Table 1.

Behavioral examples of treatment challenges in clinical health psychology practice.

Core NPD Feature(s)	Treatment Challenge	Manifestations in Mr. X	Manifestations in Ms. Y
Grandiosity/self-aggrandizement, need for admiration or special treatment	Poor boundaries	Examples: excessive calls, asking for extra time during session, requesting personal information about therapist, disregarding professional guidelines for interaction with therapist	Examples: discussions about inappropriate topics with medical providers, engaging in sexual relationships with inappropriate individuals involved in her care, expressing racist attitudes toward her therapist
Grandiosity/self-aggrandizement, need for admiration or special treatment	Ambivalence about change	Examples: unwillingness to complete homework assignments, inconsistent treatment toward therapist, inconsistent requests about therapeutic approach, avoidance of particularly painful subjects, defensiveness, intentional engagement in activities that are understood to have caused distress in the past	Examples: explicit desire to reduce distress and improve interpersonal function while simultaneously demanding special treatment and being personally disrespectful to therapist in a way that impaired her ability to benefit significantly from psychotherapy
Grandiosity/self-aggrandizement, interpersonal volatility, poor distress tolerance	Cognitive distortions	Examples: all-or-nothing thinking, unrealistic goal setting, frequent feelings of failure, catastrophic thought patterns related to interpersonal relationships	Examples: inflated self-concept, negative thought patterns about certain diverse groups of people, unrealistic expectations for special treatment
Need for admiration or special treatment, interpersonal volatility, poor distress tolerance	Idealizing and devaluing providers	Examples: referred to therapist as both exceptionally talented and horribly humiliating, referred to various medical providers as world-renowned and insensitive “jerks,” when particular needs were not met	Examples: excessive consultation and second-opinion seeking, inability to maintain positive relationships with medical providers, expressed feelings of “abandonment” and concerns about incompetency when discharged from various clinics for difficult behavior
Need for admiration or special treatment, interpersonal volatility, poor distress tolerance	Poor behavioral health adherence	Examples: not adhering to appropriate dietary guidelines, not consistently using CPAP, poor management of blood glucose, unwillingness to wear compression stockings	N/A In contrast to Mr. X, who struggled significantly with adherence, Ms. Y was remarkably adherent to cancer treatment and provider recommendations
Need for admiration or special treatment, interpersonal volatility, poor distress tolerance	Help-rejecting behaviors	Examples: frequent session cancellations, emotional avoidance, volatility toward medical providers, frequent criticism of providers, lashing out when feeling vulnerable	Examples: extensive “doctor shopping” at multiple cancer centers and inflammatory comments directed at her providers, even those from whom she sought treatment