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Topic ” Narcissistic Personality disorder”

R E S E A R C H A R T I C L E

The role of shame and self‐compassion in psychotherapy for
narcissistic personality disorder: An exploratory study

Ueli Kramer1,2 | Antonio Pascual‐Leone2 | Kristina B. Rohde3 | Rainer Sachse4

1 Institute of Psychotherapy and General

Psychiatry Services, Department of Psychiatry,

Lausanne University Hospital and University

of Lausanne, Lausanne, Switzerland

2 Department of Psychology, University of

Windsor, Windsor, ON, Canada

3 Bern University Hospital and University of

Bern, Bern, Switzerland

4 Institute for Psychological Psychotherapy,

Bochum, Germany

Correspondence

PD Dr Ueli Kramer, IUP‐Dpt Psychiatry‐
CHUV, University of Lausanne, Place

Chauderon 18, CH‐1003 Lausanne,
Switzerland.

Email: [email protected]

Abstract
This process‐outcome study aims at exploring the role of shame, self‐compassion, and specific

therapeutic interventions in psychotherapy for patients with narcissistic personality disorder

(NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long‐term

clarification‐oriented psychotherapy. Their mean age was 39 years, and 10 were male. On aver-

age, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated

using the Classification of Affective Meaning States and the Process‐Content‐Relationship Scale.

Outcome was assessed using the Symptom Check List‐90 and Beck Depression Inventory‐II.

Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30).

In Session 36, the presence of self‐compassion was linked with a set of specific therapist inter-

ventions (process‐guidance and treatment of behaviour‐underlying assumptions; 51% of variance

explained and adjusted). This study points to the possible central role of shame in the therapeutic

process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to

access underlying self‐compassion.

KEYWORDS

clarification‐oriented psychotherapy, emotion processing, interaction process, narcissistic

personality disorder, self‐compassion, shame

1 | INTRODUCTION

Patients with narcissistic personality disorder (NPD), or pathological

narcissism, may present at times with self‐enhancing grandiosity,

whereas at other times with a brittle or fragile sense of self. Such con-

trasting self‐presentation of patients with the same underlying prob-

lems should be integrated in a comprehensive understanding of the

disorder (Caligor, Levy, & Yeomans, 2015; Levy, Ellison, & Reynoso,

2011; Ogrodniczuk & Kealy, 2013; Pincus & Lukowitsky, 2010; Pincus

& Roche, 2011; Roepke & Vater, 2014; Ronningstam & Weinberg,

2013). Core psychological features of NPD encompass a deficit in

self‐definition and affect regulation, a brittle sense of self and a lack

of empathy which foster biased conceptualizations of Self and Other.

Self‐enhancement, in particular a sense of grandiosity, exaggerated

entitlement, or arrogance may help maintain a stable self‐image. Often

more implicitly, fluctuating self‐esteem, self‐criticism, and affect dys-

regulation persist.

The quality of emotional processing underlying these core fea-

tures of NPD is of key interest. Deficits in emotional processing as

found on several dimensions which may be linked with the underlying

subjective experience of shame. Emotional processing with regard to

the Self lacks depth, that is, low levels of emotional self‐awareness,

and with regard to the others, that is, deficient emotion recognition

and lack of empathy (Dimaggio & Attina, 2012; Marcoux et al., 2014;

Pincus & Lukowitsky, 2010; Ritter et al., 2011; Ronningstam, 2016;

Sylvers, Brubaker, Alden, Brennan, & Lilienfeld, 2008). Lack of emo-

tional empathy may explain the interpersonal difficulties reported as

part of the NPD diagnosis (Ogrodniczuk, 2013). This lack of empathy

in NPD has been discussed as a prerequisite for the self‐referential

processing bias related to self‐enhancement and grandiosity: It

becomes key to focus on the underlying emotional issues related with

the understanding of the Self as shameful.

