasure. People with schizoid PD can function in society, especially in jobs that do not require frequent interpersonal interactions. There is some heritability of the personality traits associated with the disorder (e.g. low sociability & warmth). Schizoid people may not be motivated to get treated, and the interpersonal closeness of therapy may be experienced as stressf ul rather than supportive. Psychological treatments focus on increasing awareness of one's feelings, social skills and social contacts. Social skills are trained through role-playing with the therapist and homework assignments in which the client tries out new social skills with other people. There may be a link between symptoms of schizoid PD and autism (e.g. lack of emotional responsiveness and the tendency to be withdrawn). These is some evidence of a modest genetic link between the 2 disorders. Schizotypal Schizotypal personality disorder - also involves detachment from social relationships, but in addition to that, there is also an extreme discomfort with such relationships, and a pattern of odd thinking and eccentric behaviors. Schizotypal persons tend to be highly superstitious or fascinated with the paranormal, and may even have bizarre perceptual experiences, such as “seeing” things happening far away. Others consider their behavior & appearance odd, peculiar or eccentric. Schizotypal PD is often comorbid with paranoid & avoidant PD. Cognitive & perceptual distortions fall into 4 categories: Paranoia - as in paranoid PD, schizotypal people perceive other people as deceitful & hostile, which leads to social anxiety. Ideas of reference - they tend to believe that random events or circumstances have a particular meaning just for them. For example, they may think it highly significant that a fire occurred in a store in which they had shopped only yesterday. Odd beliefs & magical thinking - for example, believing that others know what they are thinking. Illusions - that are just short of hallucinations (e.g. believing that they see people in the patterns of wallpaper). Their speech is circumstantial, vague or overelaborate. They may be easily distracted or may fixate on an object for a long period of time, lost in thought or fantasy. Although symptoms are similar to schizophrenia, they are not as severe, and people with schizotypal PD keep basic contact wit h reality. Odd/eccentric beliefs cannot be part of cultural beliefs. Heritability from twin studies is 0.81. There is high evidence that schizotypal personality disorder is transmitted genetical ly. A gene that regulates the NMDA receptor system has been associated with both schizophrenia and schizotypal PD. Like people with schizophrenia, people with schizotypal PD have abnormally high dopamine levels in some brain areas. These abnormalities tend to be less severe in schizotypal PD, perhaps reflecting the less severe symptoms. People with schizotypal PD tend to have more frequent histories of childhood adversities compared to the general population. Schizotypal PD is treated with the same drugs used for schizophrenia (neuroleptics and atypical antipsychotics), typically at lower doses. These drugs relieve psychotic-like symptoms. Antidepressants are sometimes used for schizotypal PD patients who experience significant distress. In psychological treatment, establishing a good relationship first is crucial, due to paranoia & social anxiety. The next step is to help the client increase social contacts and learn socially appropriate behaviors. In cognitive therapy, the key component is teaching the patients to look for objective evidence in the environment to support their thoughts and disregard bizarre thoughts. Cluster B: Dramatic-Emotional personality disorders Borderline personality disorder Borderline personality disorder - involves extreme instability in one's own self-image and in one's relationships with others, along with extreme impulsivity in various contexts. Borderline individuals have intense & unstable love/hate relationships with others, and tend to worry frantically about the possibility of being abandoned. Impulsive behavior can include drug abuse, eating binges, spending sprees, sexual escapades (sexual experiences involving risk or excitement) & self-harming behaviors (e.g. self-mutilation or suicide attempts). Borderline people are extremely moody, have little sense of personal identity or of meaning in life. Periods of extremer self-doubt alternate with periods of grandiose self-importance accompanied by a need for others to support their self-esteem. They are prone to dissociative states, in which they feel unreal, lose track of time, and may even forget who they are. Borderline patients often report an emptiness that makes them cling to new acquaintances & therapists in order to fill their internal void. They misinterpret other people's everyday actions as abandonment or rejection. For example, if a therapist has to cancel an appointment because of illness, a client with borderline PD may interpret this as rejection by the therapist and become very depressed or angry. Comorbidities include substance abuse, depression, GAD, specific phobias, panic disorder & somatization disorder. 75% of borderline patients attempt suicide and 10% die by suicide. >85% of patients show remissions of symptoms within 10-15 years and only a minority of those in remission have a relapse. Ability to hold a job significantly improves, but stable & positive social relationships remain difficult. Psychopathology Page 2  Ability to hold a job significantly improves, but stable & positive social relationships remain difficult. Relapse is usually triggered by stressful life events and lack of social support. Borderline patients have deficits in regulating emotion and they are unwilling to tolerate emotional distress in order to rea ch a goal. They experience a more negative emotional baseline, more emotional variability, and a slower return to their emotional baseline. Cognitively, they are hyperattentive to negative emotional stimuli, their memories tend to be more negative, and they tend to make negatively biased interpretations of situations. They engage in attempts to suppress negative thoughts, but those are usually unsuccessful and lead to rumination or acting out impulsively on those thoughts. They tend to have more negative views of others and of relationships, sometimes struggle to empathize with others' perspectives, and engage in poor problem solving in social scenarios. People with BPD more often have a childhood marked by instability, neglect, abuse and parental psychopathology. These factors could have contributed to difficulties in regulating emotions and in attaining a positive, stable identity thro ugh several mechanisms. A history of exposure to abuse, neglect, criticism, and emotional invalidation by significant others makes it difficult for people with borderline personality disorder to learn appropriate emotion-regulation skills and to understand and accept their emotional reactions to events. People with this disorder rely on others to help them cope with difficult situations but do not have enough self-confidence to ask for this help in mature or effective ways. They become “manipulative” and indirect in their attempt to gain support from others (e.g. by injuring themselves or creating crises), and their extreme emotional reactions to situations lead to impulsive actions. They tend to see themselves and other people as either all good or all bad and to vacillate between these two views ( splitting). For example, a person with borderline personality disorder might view her partner as the sweetest, most caring person in the world when they are getting along, but when he does something frustrating, she might suddenly view him as totally unsupportive, unintelligent, and selfish, with no sense that he could have a mix of these positive and negative characteristics. The amygdala & hippocampus are smaller in volume in borderline patients. Amygdala activity in response to pictures of emotions are greater. There are structural & metabolic abnormalities in the PFC. The disorder runs in families and is