Briefly describe narcissistic personality disorder, including the DSM-5 diagnostic criteria. Explain a therapeutic approach an

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: [email protected]

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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

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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

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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.

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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 …

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

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

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

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

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

3 Department of Medical B

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