Patients with NPD tend to present with low levels of emotional

awareness (Joyce, Fujiwara, Cristall, Ruddy, & Ogrodniczuk, 2013;

Lecours, Briand‐Malenfant, & Descheneaux, 2013; Mizen, 2014;

Ronningstam, 2016). Difficulty in describing one’s inner emotional

states has also been associated with grandiose and entitlement traits

(Lawson, Waller, Sines, & Meyer, 2008). These results might indicate

that these patients lack the capacity to be aware of their emotional

life and of its deeper meanings. In her conceptual and clinical account

Received: 3 July 2017 Revised: 26 October 2017 Accepted: 30 October 2017

DOI: 10.1002/cpp.2160

272 Copyright © 2017 John Wiley & Sons, Ltd. Clin Psychol Psychother. 2018;25:272–282.wileyonlinelibrary.com/journal/cpp

of the perceptual recognition of emotion in individuals with NPD,

Ronningstam (2005) put forward a triad of emotions to which

patients with NPD respond with less accuracy: These patients seem

to have difficulties to identify fear, shame, and anger in others (see

also Lewis, 1971; Morrison, 1983). At the same time, these emotions

play an important role in the subjective experience of patients with

NPD: It was shown that they present with higher levels of explicitly

reported shame and an implicit proneness to shame (Ritter et al.,

2014). Implicit self‐related shame may be a trigger for developing high

standards, an excessive drive for success, and perfectionism (Dimag-

gio & Attina, 2012; Sagar & Stoeber, 2009). Ronningstam (2016)

added to this elaboration that other‐related shame, for example, attri-

butions of the other people as unworthy or defective, may result in

the expression of aggression and hatred, along with blaming, dismis-

sive, or overly critical attitudes (Caligor et al., 2015; Kernberg, 1992;

Ogrodniczuk, 2013; Sachse, Sachse, & Fasbender, 2011). As such,

malignant forms of narcissism may be characterized by the intentional

destructiveness of the significant other (Kernberg, 2004). If this

aggressiveness is turned inwards, it may result in suicidal thoughts

and actions, which may—paradoxically—have an important function

in maintaining the individual’s belief system (Maltsberger,

Ronningstam, Weinberg, Schechter, & Goldblatt, 2010; Ronningstam,

2016). Additionally, fear may be an important emotion tendency in

NPD (Kernberg, 2004, 2008). These patients may fear of “losing face”

in social interactions, again a shame‐based emotion (Kramer,

Berthoud, Keller, & Caspar, 2014; Lecours et al., 2013), or their self‐

control; they may experience fear of social exposure, to be humiliated

and to experience shame in the future. Because of the shame‐based

organization of the latter, authors have also called this emotion

“shame‐anxiety” (Pascual‐Leone & Greenberg, 2005). Because these

shame‐based emotional states are difficult to bear for most persons;

hostile anger is a common defensive interactional manoeuver

(Pascual‐Leone, Gillis, Singh, & Andreescu, 2013). Patients with NPD

have often developed a host of other agency‐enhancing interactional

manoeuvers as well, like boasting, using imagery of grandiosity, set-

ting exaggeratedly ambitious work goals, engaging in competitiveness,

or, also, using harsh self‐criticism, self‐hatred, and self‐contempt.

Patients with NPD have often developed explicit and implicit strate-

gies for avoiding the hurtful experience of shame (Lecours et al.,

2013).

In sum, effective therapy for core shame in patients with NPD

needs to take into account the interactional consequences of the

shame‐based organization as a first step, and then in a second step

deepen and transform the experience of shame.

1.1 | Shame: A dynamically changing emotion

According to emotion‐focused theory, shame may be defined

(Greenberg & Iwakabe, 2011) as an affective‐meaning state (or self‐

organization) composed by the internalized evaluative process of

self‐despising or self‐loathing information. As immediate consequence

of such an implicit (or explicit), self‐organization is the tendency to hide

or to make himself or herself “invisible” to the outer world. Clinical

observation of cases—including patients with NPD—has it that patients

may present with maladaptive shame (Greenberg, 2015; Greenberg &

Iwakabe, 2011). Maladaptive shame may involve the individual’s

understanding of his or her person as fundamentally flawed, unworthy,

or despicable: despite explicit messages from other people expressing

the opposite, the person continues to feel, at the core and often implic-

itly, fundamentally flawed.

