Historically, patients suffering from pathological narcissism, including narcissistic personality disorder (NPD), were considered challenging and hard to treat. Since the second half of the 20th century new treatments have been developing heralding a growing hope that transformative treatment of patients with pathological narcissism is possible. Recent developments of phenomenology, childhood antecedents, longitudinal course, and putative mechanisms inspired a greater hope as well. This invites clinicians and researchers to take an approach that is evidence-based, destigmatizing, and collaborative that considers that at least some of the treatment challenges as co-created by both the therapist and the patient. Further, new treatments add hope by ameliorating such challenges of patients with pathological narcissism as fragile alliance, limitations of reflectiveness and grieving. Novel treatments are evidence- and principles-based and different approaches to effective treatment development are described. Inspired by these developments in the field, this Issue of the Journal of Clinical Psychology: In Session was conceived as an opportunity for clinicians from different treatment approaches to come together and share their experiences in treating patients with pathological narcissism. The hope is to find common language to understand these patients and their treatment, understand what contributes to change, as well as learn from commonalities and differences among these treatments. In doing so, this Issue is hoping to promote destigmatizing, pragmatic approach that prioritizes evidence-based efforts to understand the patient and collaborative approach to promoting change.

Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization (WHO)’s International Classification of Diseases (ICD-11). This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of CPTSD. SNT balances interventions that address current day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man. The treatment introduces client tailored coping skills for current minority stress, discrimination and micro-aggressions as well as trauma-focused interventions regarding events from his childhood and the death of his partner and many members of his community due to the AIDS epidemic. Qualitative and quantitative outcomes are summarized. Implications regarding the relevance of SNT for sexual and gender minority (SGM) individuals is discussed.

Background Misophonia is often characterized by excessive negative emotional responses, including anger and anxiety, to “trigger sounds” which are typically day-to-day sounds, such as those generated from people eating. Misophonia (literally ‘hatred of sounds’) has commonly been understood within an auditory processing framework where sounds cause distress due to aberrant processing in the auditory and emotional systems of the brain. However, recent evidence from brain imaging shows involvement of the motor system while listening to trigger sounds suggesting that the perception of an action (e.g., mouth movement) produced by a trigger person, not the sound per se, drives distress in misophonia. Observation or listening to sounds of another’s actions are known to prompt automatic mimicry/imitations. Apart from anecdotal evidence and a few case studies, a relationship between mimicry and misophonia has not been evaluated. Method We addressed this ‘gap’ by collecting data on misophonia symptoms and mimicry behaviour using online questionnaires from 676 participants. Results The analysis shows, (i) the tendency to mimic varies in direct proportion to misophonia severity assessed using a self-reported questionnaire, (ii) compared to other human and environmental sounds, trigger sounds of eating and chewing are more likely to trigger mimicking, and (iii) the act of mimicking provides relief from distress to most people with misophonia. Conclusion Mimicry is widely prevalent in misophonia and is elicited by the most common trigger sounds of eating. The data provides support to the model that misophonia is not a disorder of sound-processing but rather its basis lies in social perception.

Objective: A qualitative study sought to understand the transition experiences of United States (U.S.) military Service members found “unfit for duty” following medical and physical evaluation boards (MEBs and PEBs). Methods: Confidential telephone interviews were conducted with 25 current and prior Service members. Participants were asked to share their experiences before, during, and after the MEB and PEB processes. To that end, interview questions were designed to gather the following types of transition experiences: (1) health conditions experienced during the medical disability evaluation process; (2) reactions to being recommended for separation, (3) transition-related stress and challenges, and (4) coping strategies. Salient themes were identified across chronological narratives. Results: Conditions that participants’ experienced included debilitating physical (e.g., injury) and/or mental health (e.g., post-traumatic stress disorder) conditions. In response to the “unfit for duty” notice, some participants reported emotional distress (e.g., anxiety, sadness, anger) connected to a sense of uncertainty about the future. Other participants reported relief connected to a sense of progression toward their medical disability claim status. Transition stress included the length of the MEB/PEB process, impact of the COVID-19 pandemic on the process, experiences of financial stress, impact on family life, and the compounded effect of these stressors on emotional distress, including depression and suicidal thoughts. Participants reported using adaptive (e.g., psychotherapy) and maladaptive (e.g., excessive drinking) strategies to cope with stress. Conclusions: The notable emotional distress and transition stress experienced by Service members found “unfit for duty” highlight the need for increased support and interventions to facilitate adaptive coping strategies during this vulnerable period.

Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalytic principles, while others argue they enhance coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient’s experience and that homework may be an important component of treating personality disorders. We present the case of a man diagnosed with narcissistic personality disorder to illustrate this: the patient, wrestling with social relations and control dynamics within therapy, was assigned homework aimed at curbing his compulsive caregiving and exploring its underlying motives. This exercise led him to understand his actions stemmed from avoidance of exposing his vulnerabilities. Subsequently, he was able to engage with relationships from diverse perspectives and discover new meanings. We advocate that homework tasks can be successfully incorporated into the relational psychoanalytic approach, fostering self-reflection and facilitating transformative change in patients with personality disorders.

In order to treat persons suffering from narcissistic personality disorder (NPD) it is necessary to agree on therapeutic goals and om tasks to undertake in order to meet them. This is difficult with NPD, as they have difficulties finding meaningful goals to strive for, other than the quest for status. Moreover, in order to change they need to expose themselves to experience painful feelings such as shame, guilt or fear, feelings that they automatically tend to keep at bay. Finally, they have problems forming a benevolent image of their therapists and to harken to it in order to cooperate towards mutually agreed goals and tasks. As a consequence, NPD patients ask for change but hardly engage themselves in the work necessary to achieve it. Therapists therefore need to pay the uttermost attention to drafting, negotiating and continuously updating a reasonable and realistic therapeutic contract. In this paper we describe the story of a man in his thirties with NPD who was ridden with depression, guilt, envy and anger and did not find ways to pursue the healthy and adaptive behaviors he would need to pursue in order to leave a richer social life. The therapist overcame ruptures in the therapeutic alliance and then involved the patient in a process where they set the steps to follow, making sure the patient was convinced they made sense. After a contract was reached progress became possible. Implications for the role of the therapeutic contract in NPD treatment are discussed.

Persons with dependent personality disorder (DPD) have difficulties describing their inner world, and in realizing their negative ideas about the self, such as being weak, unworthy or powerless are just ideas. As a consequence, they tend to over-rely on others and may lose control over their emotions. Treating these persons can gain benefits from including body-focused techniques as they can promote a) awareness of internal states, b) better emotion regulation, c) the capacity to consider their negative ideas about themselves as not necessarily true, and d) gain power of and agency. We will describe the therapist used body-focused techniques in the context of Metacognitive Interpersonal Therapy when treating Lia, a 40-year-old woman suffering from DPD who also suffered from generalized anxiety disorder and had difficulties in making autonomous choices. She had a romantic relationship with a man she described as distant and judgmental so she felt lonely and not entitled to express her discomfort or capable to break up. The therapist used body-focused techniques, together with behavioural exposure, mindfulness and guided imagery, in order to let Lia be more aware of her thoughts and feelings, and then to regulate affects and realize she had previously capacities. At therapy termination anxiety diminished and she could break up with the partner and start a new one where she felt free to express herself. We suggest how bodily-focused techniques can be used to enhance therapy effectiveness in DPD.

Intuitive Eating Scale-2 (IES-2) is a measurement of intuitive eating behaviors and has been validated, with traditional latent variable approaches, in youth and adults from a number of different populations, including college students in China. However, there still lacks the evaluation of the psychometric properties of the IES-2 in adults from the Chinese general population. Moreover, psychometric network analysis, as a complement to traditional latent variable approaches, has not been used for examining the psychometric properties of the IES-2. Thus, the present study aimed to use a psychometric network approach to evaluate the psychometric properties of the IES-2 in Chinese adults from the general population. A sample of 700 Chinese general adults (50% women; M age = 31.13 years, SD = 9.19) were included in the present study. Psychometric network analysis was performed by using EGAnet and psychonetrics packages on R 4.2.0. Exploratory graph analysis (EGA) identified four dimensions, which were well-separated in the estimated network. The network structure showed excellent stability and metric measurement invariance (i.e., network loadings) across men and women. Furthermore, several items in the IES-2 were identified as key nodes in the network of the IES-2 that may be important for the developement and maintenance of intuitive eating. For example, two items related to reliance on body cues were the most impactful nodes in the complete network. The findings of our study provide further understandings of the IES-2 from the perspective of network analysis and have implications for related applications of intuitive eating interventions for general populations.