heritable. Early abuse and maltreatment also are associated with changes in the structure and organization of the brain, particularly th e amygdala and hippocampus, which may explain in part why child abuse could contribute to the deficits seen in people with the disorder Dialectical behavior therapy is one of the first effective psychotherapies for borderline PD. It focuses on gaining a more realistic & positive sense of self, learning adaptive skills for solving problems and regulating emotions, and correct dichotomous thinking. Therapists teach clients to monitor self-disparaging thoughts and black-or-white evaluations of people and situations and to challenge these thoughts and evaluations. Therapists also help clients learn appropriate assertiveness skills to use in close relationships so that they can express their needs and feelings in a mature manner. Systems training for emotional predictability and problem solving (STEPPS) is a group intervention for borderline patients that combines cognitive techniques challenging irrational & maladaptive cognitions and behavioral techniques addressing self -management & problem solving. Transference-focused therapy is a psychodynamic therapy that uses the relationship between patient & therapist to help patients develop a more realistic & healthier understanding of themselves and their interpersonal relationships. Mentalization-based treatment is based on the theory that borderline patients have fundamental difficulty understanding the mental states of themselves & o thers due to traumatic experiences in childhood and poor attachment to their caregivers. This therapy provides patients with validation & support, in addition to helping them appreciate alternatives to their subjective sense of self & others by using the therapist-client relationship and relationships with others to illustrate those alternatives. Psychotherapy is the first-line treatment for borderline PD. Adding a drug treatment to an effective psychotherapy does not appear to bring benefits, and is mostly recommended for comorbid disorders Mood stabilizers and atypical antipsychotics may be useful in treatment. There is no evidence for SSRI efficacy. Histrionic personality disorder Histrionic personality disorder - characterized by an exaggerated display of emotions and by excessive attention seeking. Histrionic individuals have an intense need to be the center of attention &they feel uncomfortable when they are not. They use their physical appearance to draw attention, and have a seductive, sexually provocative style. They display emotions in a dramatic & exaggerated way, yet these emotions are shallow and volatile. They are easily influenced by others & consider casual acquaintances as much closer relationships than they are. Antisocial personality disorder Antisocial personality disorder - characterized by a tendency to disregard & violate the rights of others. Antisocial individuals are very deceitful, exploit others for personal gain and feel no remorse for the caused harm to others. They also tend to be aggressive, irresponsible, impulsive and reckless. Narcissistic personality disorder Narcissistic personality disorder - involves the tendency to consider oneself as a superior individual who deserves the admiration of others, and a selfish lack of concern for others' needs. Narcissistic people think they are entitled to special treatment and admiration, and generally have an arrogant style, often exploiting others and failing to appreciate their needs. Psychopathology Page 3  appreciate their needs. They are shallow in their emotional expressions and relationships with others. They also tend to fantasize about having high status and to envy those who are highly successful. In interpersonal relationships, they make entitled demands on others to follow their wishes, ignore or devalue the needs of others, exploit them to gain power, and are arrogant and condescending. Despite needing others' admiration, they do not experience the same abandonment concerns (as in borderline PD). Narcissistic people can be successful in societies that reward self-confidence & assertiveness (e.g. US). However, they sometimes overestimate their abilities and may make poor career choices & experience many failures, annoying & alienating the important people in their lives. They tend to seek treatment for depression and for trouble adjusting to life stressors. NPD is also associated with antisocial personality disorder. Their self-motivated, deceitful and aggressive acts and lack of empathy are quite similar to some aspects of APD. However, NPD individuals can be differentiated from APD individuals by their sense of grandiosity and self-importance. In the US, 7.7% of men and 4.8% of women are diagnosable with narcissistic PD. The disorder is more prevalent in young adults, probably due to social & economic conditions that support more extreme versions of self-focused individualism. People diagnosed with the disorder have high rates of substance abuse and mood & anxiety disorders. They also have higher rates of physical and sexual aggression, impulsivity, homicidal thoughts, and suicidal behaviors. From a psychodynamic perspective, NPD is a set of maladaptive strategies for managing emotions and self -views. People with the disorder did not develop a realistically positive view of themselves or adaptive strategies for handling stress as children, so they rely on praise and domination of others for their self-esteem. Narcissistic traits may result from childhood experiences with cold, rejecting parents who rarely respond with praise at their children's achievements or displays of competence. ○ Because of these experiences, children try to find ways of defending against feelings of worthlessness, dissatisfaction and rejection by convincing themselves that they are worthy & talented. ○ This results in someone with a vulnerable self-esteem who seeks reassurance and who has developed a lack of empathy with others because of the cold and uncaring parenting they have experienced. However, it has also been argued that narcissistic PD may develop from parents who treat their children too positively in a way that creates unrealistic, grandiose self-perceptions. Grandiose narcissism - involves coping with difficulties in self-esteem by viewing oneself as superior & unique and by engaging in grandiose fantasies. These people are arrogant, entitled, manipulative, exploitative, envious, and aggressive, especially when distressed. They may engage in criminal or violent acts. Vulnerable narcissism - involves coping with difficulties in self-esteem by engaging in grandiose fantasies to reduce intense shame. Such people are self-focused, hypersensitive to rejection and criticism, distrustful, and thus avoid others. For example, a vulnerable narcissist may feel extreme shame at being passed over for a job, and respond to this shame by claiming she was overqualified. The 2 types of narcissism share the personality trait of interpersonal antagonism. NPD is associated with a history of childhood physical abuse or neglect, and with having a parent who was abused or who had a mental health problem. Narcissistic personality traits make it difficult to form a therapist-client alliance, because they tend to see any problems they have as a result of others' weaknesses and problems. Therapists use cognitive techniques to help these clients develop more realistic expectations of their abilities and more sensitivity to the needs of others by teaching them to challenge their self-aggrandizing ways of interpreting situations. Such self-understanding and changes in self-serving biases rarely happen for people with NPD and they often drop out of therapy as soon as the acute problems lessen. No systematic psychotherapy or medication treatment studies have been published. Cluster C: Anxious-Fearful personality disorders Avoidant Avoidant personality disorder - defined by social inhibition and shyness, feelings of inadequacy, and oversensitivity to potential negative evaluation. Avoidant people have such strong fears of criticism, disapproval, and rejection that their social