When it is part of the patient’s presentation, engaging this mal-

adaptive form of shame is an essential passageway in the process of

transforming emotion (Kramer, 2017; Pascual‐Leone, 2009; Pascual‐

Leone, 2017; Pascual‐Leone & Kramer, 2017), which may be particu-

larly important in psychotherapy of NPD. The process of emotional

transformation describes how patients’ maladaptive emotion is

changed by emotion, that is, how patients move from non‐differenti-

ated and poorly integrated to adaptive and integrated emotional

experiences (Pascual‐Leone, 2009). Engaging in and transforming

shame seem essential for change in patients with NPD, because we

assume that maladaptive shame is strongly connected with negative

evaluations about the self which may contribute to a brittle sense

of self, to an unstable self‐image, and to other identity‐related prob-

lems in NPD. Early components of the emotion transformation pro-

cess (Pascual‐Leone, 2009), also called early expressions of distress

(see Figure1; global distress and rejecting anger), may be secondary

reactions to maladaptive shame and a more fundamentally fragile

sense of self. This conception assumes that rejecting anger involves

the person expressing strong resentment by rejecting or blaming the

other, generally in an intensive and non‐agentic way. Later compo-

nents of the emotion transformation process (Pascual‐Leone, 2009)

—also called primary adaptive emotions (see Figure1)—are assumed

to be underpinned by a new construction of meaning or insight. The

most important emotional states identified in this group are assertive

anger, grief, and self‐compassion; and they involve an individual’s

experientially accessing, developing, and articulating an unmet exis-

tential need or wish. For patients with strong shame‐based organiza-

tions, the transformational process might involve an individual’s

development of self‐compassion. According to this dynamic concep-

tion (Pascual‐Leone, 2009), self‐compassion is an elaborated

affective‐meaning state where the person actively gives himself or

herself what was ultimately needed at the core in his/her

Key Practitioner Message

• An active therapeutic focus on shame may be useful in

patients presenting with narcissistic personality

disorder, in particular in the working phase (after

Session 20) of the therapy process.

• The emergence of self‐compassion may be fostered by a

process guiding intervention, in advanced working phase

sessions (after Session 35) with patients with narcissistic

personality disorder.

• Once patients with narcissistic personality disorder

experientially access shame in session, its decrease

over the course of the working phase of therapy might

serve as an indicator of productive therapy process.

KRAMER U. ET AL. 273

development. Self‐compassion is therefore an adaptive way of expe-

rientially accessing one’s own core needs, requiring a representation

of these needs and of one’s sense of self, which is deficient in

patients with NPD, but might be formed through psychotherapy.

The patient’s experiential access of self‐compassion can hence be

seen as a marker of good progress in emotional transformation of

core shame in NPD.

1.2 | Clarification‐oriented psychotherapy (COP) for
core shame in NPD

COP is an integrative form of psychotherapy, based on humanistic

and interpersonal concepts, that was specifically developed for

patients with personality disorders, and NPD in particular. COP

assumes that patients with NPD present with two action systems:

(a) an authentic action system and (b) a strategic action system

(Sachse et al., 2011). The authentic action system includes a person’s

direct access to information related to his or her healthy need satis-

faction which helps the person to adaptively respond to the interac-

tion partners. These authentic actions are based on motives and

involve a direct experiential access and expression of the underlying

need to the interaction partner. In contrast, the strategic action system

describes the interactional manoeuvres, by using indirect expressions

of the underlying need. The use of interactional manoeuvers by the

person might leave him or her dissatisfied with the actual interac-

tions—sometimes without one being fully aware of it. According

to Sachse et al. (2011), this process explains the presenting interper-

sonal problems of NPD. Such interpersonal manoeuvers involve an

external—interpersonal—focus and explain the occurrence of what

the typical compensatory manoeuvers of NPD (Ronningstam, 2016).

For example, it may involve a patient presenting to others as free of

any problems or of someone who denies any need for treatment,

invincible, and grandiose. At other times, the patient with NPD pre-

sents as someone with a particular “gift” for which the interlocutor

should admire him or her or, finally, as someone who is so fragile

that he or she requires special care and attention by the interaction

partner. The therapy process in COP undergoes several phases.

The initial 10 to 20 sessions encompass the in‐session resolution

(i.e., reduction) of such interpersonal manoeuvers by offering a par-

ticularly responsive therapeutic relationship tailored to the underly-

ing motivational system. Sachse et al. (2011) propose to use the

complementary or motive‐oriented therapeutic relationship (for a

clinical example of this intervention type with a patient suffering

from NPD, see Kramer et al., 2014). As part of the initial sessions

and only when the interactional manoeuvres are significantly

reduced in‐session, the patient defines the therapeutic goal, which

includes the definition of the actual problem, which will then serve

as the vector for all further clarification and deepening work.