EFT is an empirically supported treatment of depression for individuals, and is also considered to be an integrative, transdiagnostic therapy approach focusing on emotions that are the cause of a client's emotional pain and suffering. The target of treatment is to facilitate emotional processing to change unhealthy emotion schemes that underlie current symptoms of depression. The therapist is highly attuned to the client's moment-by-moment process to promote in-session work on emotion, alongside experiential teaching. In-session work is consolidated and expanded by between-session homework, which is viewed as a natural extension of the in-session work. EFT views the therapist as an emotion coach who offers interventions within a client's developmental and experiential learning capabilities to move them to their end goals. A case example is discussed to illustrate how homework is used effectively in treating a depressed client in relation to treatment principles over the course of treatment.

Objective: Intrusive thoughts are characterized by a sense of intrusiveness of foreign entry into cognition. While not always consisting of negative content, intrusive thoughts are almost solely investigated in that context. Involuntary Musical Imagery (INMI) offers a promising alternative, as it is a type of involuntary cognition that can be used to evaluate intrusiveness without negative content. Methos: In Study 1, 200 participants completed self-report questionnaires to assess several aspects of intrusiveness: meta-awareness, control, repetitiveness, frequency, and subjective experience of INMI. In Study 2, 203 participants completed self-report questionnaires to explore the clinical characteristics (depression, stress, anxiety, and rumination) which might mediate the connection between INMI frequency and INMI negative experience. Results: Study 1 revealed, through exploratory factor analysis, that intrusiveness shares variance with the negative experience of INMI but not with INMI frequency. In study 2, ruminative thinking was found to mediate the relationship between frequent INMI and negative experience of INMI. Conclusion: These results suggest that INMI might be used to investigate intrusiveness in the lab without the potential confound of negative emotions. In addition, the results suggest that neither the content nor the frequency of intrusive thoughts can solely explain why these thoughts are aversive to some but not others. Ruminative style might be the missing link to explain how and why these intrusive thoughts become aversive and obsessive. In other words, we suggest that the cause for intrusiveness lies not in the thought or repetitiveness, but in the thinker.

Substance use disorders (SUDs) are highly prevalent and have deleterious effects on one’s health and well-being. Inpatient treatment for SUDs reduces patient relapse, which subsequently ameliorates these negative effects on the individual and society. Additionally, those who complete treatment are less likely to relapse compared to those who do not complete treatment. Thus, maintaining patient engagement in treatment and reducing the rates of those leaving against medical advice (AMA) is particularly important. Examining the factors and comorbidities that may contribute to treatment dropout has the potential to identify at-risk patients in need of additional individualized intervention. The current study aimed to examine comorbid anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms as predictors of dropout AMA in a residential substance use treatment population. Results showed that patients with social anxiety were more likely to leave treatment AMA, while those with PTSD were more likely to complete treatment. Findings suggest that PTSD-specific treatment, as offered in this facility, may help with patient retention, while group focused therapy may be distressing to those with social anxiety. Clinical implications of this research may include incorporating evidence-based practice for social anxiety early during inpatient treatment to reduce anxiety such that patients may better engage with SUDs treatment.