interactions are severely restricted (they are unwilling to participate socially unless certain of being liked, and tend to avoid work activities that involve interpersonal contact). Avoidant people, like schizoid & schizotypal, lack social connection, but they actually want it - they are just afraid of rejection. Dependent Dependent personality disorder - characterized by an excessive need to be taken care of and by submissive, clinging behavior and fears of separation. Dependent individuals require a great deal of advice and reassurance even in making everyday decisions, and lack the confidence to undertake projects on their own. They need other people to take responsibility for important features of their lives, and feel unable to take care of themselves when alone. They are willing to sacrifice a lot to maintain the support & nurturance of others, e.g. by volunteering to do unpleasant tasks or by avoiding any expression of disagreement. They desperately seek a new relationship if a close relationship ends. Psychopathology Page 4  They desperately seek a new relationship if a close relationship ends. Obsessive compulsive Obsessive-compulsive personality disorder - involves preoccupation with orderliness, perfection and control. The obsessive-compulsive person tends to be so preoccupied with details (e.g., lists, schedules) that the entire point of an activity is lost. He/she may be so concerned with attaining perfection and following specific rules that he/she fails to complete their tasks or projects, or delegate any tasks to others. He/she tends to put work ahead of personal relationships and to be highly stubborn and inflexible. There is a tendency to hoard money unnecessarily (rather than spend it) and to hoard objects unnecessarily (rather than discard them). This is not OCD. OCD involves repeated behaviors (e.g. hand washing, counting or tapping) and is not a personality disorder. Alternative DSM-5 model for personality disorders Limitations of the categorical approach to personality disorders include overlap in diagnostic criteria of the 10 PDs, poor a greement between clinicians when diagnosing PDs, variability in symptom severity over time (people go in and out of the diagnosis in different periods of thei r lives), not covering all pathological personalities, disconnection from the fundamental personality traits that are consistent across cultures. Extreme scores on Big 5 measures are highly associated with personality disorders. 50% of the individuals diagnosed with a personality disorder do not receive the same diagnosis 2 years later, suggesting that a dimensional approach may be more appropriate than an all-or-none categorical approach. The DSM-5 section III includes an alternative model of personality disorders that involves a dimensional (continuum) perspective. This alternative model views PDs as impairments in personality functioning and presence of pathological personality traits. D iagnosis involves 3 steps: Determine an individual's level of functioning in terms of their sense of self (identity) or their relationships with others on a scale from little/no impairment to extreme impairment. At least moderate impairment is required to diagnose a personality disorder. Determine if the individual has any pathological personality traits (negative affectivity, detachment, antagonism, disinhibition, psychoticism). The presence of pathological personality traits is also required for diagnosis. These must be developmentally & culturally inappropriate and not caused by substances or medical conditions. Determine if the individual meets criteria for any of the 6 specific disorders in the alternative model (antisocial, avoidant, borderline, narcissistic, obsessive- compulsive, and schizotypal). If criteria for none of these disorders is met, but there are difficulties in sense of self and relationships together with pathological personality traits, the diagnosis personality disorder - trait specified is given. If this diagnosis is used, the pathological personality traits are specified. For example, someone who does not meet the 6 disorders' criteria, but is highly prone to anxiety about whether other people like him and also behaves irresponsibly in an attempt to gain attention may be diagnosed with personality disorder - trait specified. This makes the DSM-5 alternative model a hybrid model, which includes both categorical & dimensional aspects. Pathological Narcissism and Narcissistic Personality Disorder: Recent Research and Clinical Implications - Ronningstam (2016) This review looks at recent research on how emotion regulation and empathy work in narcissistic personality disorder, with a focus on agency, control and decisiveness. Disconnect between feeling and relating - a clinical perspective Patients with NPD are known for being emotionally detached with negative reactivity, interpersonal maneuvering, or critical a ttitude, which is the main reason for the difficulties engaging them in treatment. They have difficulties connecting their own affects and compatible emotions to verbal formulations and interpersonal relation ships. Instead, they can talk and relate in ways that control the interaction, by either detaching and/or enhancing themselves. Consequently, the interaction is separate from and not accompanied by matching, attuned, and appropriate emotional expressions (tone of voice, choice of words, interpersonal manner, etc.). The patients speak at the clinicians, not to the clinicians and vice versa, the clinicians’ regular interventions cannot reach the patients’ internal world or engage thei r reflective capability. Sometimes the patient can focus attention and be totally immersed and preoccupied with a specific issue; other times the pati ent can be distant, dismissive, and demanding. Either pattern can readily cause clinicians to feel criticized, mistreated, or disengage. Still other patients can immerse clinicians in their own self-enhancement, making them into a passive idealized listener faced with unrealistic expectations, or causing them to feel devalued, incompetent, and discarded. These experiences tend to evoke strong reactions in clinicians, who may act from a position of feeling either angry, apologet ic, or dismissed, or idealized but disarmed and confused. Such reactive interventions tend to redirect focus away from the patients’ problems and reasons for being in treatment, towards hasty interpretations, judgmental statements and speculations about the patients’ underlying motives, intentions, or prognosis. Disconnect between feeling and relating - an empirical perspective Psychopathology Page 5 Deficits in prefrontal gray matter volume are observed in NPD. These deficits affect their emotion regulation and emotional e mpathic processing, potentially contributing to self-referential processing bias. Study: sympathetic activation and negative reactions were identified in NPD in response to happy stimuli, but indifference wa s found to fearful/sad stimuli. This suggests a base for narcissistic emotion regulation, potentially related to a compromised empathic ability. Alexithymia Alexithymia - difficulties in the ability to identify & describe feelings in words and to differentiate feelings from bodily sensations cau sed by emotional arousal. Study: in patients with narcissistic traits and comorbid eating disorder, core narcissism (grandiosity, entitlement) was asso ciated with compromised ability to describe one's own feelings to other people. Self-focused attention was suggested to undermine the understanding of differences between one's own and others' emotions. Narcissistic defensiveness was associated with compromised ability to identify one's own feelings and differentiate them from somatic experiences. Study: people high on narcissism (measured by the Narcissism Inventory) had a higher degree of alexithymia and lower deactiva tion in the right anterior insula (associated with empathic stimulation). NPD patients may also have problems with expressing emotions using language. This could be due to disruption in a biological pathway which represents subcortical affect & visceral sensations as