The core working phase of COP for NPD—typically after sessions

15–20—involves the patient’s exploration of momentary experi-

ences and constructing relevant personal meaning, with the aim of

broadening and deepening the patient’s scope of self‐understanding

(self‐processes related to the identified problem). COP increases the

patient’s awareness with regard to the central functions underlying

his or her interpersonal manoeuvers. Internal determinants, such as

core affects, needs, assumptions, and motives related to shame, are

deepened during the working phase of this treatment which is only

feasible when the patient can reliably use internal information

(without reusing an external focus, as in the earlier sessions of

therapy). In a final treatment phase of COP, the therapist fosters

change in the internal determinants by using various techniques,

including a version of a two‐chair dialogue for fostering change.

In a recent effectiveness study on 29 patients with NPD undergo-

ing COP, pre‐post effect sizes were found to be large (d’s varying

between 1.2 and 2.3; Sachse & Sachse, 2016).

From a psychotherapy process perspective, Kramer, Pascual‐

Leone, Rohde, and Sachse (2016) demonstrated for 39 patients with

a variety of personality disorders (including NPD), that good outcome

cases—defined as a reliable clinical change index greater than 1.96

(Jacobson & Truax, 1991) on outcome measures—were characterized

by more self‐compassion and rejecting anger in early working phase

sessions—session 25—than poor outcome cases. This result points

H
ig

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gnis secor

P
lanoito

m
E

fo
eerge

D
L

o
w

Primary
Adaptive
Emotions

Early
Expressions
of Distress

Rejecting
Anger

Acceptance
and Agency

Grief /
Hurt

Assertive Anger
or

Self-Compassion

Need

Start

Global
Distress

Shame /
(Fear)

Negative
Evaluation

FIGURE 1 Sequential model of emotional
processing (adapted with permission from
Pascual‐Leone & Greenberg, 2007)

274 KRAMER U. ET AL.

to the potential centrality of self‐compassion in psychotherapeutic

change of NPD, however, it is unclear whether the patient’s experien-

tial access to self‐compassion increases over the course of the work-

ing phase in COP. Access to rejecting anger was interpreted as an

important stepping stone towards such deeper and more meaningful

emotional processing (Pascual‐Leone, 2009; Figure1). One further

stepping stone towards deeper processing may be the access of

shame (see Figure1) which we expect should be accessed and

transformed (i.e., diminished in intensity) throughout the working

phase of COP for NPD. We expect that such between‐session change

of shame in the working phase of therapy would depend on the

degree of the patient’s initial functioning and would be linked with

outcome in COP. Kramer et al. (2016) showed that a therapist’s pro-

cess‐guiding towards patient’s core issues in the first part of early

working phase sessions was linked with the engagement in shame

(or fear) in the second part of the same session. It remains unclear

what the role of self‐compassion is in later working phase sessions

for patients with NPD. From an emotion‐focused perspective

(Greenberg, 2015; Pascual‐Leone, 2009), self‐compassion may

emerge in the context of a trustful patient‐therapist interaction,

allowing the patient to experientially access and acknowledge his/

her inner motives and needs. This exploratory study aims at address-

ing these issues for a subsample of the cited study, by more closely

examining patients who presented with NPD over the course of the

working phase of COP.

1.3 | Study hypotheses

This process‐outcome study focuses on the early and late working

phase of COP for NPD. By doing so, we will focus on the standard def-

inition of NPD by Diagnostic and Statistical Manual of Mental Disorders‐

IV (DSM‐IV; American Psychiatric Association, 1994). During working

phase, the patient’s (less productive) interactional manoeuvers are

reduced in session, and the patient is able to attend to the current

inner experience in a potentially productive way; these processes

may occur after the initial 20 sessions of COP. For this reason, we for-

mulate hypotheses on emotional processing after Session 20.

H1a Shame decreases from early working phase session

(25) to late working phase session (36).

H1b Change in shame is negatively related with symp-

tom intensity in patients with NPD; the greater the symp-

tom load at intake, the smaller the change in shame in the

working phase of therapy.

