In a previous blog, I promised to further unpack a proposed metaphor: problems are pregnant with intrusive parents. I suggested that when we become aware of a problem, if we look further there will most likely be other little problems on the inside, and likely bigger ones on the outside. In this visit, I want to introduce the concept of delay discounting into the conversation to further honor a 2010 suggestion of the National Institute of Mental Health (NIMH), encouraging the use of Research Domain Criteria (RDoC) as a way to unpack the assessment, treatment planning, and healing of comorbidities.
The issue is, when a client offers a presenting problem, what are good ways for counselors to understand the associations among those problems to better assist clients? A key hope of the NIMH is that the RDoC will provide a framework where counselors and other healthcare practitioners will seek out particular mechanisms associated with the complexities of comorbidity.
In this regard, I therefore want to identify the concept and practice of delay discounting as a useful mechanism to unravel comorbidity. Coleman et al. (2022: 1) posit, “Delay discounting (DD) is an aspect of decision-making wherein the rewarding value of a commodity decreases as a function of temporal delay to its availability…. Individuals with greater than average DD are said to exhibit a decision-making bias in the direction of preferring smaller, more immediate over larger, delayed rewards….”
The researchers go on to explain that DD is associated with a “variety of psychiatric conditions, including substance use disorders, affective disorders, schizophrenia, bulimia nervosa, binge-eating disorder, and borderline personality disorder (2022:1).
One of the things that I find most appealing about these research findings is that although there may be some biological and neurological foundations to DD, it is also susceptible to social, cultural, cognitive, and behavioral presentations. For counselors, teasing our the cognitive- behavioral components of comorbidity that are associated with DD can likely help clients to realize important breakthroughs on their paths to healing.
Interestingly, Narcissistic Personality Disorder (NPD) is the particular problem of concern in the Coleman et al. (2022) article. However, although narcissism is comorbid with several other conditions, DD itself is not universally relevant to all components of NPD. For instance, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5), Section III identifies three criteria for NPD: grandiosity (overriding need for admiration and admiration to maintain sense of exaggerated self-importance; entitlement (excessive wants for favorable treatments to support self interests); and vulnerability (when challenges to self-interests frequently lead to inability to regulate self-concept, feelings, and behaviors.
Although narcissism is often referenced as an umbrella tendency that drives or is driven by other comorbidities, its association with DD must be understood with caution. Coleman et al. found small to moderate support for trait grandiosity and entitlement. However, the association with DD and vulnerability was not supported.
So what now?
Well, the moral of the story is that we need to remain vigilant to continue avoiding mistaking the forest for the trees, or the trees for the forest. It is important for counselors to help clients understand inter and intra associations with comorbidity. Even after we remove the skin of the onion, and a few damaged layers on the outside, there may be more layers that require specific attention.
We need to find those hidden layers on the journey to help clients to further help themselves.
Written By: Peter, Masters Level Intern
Coleman, S. R. M., Oliver, A. C., Klemperer, E. M., DeSarno, M. J., Atwood, G. S., & Higgins, S. T. (2022). 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