emotional feelings which in the relational context become available to be symbolized as words. In narcissism, this pathway can be potentially disrupted by biological and relational (relating to how individuals interact or relate to others) as well as psychological factors, contributing to egocentric self-focus and failure to accept & incorporate others' views. Emotion recognition and processing There is evidence of emotion recognition deficits in NPD. Study: patients with NPD, although considering themselves as sensitive to others' feelings, were less accurate in recognizing emotional expressions in others, especially those related to feelings of fear and disgust. There is clinical & empirical evidence of specific challenges in NPD in processing shame, fear and anger. Shame in NPD can be rooted in complex/traumatizing developmental experiences including disruptions in attachment. Since it is usually painful and paralyzing, shame can also be hidden and easily bypassed. Feelings that relate to explicit other-directed attributions tend to evoke shame-based aggressive, critical, or blaming reactions, while implicit shame can drive more consistent self-enhancing regulatory strategies (e.g. perfectionism and competitiveness). Feelings of shame in NPD can contribute to difficulties in emotion processing and to underlying fragility & hypersensitivity. Feelings of fear in NPD relate mostly to internal anticipations of failure (e.g. fear of losing control, getting overwhelmed, paralyzed). Other types of fear are evoked by external experiences of exposure, losses, humiliation etc. Fear is central in pathological narcissism and can evoke negative escalating cycles (including fear of the fear). Some fear-processing strategies in NPD serve to redirect attention towards agency-oriented goals, ambitions and aspirations, or competitive/risk-taking actions to secure & enhance self-esteem. Sudden & overwhelming experiences of fear that are not possible to process with regular narcissistic defensive self-enhancing or avoiding strategies (e.g. bankrupt, demotion, divorce) can escalate comorbid conditions such as depression or substance abuse, and significantly increase suicide risk. Aggressivity is central to NPD and can serve protective & enhancing, as well as destructive functions. Aggression can be motivationally well included in ambitions, perfectionism, competitiveness and exceptional competency. It can also be more present in patient's interpersonal condescending, critical views that can negatively influence their intimate, social and professional affiliations. However, aggression can also be self-directed, expressed in extremely harsh self-criticism, devaluation, or self-hatred that affects self-regulation in less obvious ways (e.g. it can be expressed in chronic suicidality, which paradoxically can maintain a patient's internal control and interpersonal functioning). Empathic functioning Empathy - an emotional response that is produced by the emotional state of another individual without losing sight of whose feelings be long to whom. Empathy depends on the ability to engage in both emotional contagion and cognitive theory of mind functions, as well as self-regulatory processes, motivation, and social skills & decisions. In the DSM-5 section III, empathy is a dimension of personality functioning, related to comprehension and appreciation of others’ experi ences and motivations, tolerance of differing perspectives, and understanding of the effects of one’s own behavior on others. Empathic ability in NPD is considered compromised and fluctuating, influenced by interaction between deficits, capabilities a nd motivation. Patients with NPD showed no deficits in cognitive empathic capability, but significant impairment in emotional empathy with failures in emotional mirroring and responsiveness. Patients with NPD have intact ability to identify others’ thoughts, feelings, and intentions, but a variability in motivational underpinnings of empathic engagement with tendencies to overestimate one’s own capacity for emotional empathy. Neuroimaging studies show that NPD patients have the ability to feel empathy (as evidenced by somatosensory activity in response to others' pain + increased attention to the somatic representations of observed pain in others), but that does not translate into caring responsiveness. Empathic functioning in NPD can engage and alternate between self-enhancement and competence, critical or aggressive reactivity, and ignorance and withdrawal. Clinical observations of narcissistic patients describe oscillation between susceptible awareness with sometimes intense negative reactivity (pain, intolerance, irritability), which can co-exist with obliviousness or ignorance. Alternatively, they can show significant interpersonal fluctuations altering between self-motivated and skillful self-promoting engagement, aggressive rejections, and emotional coldness or dismissive avoidance. Motivation, self-regulation, and agency - further empirical perspectives Psychopathology Page 6 Motivation, self-regulation, and agency - further empirical perspectives Some people with NPD may focus on self-enhancement by being aggressive, while others may engage in self-protective dismissal, rejection or avoidance of situations. Understanding the difference between approach and avoidance motivation can be applied to fluctuations in self-enhancing/grandiose and self- devaluing/vulnerable narcissistic states and their accompanying strategies. There's a higher risk of suicidality when there's less impulsivity in NPD. This might mean that, in some cases, suicidal behavior in people with narcissistic traits is a way self-esteem regulation combined with agential efforts to gain control of life. Implications for therapeutic alliance and interventions In therapy with people who have NPD, it's important to understand how they might show both strengths and weaknesses. For therapists, the challenge is to figure out how to work with these patients, acknowledging their strengths while also addressing their difficulties. It's crucial to not just focus on the obvious signs of narcissistic behavior or criticize their actions but to also recognize their abilities and emotions in a supportive way. For example, if a patient describes problems at work and seems upset about changes in his boss's behavior, a therapist might choose to focus only on criticizing the patient for having conflicts with coworkers and being angry with the boss. However, a better approach could involve acknowledging the patient's competence in handling work tasks while also understanding his fears about uncertain changes at his job. By recognizing the patient's feelings and abilities, the therapist creates a more supportive environment, making it easier for the patient to reflect on & share his experiences and emotions. It's a way to start therapy by connecting with the patient's perspective and gradually exploring deeper emotional issues. Does self-love lead to love for others? A story of narcissistic game playing - Campbell (2002) There is a popular belief that loving the self makes it possible/easier to love others, but the exact causal chain remains un clear. The stance that self-love can make it difficult to love others has also been proposed (Narcissus' myth). What is narcissism? The authors define narcissists/nonnarcissists as people who score high/low on narcissism personality measures for the scope of this article. Narcissism and relationships Views of self and other Narcissists think very highly of themselves and are less concerned with relational intimacy. Narcissists believe that they are unique, smarter and more attractive than others. In particular, they report being much better than others on agentic traits (e.g. intelligence, social extraversion), and no better than others on communal traits (e.g. morality, caring). They also don't deem the latter traits as important as the former. High self-esteem individuals, on the other hand, see themselves as more agentic (not as much as narcissists) and more communal than others see themselves. Narcissists show self-focus rather than other-focus, report