H2a Late‐working phase sessions (36) present with more

in‐session self‐compassion than earlier working phase ses-

sions (25).

H2b The presence of self‐compassion in the second part

of late working phase sessions (i.e., after minute 20 into

the session) is linked with the quality of the patient‐ther-

apist interaction in the first part of the same sessions (i.e.,

between minutes 10 and 20).

H3 In‐session shame is related to symptom change post‐

treatment.

2 | METHOD

2.1 | Participants

2.1.1 | Patients

Seventeen patients participated in this naturalistic trial. These patients

were self‐referred and consulted at a German‐speaking Consultation

Center specialized in the treatment of Personality Disorders (PDs).

All participants met criteria on the Structured Clinical Interview for

DSM‐IV Axis II Disorders for NPD, although their initial explicit formu-

lation of their problem might be consistent with a different psycholog-

ical disorder. All patients participated in an earlier process‐outcome

analysis (Kramer et al., 2016) which used a mixed sample of N = 39

patients suffering from various personality disorders, of which

N = 20 presented with NPD. In order to be included in the primary pro-

cess‐outcome analysis, the patients must present with PD, have pro-

cess and outcome data available, and must not present with

schizophrenia nor bipolar disorder. In order to be selected for the cur-

rent specialized analysis, patients must present with NPD and have

one additional audio‐ or video tape from session 36 (or, if not available,

37). For n = 3 individuals from the sample of the primary analysis, these

tapes did not exist or were not available. Therefore, the present sample

is composed of a total of N = 17 patients. In addition to the NPD diag-

nosis, seven (41%) presented with comorbid major depression, four

(24%) with substance abuse, two (12%) with somatoform disorder,

and one (6%) with generalized anxiety disorder. On axis II, four patients

(24%) presented with an additional comorbid personality disorders:

two (12%) with histrionic, one (6%) with dependent, and another

(6%) with avoidant personality disorders. DSM‐IV‐diagnoses (APA,

1994) were established by trained researcher‐clinicians using the

Structured Clinical Interview for DSM‐IV (First, Spitzer, Williams, &

Gibbons, 2004) for axes I and II of the DSM‐IV. The mean age of the

sample was 39.4 years (SD = 9.9) and ranged between 22 and 60;

seven patients were female (41%). All patients gave written informed

consent for their data to be used for research. The study was approved

by the institute’s internal board.

2.2 | Treatment

COP represents an adaptation of client‐centred psychotherapy to the

specific problems related with personality disorders, and in particular

NPD (Sachse et al., 2011). This treatment involves the step‐by‐step

working through of specific interpersonal manoeuvres, such as pre-

senting oneself as being invincible or particularly vulnerable in order

to justify demands for assistance in specific domains. After the focus

on the interpersonal manoeuvers, the core task of the COP therapist

is to clarify and render explicit the network of assumptions, emotions,

and motives underlying a patient’s clinical presentation (Sachse et al.,

2011) where it is assumed that, particularly for NPD, a fragile sense

of self together with self‐evaluations about oneself as worthless and

flawed underlie the presence of shame. Therefore, the treatment pro-

motes certain types of emotional transformation related to shame and

associated negative self‐evaluations. A manual describes the stages

and techniques involved in COP for NPD (Sachse et al., 2011), which

was used to train all therapists who were also supervised by the

KRAMER U. ET AL. 275

model’s developers. Treatments lasted between 45 and 99 weekly ses-

sions with a mean of 64 sessions (SD = 10).

2.3 | Instruments

2.3.1 | Symptom Check List SCL‐90‐R (Derogatis, 1994)

This questionnaire consists of 90 items addressing various signs of dis-

tress. Our study used the Global Severity Index (GSI; score ranging

from 0 to 4), which is a mean rated over all symptoms. Clinical cut‐

off score is .80. The German version was used in this study and previ-

ously yielded satisfactory validation coefficients (Franke, 1995). Inter-

nal consistency (Cronbach’s alpha) for this sample was .94.