Treatment of patients with pathological narcissism presents several challenges and there is paucity of published case reports that document meaningful and durable change in patients suffering from this condition. Using descriptive and atheoretical language, this paper presents a treatment of a young adult in his transition from young adulthood to middle adulthood while he was negotiating complex residues of his experiences of growing up along with developmental challenges related to work and love. Against the backdrop of these transitions, the patient was working through various aspects of functioning related to pathological narcissism. Initially, given academic pressures and past romantic disappointments, he was confronting issues related to perfectionism, self-criticism, and avoidance. While he was able to move past some of these dynamics and function academically, later challenges related to becoming an independent adult led to a retreat into an avoidant state of futility and pessimism. Working through painful family dynamics related to not being seen and controlled, along with a deepening attachment in therapy as well as confrontation with realities of his life, led him to take steps towards greater independence. Thereafter, his treatment focused on learning from life experiences such as a newly developed career and romantic life, accepting the complexity of self and others, and tolerating disillusionments.

Objective: Cognitive Behavior Therapy (CBT) is an effective treatment for anxiety and depression disorders. Nonetheless, nearly 50% of all patients do not respond. Besides other factors, this seems to be linked to the experience of traumatic life events. This study aims to assess the effects of trauma history on the choice of therapy interventions and treatment outcomes. Methods: We analyzed data from 340 CBT outpatients diagnosed with a depression or anxiety disorder and possibly a trauma history treated under naturalistic conditions. Based on their written therapy files, we collected information on trauma history, psychiatric diagnoses, duration of therapy, applied interventions, and severity of depression and anxiety symptoms at the start and end of therapy. The influence of trauma, diagnoses, and intervention use on the development of depression and anxiety symptoms were analyzed. Results: Patients with a trauma history reported higher overall depression and anxiety symptoms than those without trauma. No differences in the duration of therapy, applied interventions, or decrease in symptom severity were found between patients with and without a trauma history. Trauma-specific interventions failed to boost treatment success; however, they were also seldom applied. Conclusion: Although no differences between traumatized and non-traumatized patients were found for naturalistic CBT, traumatized patients maintained higher levels of symptom severity irrespective of diagnoses. These results indicate a need for more trauma-specific and personalized interventions. Therapists may need evidence-based guidelines to personalize CBT for patients with a trauma history and high symptom severity.

Aim The primary aim of this study was to conduct an open pilot clinical trial of a brief mindfulness-based intervention for persistent postconcussion symptoms that occur after mild traumatic brain injury in military service members. For many service members, operational tempo and other time constraints may prevent them from completing a standard mindfulness-based stress reduction course. Thus, this study sought to examine the effectiveness of a five-session intervention called Mindfulness-Based Stress, Pain, Emotion, and Attention Regulation (MSPEAR). Methods Participants were active duty service members with a history of mild traumatic brain injury (TBI) and persisting postconcussion symptoms, all of whom were recruited from an outpatient TBI rehabilitation program at a military treatment facility. Of the 38 service members that were initially enrolled, 25 completed the 5-session MSPEAR intervention, and 20 returned for a 5-week follow-up evaluation. Questionnaires assessing perceived stress, positive affect, pain interference and catastrophizing, sleep disturbances, perceived behavioral and attention regulation, self-efficacy, and satisfaction with life were administered at pre-intervention, post-intervention, and at 5-week follow-up intervals. Neuropsychological testing at pre-intervention and 5-week follow-up included performance validity measures, attention, working memory, and executive function measures. Results Improvements in perceived stress, positive affect, behavioral regulation, metacognition, sleep disturbance, self-efficacy, and satisfaction with life were found immediately after the MSPEAR intervention and were maintained at the 5-week follow-up. Magnification and helplessness aspects of pain catastrophizing improved when comparing pre-intervention to the 5-week follow-up. Pain interference was not significantly different across study assessment times. Neuropsychological testing revealed improvements in sustained attention, working memory, cognitive flexibility, and inhibitory control when comparing pre-intervention to the 5-week follow-up assessment. Conclusions The MSPEAR intervention appears to show promise as a brief and effective therapy for specific postconcussion symptoms after mild traumatic brain injury in military service members. Each of the components of MSPEAR including stress, pain catastrophizing, emotion, and attention regulation showed improvements in this study, and bears further investigation in a larger scale, preferably randomized controlled trial in those active duty military service members who experience persisting symptoms after a mild traumatic brain injury.