diminished empathy and a lesser need for intimacy than nonnarcissists. Self-regulation strategies Narcissists use interpersonal relationships for self-regulation, particularly for self-enhancement. They often do this by seeking and expressing superiority to or dominance over others by drawing attention to themselves or performing exhibitionistic acts. When narcissists are impaired in their drive for superiority, they may simply take credit for others' success and blame others for failure (self-serving bias). They may also express anger and aggression when they cannot express superiority. Narcissists' anger and hostility may rarely emerge if things are going their way. They are considered entertaining, energetic, and socially confident by others. They like to be surrounded by successful/popular people. To get this contact, they can be charming, flattering, or simply enjoyable to be around. In romantic relationships, narcissists seek status and self-esteem rather than intimacy or caring. They are attracted to people who meet those needs. Although they seek perfect partners, they maintain their self-esteem and dominance by rating themselves as superior to their romantic partners and they do not rate their partners better than others. Narcissists also report less commitment in their dating relationships, mostly due to their perception of elevated alternative s to the relationships. They report having multiple alternatives to their relationships and also report attending to those alternatives by e.g. flirting with other people. They also report higher socio-sexuality (they tend to desire multiple sexual partners and are less likely to link sex with intimacy). Narcissism and love Conceptualizing love Love in this article is conceptualized as having 6 styles: Eros - physical passion and a desire for rapidly escalating romantic involvement. Ludus - game playing, an aversion to partner dependence, attention to extradyadic others, and deception. Psychopathology Page 7  Ludus - game playing, an aversion to partner dependence, attention to extradyadic others, and deception. Storge - an emphasis on companionship and trust in relationships. Pragma - a pragmatic or practical approach to romantic relationships. Mania - an often painful obsession with the love object and alternating experiences of joy and sorrow in the relationship. Agape - a selfless regard for the well-being of the romantic partner. A model of narcissists' approach to love Relationships are good for narcissists because they provide positive attention and sexual satisfaction, but they are bad in t hat they demand emotional intimacy and restrict attention and sexual satisfaction from other partners. The ideal solution for narcissists is to find a way to receive the benefits of a relationship without having to endure the costs. The authors suspect that the ideal solution for them is to begin and maintain a relationship with a partner using charm, extr aversion, and confidence. This gives narcissists access to positive attention, esteem, and sexual resources. Then, the next goal is to keep this relationship from becoming too intimate or emotionally close. Finally, narcissists would covertly seek out other potential romantic partners. This strategy would allow maintaining power and freedom in the existing relationship. This strategy clearly corresponds to the Ludus (game playing) love style. Additional hypotheses The authors hypothesize that narcissism will be negatively related to eros, storge & agape and positively related to pragma, and no link with mania. The primary finding of research on self-esteem and love is that people with high self-esteem are less likely to experience mania and more likely to experience eros. The authors expect to replicate these associations. The present research The relationship between narcissism and self-reported love styles is examined in the current research. Self-esteem is also assessed to replicate past research on self-esteem and love and to control for the potentially confounding role self-esteem plays in the narcissism–love styles association. Study 1 Sample A is asked to report their general view of love in romantic relationships. Sample B consists of participants who are in dating relationships (average relationship length = 16.4 months). They are asked to report their experience of love in the current relationship. Narcissism was positively related to Ludus in a both samples A and B. These effects remained significant when self-esteem was controlled for. The negative association between narcissism and storge, a positive association between narcissism and pragma, and a negative association between narcissism and agape were found but only in 1 of the 2 samples. In both samples self-esteem was negatively related to mania. Study 2 This study analyzes the mediating role of need for power and need for autonomy in relationships in the narcissism -Ludus relationships. Principle of least interest - the individual less interested in the relationship has more power. If narcissists seek power and freedom in their dating relationships, the adoption of a game-playing love style should give them this power and freedom. Participants in the study were chosen in the same way that sample B was chosen in study 1. They reported their love styles in their current, ongoing romantic relationship and their needs for power and autonomy. The results show that the link between narcissism and Ludus is mediated by both of these needs. In other words, narcissists’ game-playing approach to romantic relationships reflects their pursuit of power and desire for autonomy in the relationship. Study 3 This study examines the outcome of a game-playing approach to romantic relationships. Psychopathology Page 8 This study examines the outcome of a game-playing approach to romantic relationships. The hypothesis is that, to the extent that narcissists are game playing in their romantic relationships, they will also report being less committed and more likely to perceive and seek out relationship alternatives. Participants include students in an ongoing romantic relationship. They completed self -report measures on narcissism, love styles in their current relationship, self - esteem, commitment, perceived alternatives and attention to alternatives. Narcissism correlated positively with Ludus, pragma and eros (marginally) and negatively with agape and storge (marginally). There was a strong negative relationship between narcissism and agape for men. This relationship did not exist for women. Self-esteem correlated negatively with mania and positively with eros. Ludus mediated the relationship between narcissism and commitment. Therefore, to the extent that narcissists were ludic in their ongoing romantic relationship, they were less likely to be committed. As with commitment, to the extent that narcissists were game playing in their romantic relationships, they also perceived enh anced alternatives. The link between narcissists’ ludic love styles and commitment was partially but not fully explained by alternatives. Study 4 In study 4, the disadvantages of using self-reports only are overcome. In this study, 2 samples are used. Participants in both samples described their past relationships with two individuals, one who fit the description of a narcissist, and one who fit the description of a nonnarcissist (thus each participant writes 2 narratives). In Sample A, a full narrative account of the relationship was given. In sample B, only a brief (1 paragraph) account was give n. Narcissists were described by their past partners as game players and as being unfaithful in their relationships, more flirta tious with others, more dishonest and deceptive, and more controlling & manipulative. Infidelity was reported in 24% of the narratives about narcissists and only 4$ of the narratives about nonnarcissists. Those who dated narcissists took more time to gain insight into their personality, and this impression changed over the course of the relationship. This suggests that narcissists used deceptive self-presentation in the relationship. Study 5 In this study, heterosexual couples are given a