2.3.2 | Beck Depression Inventory‐II (BDI‐II; Beck, Steer, &
Brown, 1996)

The German version of the BDI‐II was used; this version has shown

satisfactory validation coefficients (Hautzinger, Bailer, Worall, & Keller,

1995). This self‐report measure assesses depressive symptoms using

21 items. The intensity of each symptom is rated on a 4‐point Likert‐

type scale (0–3). The sum score of all items is computed, with the clin-

ical cut‐off of 10 for mild depression. Internal consistency for the scale

for this sample was .89.

2.3.3 | Classification of Affective‐Meaning States (CAMS;
Pascual‐Leone & Greenberg, 2005)

The CAMS is an observer‐based rating system for the assessment of

distinct affective meaning states that emerge during the course of

therapy sessions and that can be reliably categorized according to pre-

cisely defined criteria involving para‐verbal and verbal markers. It has

been developed based on emotion‐focused theory (i.e., Greenberg,

2015). In this study, the CAMS assesses two affective‐meaning states

which are the central subjective emotion categories: (a) shame

(and fear) and (b) self‐compassion. A manual (Pascual‐Leone &

Greenberg, 2005) guides the rater for the task of the moment‐by‐

moment analysis of audio‐/video‐recordings. Several studies have

demonstrated excellent reliabilities and validity of the CAMS (e.g.,

Kramer et al., 2015; Pascual‐Leone, 2009). Raters in this study were

blind to one another’s coding on the CAMS, to treatment outcomes

of cases they were coding, and to research hypotheses. Reliability

was demonstrated in the parent study on a subsample of n = 10 ses-

sions out of 34 sessions (29%) of cases with NPD. The results for

inter‐rater reliability on the distinct emotion categories were excellent

(Mean Cohn’s κ = .91; SD = .11, ranging between .71 and 1.00).

2.3.4 | Processing‐Content‐Relationship Scale
(Bearbeitungs‐, Inhalts‐ Beziehungsskalen [BIBS; Sachse,
Schirm, & Kramer, 2015])

Processing‐Content‐Relationship Scale is an observer‐rated instru-

ment assessing the quality of the therapeutic interaction according to

COP. Each of the 54 items is rated on a Likert‐type scale, ranging from

0 to 6. Global ratings are made for both patient’s and therapist’s contri-

butions to the therapy process using segments lasting 10 min of the

middle of the video‐/audio‐recorded session (between Minutes 10

and 20). On this scale, higher scores reflect better interaction quality.

From the patient’s perspective, three subscales are defined (process,

content, and relationship), from the therapist’s perspective, six sub-

scales are defined (relationship, understanding, process‐directiveness,

therapeutic work with focus on of process, on relationship, and on

content assumptions); this study includes the three patient’s subscales

and the theoretically central therapist’s subscales of process‐

directiveness, therapeutic work with focus on relationship, and on

basic assumptions. Excellent psychometric properties were reported

for the BIBS (Sachse et al., 2015). In particular, accuracy for patients

with personality disorders was demonstrated, as well as the validity

of coding a midsession segment instead of the entire therapy session.

Cronbach’s alpha for the present NPD sample (all items together) was

α = .94. In total, 18 sessions (out of a total of 34 sessions) of the NPD

cases were rated by two raters independently that represents a 53% of

reliability sample, and the reliability was excellent (Mean Intraclass

Correlation Coefficient; ICC (1, 2) = .93; SD = .06; range between .81

and .98; Shrout & Fleiss, 1979).

2.4 | Procedure

2.4.1 | Session selection

Two therapy sessions from the beginning and end of the working

phase (i.e., midtreatment vs. late‐treatment) were chosen and analysed

for this study. Session 25 was selected for analysis and served as the

basis for our earlier process‐outcome analysis (Kramer et al., 2016),

in order to ensure that there is an early working phase session which

is not dealing with interpersonal manoeuvres anymore (see above). In

addition, session 36 was selected for analysis and served as late‐

working phase session. This session was selected as being as much dis-

tant from the early session and not yet being part of the termination

phase of therapy (starting after sessions 38–40 for some cases). This

target late‐working phase session was not available in only one case,

so the closest available session (i.e., 37) was used in this case.

2.4.2 | Raters, training, and coding procedures

A total of five raters were used for both scales (CAMS and BIBS).

NR326 Mental Health Nursing

RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 1

Purpose
The student will review, summarize, and critique a scholarly article related to a mental health topic.