booklet of personality measures to complete. At time 1, narcissism, self-esteem, and love style scales are included in the questionnaire. At time 2 (7 weeks later), the same questionnaires were completed. Participants also rated their partner's level of game playing. Partners tended to agree on how much a particular person in the couple is ludic. Narcissism predicted Ludus reported at the present time and also Ludus reported 7 weeks in the future. Self-reported levels of narcissism were related to one's partner's perception that one is a game player. Partner B's perception of partner A's Ludus was predicted both by partner A's perception of his/her own Ludus and by partner A's perception of his/her own narcissism. Partners' narcissism scores were positively related both at time 1 and 2. This may reflect the fact that narcissists are dating narcissists in the relatively enduring relationships studied here. General discussion Meta-analysis of the first 3 studies shows that narcissism is positively linked to Ludus & pragma, Psychopathology Page 9  Meta-analysis of the first 3 studies shows that narcissism is positively linked to Ludus & pragma, and negatively linked to Agape. Studies 4 and 5 confirm the link between narcissism and game-playing. In all studies, individuals with high self-esteem reported less mania. "Isn't it fun to get the respect that we're going to deserve?" Narcissism, social rejection, and aggression - Twenge (2003) Experimental & correlational evidence shows that young people who are socially rejected are more aggressive toward others. However, even though many children are rejected by their peers, only a few become school shooters or perpetrate serious aggression toward others. Some rejected children & adults become sad/anxious instead of becoming angry & aggressive. Real-life events and previous research suggest that narcissism may be a crucial moderator of aggressive & angry reactions to rejec tion. Narcissism is also linked to violent incidents, from marital violence to rape. In many cases, violence is part of a strategy for gaining respect and retaliating against a person or group that has caused t he self insult or harm. Narcissism and aggression When narcissists confront evidence that disagrees with their self -views, they externalize blame, and are likely to react to threats with anger rather than sadness or anxiety. Links with aggression Men imprisoned for a violent crime often have higher narcissism scores than male college students. When they receive failure feedback, narcissists get angry, blame others, and are willing to derogate them. Aggressive responding has not been shown to extend to non-involved others (it's always the sources of threats that the aggression targets, there is no displaced aggression). Social rejection and aggression There is a plethora of evidence that people sometimes react to social exclusion with aggression. However, there are individual differences in how aggressively people respond to rejection. The authors hypothesize that narcissism is one of these moderating individual differences. Study 1 Participants complete self-reports on self-esteem, narcissism, feelings of inadequacy, and then tell a story about a time they got rejected. Then they are asked to recall a past even from their lives, responding to the following prompt: Think about a time when you were rejected by a person or a group about your own age. (If the rejection is by an organized gro up of people make sure it is of people about your same age. For example, being rejected from a college or job is NOT what we are asking about.) That is, describe an episode in which you wanted to spend time with or do something with someone and that person or persons did not let you. Please do NOT describe a romantic rejectio n, if possible. If you have several instances in mind, try to choose one that is either especially memorable and/or especially recent, so the experience will be fresh in your mind and your thoughts and feelings easy to recall. Please tell the whole story. Please describe the circumstances, how you felt, and what you did. After that, participants complete a mood measure, in reference to the time they felt rejected. The measure included items des igned to measure both externalized and internalized negative emotions (i.e., anger vs. more internal emotions such as sadness or anxiety). Narcissism was related positively to anger and negatively with internalized negative effect after a reported past, rejection experience. This finding stands when gender and self-esteem are controlled => narcissism uniquely predicts anger after a rejection experience. Study 2 A group of people performed a get-acquainted task and afterward all participants were asked to name the two people they would like to work with individually. Then some of the participants are informed that no one had chosen to work with them (social rejection) Then all participants completed the emotion scale used in study 1, which includes 7 anger items and 26 internalized negative affect items. Psychopathology Page 10 Narcissists demonstrated more anger after social rejection. Study 3 Similar to study 2, in this study participants experience a social rejection from a group of peers and they are given the opp ortunity to administer blasts of unpleasant noise to one of the group members. Participants believed they were playing a game with this one person (who was randomly chosen from the group and his/her identity was unknown to the participant), and the loser of each trial was punished by a blast of noise, delivered through headphones. Narcissism was positively correlated with aggression in this game. Study 4 Study 4 explores displaced aggression by giving participants the opportunity to aggress against an innocent third party —someone who was not a member of the group who administered the rejection. A social acceptance group was also included, randomly assigning some participants to hear that everyone had chosen them as a partner for further interaction. This allows investigating if narcissists are also more aggressive after social acceptance. In the rejection condition, narcissism was related to displaced aggression towards a new, innocent person. It was also relate d to anger, but not to internalized negative affect. In the acceptance condition, there were no relationships between narcissism and aggression or emotion. These results differed from other research that had not found evidence of displaced aggression after a specific ego threat. Since narcissists were rejected by 3/4 students from the same university, and were given the chance to aggress against another university student, they may have been compelled to aggress against the other student, as he/she may be seen as part of the rejecting group. This parallels the actual events in several school shootings, in which students who merely attended the same high school as the perpetrator were shot along with the students who actually rejected the perpetrator. General discussion The findings of the present research are particularly compelling given narcissists’ reported lack of concern for interpersona l relatedness. Narcissists are low in the need for affiliation and high in the need for power, uninterested in caring relationships, game playing rather than selfless, and willing to take credit from close others for success and blame close others for failure. This apparent independence , however, may hide a deep need for social acceptance, or perhaps for social dominance. The need is only evident in the aftermath of social rejection. Rejected narcissists are not calm or undisturbed by relational dissolution. Rather, they become angry and violent toward rejecters and third parties alike. Dos and don'ts in treatments of patients with narcissistic personality disorder - Weinberg (2020) Existing psychological treatments for NPD (psychoanalytic psychotherapy, CBT, schema- focused therapy, metacognitive psychotherapy, couples/group therapy, transference- focused therapy, DBT, mentalization-based treatment) are only marginally helpful. Pharmacological treatments are also lacking, and sometimes drugs are prescribed