Course outcomes: This assignment enables the student to meet the following course outcomes.
(CO 4) Utilize critical thinking skills in clinical decision-making and implementation of the nursing process for

psychiatric/mental health clients. (PO 4)
(CO 5) Utilize available resources to meet self-identified goals for personal, professional, and educational

development appropriate to the mental health setting. (PO 5)
(CO 7) Examine moral, ethical, legal, and professional standards and principles as a basis for clinical decision-making.

(PO 6)
(CO 9) Utilize research findings as a basis for the development of a group leadership experience. (PO 8)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.

Total points possible: 100 points

Preparing the assignment
1) Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.

a. Select a scholarly nursing or research article, published within the last five years, related to mental health
nursing. The content of the article must relate to evidence-based practice.
• You may need to evaluate several articles to find one that is appropriate.

b. Ensure that no other member of your clinical group chooses the same article, then submit your choice for
faculty approval.

c. The submitted assignment should be 2-3 pages in length, excluding the title and reference pages.
2) Include the following sections (detailed criteria listed below and in the Grading Rubric must match exactly).

a. Introduction (10 points/10%)
• Establishes purpose of the paper
• Captures attention of the reader

b. Article Summary (30 points/30%)
• Statistics to support significance of the topic to mental health care
• Key points of the article
• Key evidence presented
• Examples of how the evidence can be incorporated into your nursing practice

c. Article Critique (30 points/30%)
• Present strengths of the article
• Present weaknesses of the article
• Discuss if you would/would not recommend this article to a colleague

d. Conclusion (15 points/15%)
• Provides analysis or synthesis of information within the body of the text
• Supported by ides presented in the body of the paper
• Is clearly written

e. Article Selection and Approval (5 points/5%)
• Current (published in last 5 years)
• Relevant to mental health care
• Not used by another student within the clinical group
• Submitted and approved as directed by instructor

f. APA format and Writing Mechanics (10 points/10%)

2

NR326 Mental Health Nursing
RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 2

• Correct use of standard English grammar and sentence structure
• No spelling or typographical errors
• Document includes title and reference pages
• Citations in the text and reference page

For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library.

Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned in the review module.

NR326 Mental Health Nursing
RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 4 3

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Assignment Section and
Required Criteria

(Points possible/% of total points available)

Highest Level of
Performance

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Article Summary
(30 points/30%)

30 points 25 points 24 points 11 points 0 points

Required criteria
1. Statistics to support significance of the topic to

mental health care
2. Key points of the article
3. Key evidence presented
4. Examples of how the evidence can be incorporated

into your nursing practice

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1. Current (published in last 5 years) Includes 4 Includes 3 Includes 2 Includes 1 No requirements for

NR326 Mental Health Nursing
RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 4 4

2. Relevant to mental health care
3. Not used by another student within the clinical group
4. Submitted and approved as directed by instructor

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Total Points Possible = 100 points

  • Purpose
  • Preparing the assignment
  • Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Running head: NEGATIVE SYMPTOMS IN SCHIZOPHRENIA 1

NR: 326 Mental Health RUA

Negative Symptoms in Schizophrenia

Chamberlain University

Jaime Montelione

Fall 2018

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NEGATIVE SYMPTOMS IN SCHIZOPHRENIA 2

Introduction

Mental health illnesses affect many people worldwide among them is schizophrenia

which is a chronic mental health disorder affecting a person’s brain. Patients with schizophrenia

can experience various symptoms as well as functional impairments. Symptoms include

delusions, trouble concentrating and hallucinations (Parekha,2017). Schizophrenia also interferes

with activities of daily living, social interactions, and occupational performance. Most patients

will require financial assistance to help support themselves because only a very low percentage

of people are able to work full or part-time jobs. In fact, only 10-20% of patients with

schizophrenia can work at all. It is imperative to improve the functional outcomes for these

patients and make it a mental health priority (Velligan & Alphs, 2014).

Article Summary

This article concentrates on current methods for evaluating negative symptoms of

schizophrenia and treatments that are presently used for the patients who demonstrate these

negative symptoms. Attributes of negative symptoms are clarified by a diminished emotional

responsiveness, socialization, motivation, movement, and speech (Velligan & Alphs, 2014).

These are all identified with the pathophysiology of schizophrenia or subsidiary of different

symptoms of medications, other ailments or the environment. For instance, symptoms like

akinesia and blunted affect are created by antipsychotic medications. A depressed patient may

encounter symptoms of social withdrawal, anhedonia and a decrease in motivation (Velligan &

Alphs, 2014).

As indicated by the article negative symptoms can be evaluated by the Negative

Symptom Assessment. This assessment tool aids in finding the presence, severity and the range

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NEGATIVE SYMPTOMS IN SCHIZOPHRENIA 3

of negative symptoms frequently connected with schizophrenia (NSA, 2017). The Negative

Symptom Assessment is derived from a table of 16 domains displaying the areas of negative

symptoms which describe the behaviors that might be observed in each domain. Additionally,

important questions are asked with regard to the patient’s day to day activities and engagement

with others. However, this assessment is not useful for routine use in a public outpatient setting.

In order to be able to identify negative symptoms in this setting, a two 4-item version of the

negative symptom rating scale is utilized to rapidly distinguish and record symptoms (Velligan &

Alphs, 2014).

There are other possibilities for treatment which are generally founded on elements that

cause the symptoms. An example would be if the patient’s negative symptoms are due to taking

an antipsychotic drug or extrapyramidal syndrome. In these cases, the symptoms can be

diminished by decreasing the dosage of the particular medication currently being taken or by

prescribing a different antipsychotic drug to the patient that will produce fewer EPS.

Additionally, if the patient’s symptoms are resulting from depression then treatment of

depression will need to be considered. The article goes on to say that if antipsychotic

medications, adjunctive treatments, and psychosocial interventions are used in conjunction these

can improve negative symptom outcomes better than pharmacotherapy alone. In fact, studies

have shown that 80% of patients with schizophrenia who used combined therapy displayed

improvement in functional abilities such as daily activities, more engagement in the outside

world and overall took better care of themselves (Velligan & Alphs, 2014).

This author believes this article can be useful as an educational tool providing caregivers,

medical personnel, and nurses essential information regarding negative symptoms, assessment

and treatment options for schizophrenia. Additionally, the article can even be used as a good

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NEGATIVE SYMPTOMS IN SCHIZOPHRENIA 4

study source for students providing information about negative symptoms of schizophrenia that a

textbook may not provide.

Article Critique

This article provides relevant information with regards to the negative symptoms of

schizophrenia. It explains the assessment process and treatment options in a brief manner while

providing the reader with up to date information allowing them to enhance their knowledge of

the illness. Despite the fact that this article essentially centers around the negative symptoms of

schizophrenia it does not provide any information in regards to positive symptoms of

schizophrenia. For individuals learning about this illness for the first time, they may feel

something is absent from this article. This author believes if the article provided a brief

description of both negative and positive symptoms of schizophrenia and comparison of the two

it would make for a clearer understanding of the illness.

Conclusion

As with all mental illnesses, schizophrenia not only affects the life of the patient it also

impacts the lives of the people who care for them. Educating families about schizophrenia and its

negative symptoms displayed by the patient such as poor motivation and flat affect can help

decrease the likelihood of family members being critical of these behaviors (Velligan & Alphs,

2014). Unfortunately, negative symptoms are difficult to treat and often tend to continue longer

than positive symptoms. Recognizing symptoms is critical in order to properly treat and manage

the illness. As stated in the article the best treatment outcome results when antipsychotic

medications and psychosocial interventions like social skills training and environmental support

are instilled (Velligan & Alphs, 2014).

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https://www.coursehero.com/file/37118347/NR326RUASchizophreniaedited276572-1docx/

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NEGATIVE SYMPTOMS IN SCHIZOPHRENIA 5

References

Parekh, R., M.D., M.P.H. (2017, July). What Is Schizophrenia? Retrieved December 6, 2018,

from https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

Negative Symptom Assessment (NSA-16). (n.d.). Retrieved December 6, 2018, from

https://eprovide.mapi-trust.org/instruments/negative-symptom-assessment#review_copy

Velligan, D. I., & Alphs, L. D. (2014). Negative Symptoms in Schizophrenia: An Update on

Identification and Treatment. Psychiatric times, 31(11), 1-6.

This study source was downloaded by 100000753516947 from CourseHero.com on 11-06-2021 19:32:27 GMT -05:00

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