for treatment of comorbid conditions' symptoms. NPD is associated with absence of progress or negative treatment outcome. When comorbid with borderline PD, NPD impedes patients' progress in therapies such as mentalization-based treatment and transference-based psychotherapy. Specific NPD features (perfectionism, dismissive attachment, preoccupation with negativity, blame and criticism, manipulation and dismissal of therapist & people/contexts outside treatment, other attachment patterns (anxious-avoidant & cannot classify)) limit the therapeutic alliance and are associated with slower improvement in treatment of other disorders. Psychopathology Page 11 This article suggests a pragmatic treatment approach that promotes change and self -awareness in NPD patients. This model is based on clinical experience and is not affiliated with any particular theory. DOs Help the patient identify concrete, realistic, and measurable treatment goals that they identify as their own Treatment goals must be meaningfully related to what the patient values or wants to change. Treatment goals are the anchor of therapy, and they create motivation for change and the glue that helps the patient continue in therapy despite difficulties. Psychoeducation is an important step toward identification of realistic goals. Discussion and explanation of the NPD diagnosis is also important, although it needs to be done using the words of the patient and avoiding judgmental, nondescriptive language. Patients feel understood when they are given a clear formulation of their NPD-relevant difficulties, how they contribute to other comorbid conditions, and how they undermine important personal goals. Psychoeducation on purpose & format of therapy as well as realistic goals about what therapy can accomplish is also important. When the patient chooses perfectionistic/grandiose goals, the therapist needs to open the discussion of what these goals represent in terms of valued direction and so help reformulate the goals. Goal identification can also be promoted by validating the patient's motivation and capabilities. Identification of goals is a challenge to grandiose self-perception, and helping the patient tolerate these goals is an important step toward change. Identification of goals helps with development of autonomous motivation for treatment. Autonomous motivation - motivation that patients experience as their own, instead of one motivated by guilt, shame, the desire to please others, or compliance with external standards. Autonomous motivation is a strong predictor of treatment outcome, sometimes beyond the contribution of the therapeutic alliance. Since the therapeutic alliance with NPD patients is vulnerable to ruptures, developing autonomous motivation for treatment helps sustain the treatment in the face of challenges and helps the patient develop a sense of agency and a focus on change. An important component of this process is helping NPD patients define goals that they experience as their own. Help develop a sense of agency; identify a patient's strengths and weaknesses and help connect those to treatment goals Defining goals is closely related to helping the patient develop a sense of agency, which is central for NPD patients. Some NPD patients display remarkable accomplishments, although they still may lack a sense of agency or ownership of their li ves and goals. Self-agency is an important mediator of change in therapy, especially in NPD patients, who can have a fluctuating sense of agency. A number of interventions can help develop a sense of agency in NPD patients. Some interventions are behavioral (e.g. taking a job or assuming an important role in treatment to gaining a sense of internal control over problem solving and emotional experiences). Reflective listening helps the patient generate a meaningful narrative about himself. Resolving inconsistencies and contradictions in the discourse increases the sense of agency. A collaborative therapeutic relationship is essential to promote self-agency, otherwise the NPD patient will feel too vulnerable or disempowered to engage in treatment. Other strategies involve helping the NPD patient deal with obstacles to developing a sense of agency, such as extreme self-criticism, self-loathing, self-shaming etc. Exploring self-shaming processes and clarifying conflicting ideas are important parts of intervention. It is important to help the patient recognize the function of these processes as well as the avoidant nature of the self-critical statements. Help the patient shift from grandiosity and self-loathing to discussing experiences of real competence and weaknesses; Encourage curiosity and tolerance of uncertainty The shift toward more genuine self-experience and self-expression is one of the central processes of change in treatments of NPD patients. This process usually happens gradually when the patients are able to trust themselves as well as the therapist, and are able to acknowledge and share inner thoughts, feelings, and observations. A number of strategies and interventions promote this process. Encouraging the patient to explore & discuss internal experiences from an open-minded stance and applying a collaborative approach to clarify the patient's perspective is most helpful. Clarifying changing and incompatible perspectives on self and others, and encouraging awareness of triggers, fluctuations in self-esteem, and adaptive and maladaptive coping strategies can move the process forward. ○ The key components in this process are the therapist's curiosity about inner experience conveyed through questions and detailed explorations of various thinking/feeling/behaving patterns; the therapist's neutral validation of these experiences and his/her listening without mak ing assumptions. A second strategy is helping the patient identify the function of grandiosity and self-loathing. Grandiose self-perception and self-loathing both serve the function of distancing oneself from one’s real experiences, including from one’s body. They also provide pathological certainty and tend to limit the range of experience and self-expression. Helping the patient move beyond grandiosity or self-loathing is a gradual process that depends on close collaboration in therapy. This shift can happen when the NPD patient confronts disappointment and is able to process it in a sympathetic environment. This leads to a shift toward more integrated self-representations, a more cohesive self-narrative, a more balanced self-perception, and more grounded experiences of one’s own body. The patient becomes more able to acknowledge and embrace a wider range of internal experiences and to develop a sense of owne rship over them. As a result, the patient is able to shift from pathological certainty & pathological curiosity to the ability to tolerate uncertainty and normal curiosity about self and others. Psychopathology Page 12  self and others. Mentalizing-based strategies can also be helpful. These include challenging assumptions that are held with certainty, redirecting the patient from reporting to reflecting, and helping the patient shift back and forth from curiosity about self versus others as well as from feelings to thinking. Validating surprise, curiosity, and growing interest in understanding self and others help patients feel supported in develop ing their new capacities. It is important to avoid the following pitfalls: Pushing the patient to make behavioral changes that are not connected to values or ideals, and/or not exploring the meaning and process of making these changes. An overemphasis on the therapeutic relationship and ignoring outside events. Use an exploratory problem-solving approach to develop a collaborative therapeutic alliance Understanding and establishing a therapeutic connection with patients diagnosed with NPD can be challenging due to their atta chment patterns. Individuals with NPD often display dismissive or anxious-avoidant attachment styles, which could make it difficult to form a trusting relationship with a therapist. The therapy process should focus on three essential components: Establishing a Contractual Agreement: It's crucial to ensure safety in therapy by openly discussing treatment guidelines, expected behaviors, and potential disruptions to therapy. Collaboratively setting treatment goals, tracking progress, and problem-solving together is key. Defining Roles and Responsibilities: Negotiating power dynamics and roles within the therapeutic relationship is important. Educating patients about NPD and therapy helps set clear expectations and encourages collaboration. Building Attachment: Developing an attachment with the therapist is a gradual process that requires patience and addressing factors that hinder attachment formation. Understanding dismissive attachment as a coping mechanism stemming from relational trauma can help therapists understand patients' experiences. Strategies for building attachment include encouraging emotional expression, labeling emotions, addressing dismissiveness wit hin therapy, recognizing reversal of roles, learning from the patient's guidance, and fostering mutual accountability in therapy. Use contracts to anticipate threats to the alliance and productive collaboration, with ultimatums as a last resort Treatment contracts are vital tools that set guidelines for therapy, ensuring active collaboration between therapist and pati ent roles. These contracts establish boundaries, guiding permissible and prohibited behaviors with associated consequences. They aid in increasing compliance and attendance while decreasing dropout rates. For individuals with NPD, negotiating contracts might require more time and detail due to their resistance to limitations on their perceived power and success. Many NPD clients are likely to see such contracts as limiting their fantasies of infinite, unlimited power and success. Setting the contract helps the patient understand and start giving up narcissistic maladaptive strategies and expectations. However, therapists should be cautious not to impose ultimatums in therapy, as life ultimatums (challenges to habitual narcis sistic functioning such as life crises) can motivate change, whereas treatment ultimatums often stem from countertransference. Issuing treatment ultimatums can lead to power struggles and may jeopardize therapy, especially as dismissive attachment can make leveraging the therapeutic relationship ineffective. In essence, while life ultimatums can effectively motivate therapy, treatment ultimatums should be a last resort in therapy with individuals diagnosed with NPD. Address treatment-interfering behaviors as they come up in treatment Therapy must help the patient to develop a sense of agency and healthy responsibility that is different from either a grandio se sense of self-importance or paralyzing shame. This includes taking ownership over treatment-interfering behaviors. It is important to explore how these problems manifest not only with the therapist, but also with others. Don'ts Do not ignore countertransference Countertransference acts are the most frequent reason for treatment failures with NPD patients. Therapists of NPD patients report feeling annoyed, used, mistreated, resentful, criticized, or dismissed. Alternatively, they feel bored or experience sexual tension, and at times they can even experience wishes to be cruel or mean toward the patient. Such acts include distancing from the patient, termination of treatment, expression of irritation, objectification of the pat ient, competition with the patient, attempts to “fail” the patient, or treating the patient as a helpless victim, an unjustly treated genius, an exception, or even taking on roles in the patient’s life outside the consulting room. Once contained, countertransference provides helpful information about the patient’s internal world and the treatment relatio nship. Such reactions inform the clinician regarding typical reactions the patient is likely to evoke in others. Taken together with the patient’s history, such information provides valuable hypotheses regarding possible sources of relational difficulties. Countertransference may also provide a snapshot of the internal experiences that they patient is not yet aware of, because it sometimes reflects those. Countertransference can also be informative regarding the interpersonal pattern between the patient and the therapist. Feelings of boredom and a sense of being irrelevant or replaceable might suggest that the patient is developing a “narcissistic transference,” that is, treating the therapist as an audience, an irrelevant observer, or a “listening device.” In this case, the patient is expecting the therapist to listen and not have an opinion. Another possible countertransferential reaction involves feeling competitive with the patient. Psychopathology Page 13  Another possible countertransferential reaction involves feeling competitive with the patient. This could reflect that the patient is also feeling similarly competitive and is thus avoiding reliance on the therapist in a productive, therapeutic way. With some NPD patients, the therapist experiences sexual tension. Such a reaction might suggest efforts of the patient to reverse the power differential in therapy. Do not engage in a power struggle or misuse of power (e.g. a noncollaborative relationship) Treatment of NPD patients requires sensitivity to actual power and competence differentials between the therapist and the pat ient. Patients often strive to maintain control and may resist authoritarian or confrontational approaches from therapists. Attempts by therapists to force change or prove their superiority can lead to resistance or breakdowns in collaboration. NPD patients may sacrifice appointments or threaten legal action to protect their sense of control. Do not directly challenge the patient's grandiosity or self-loathing Both grandiose self-perception and self-loathing serve psychological purposes for NPD patients. Challenging these beliefs directly can backfire, as it often prompts patients to defend or strengthen these thoughts. For instance, challenging grandiosity can decrease the patient's sense of control and direction, while disputing self-loathing may feel invalidating. Instead, exploring the positive and negative impacts of these beliefs without directly contradicting them can help patients recognize their dysfunctional nature over time, leading to their gradual abandonment. Do not overindulge the patient's sense of grandiosity of self-loathing While many NPD patients have a history of neglect, deprivation, lack of protection & trauma, they are also actively responsib le in perpetuating their suffering. Ignoring the past means risking invalidation, while ignoring the current role of the patient denies them the sense of agency in his life story, as well as limiting hope for change. Ignoring the patient's current role tends to stall the treatment because the needs for maintaining an unrealistic grandiose o r hateful self-perception are not challenged or are overindulged. Many patients respond to such interventions with emotional disengagement, dismissal and distrust, because these interventionsdo not capture their own inner complexity of functioning. Do not use overly empathic interventions Overuse of empathic interventions, validation, or interpretation can be perceived by the patient as intrusions, attempts to c ontrol, or humiliation. Validation and, in particular, empathy may paradoxically tend to escalate the sense of loss of internal control and be perceived as foreign and anxiety provoking by patients who were only rarely exposed to them in intimate relationships. Thus, empathy should be used with caution, and the therapist should be ready to explore the patient’s own experiences of such interventions. Do not ignore self-esteem-relevant life events Life events can critically contribute to changes in NPD symptoms, especially if they involve normative disillusionments and a re accompanied by emotional support that guides the patient through grieving of unrealistic perceptions of self and others. Encouraging patients to be involved in life, that is, not to avoid friendships but to take vocational and social responsibilities is crucial. Psychopathology Page 14