Internal Processing in Patients With Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies
Abstract
Pathological narcissism (PN) and narcissistic personality disorder (NPD) have primarily been identified by striking external features, such as superiority, attention seeking and a critical or condescending attitude, and less attention has been paid to the internal processing contributing to this particular personality functioning. High dropout from treatment and challenges in building a therapeutic alliance with these patients call for further understanding of the complexity of disordered narcissism. Recent research on neuropsychological underpinnings to narcissistic pathology have provided valuable information that can inform therapeutic interventions for patients with this personality pathology. Internal processing in patients with PN or NPD is specifically influenced by compromised emotion processing and tolerance, identity diffusion, fluctuating sense of agency, reflective ability, perfectionism-related self- esteem, and ability to symbolize. The aim of this article is to review research studies with relevance for internal processing related to disordered narcissism and integrate findings with therapeutic strategies in alliance building with these patients.
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NPD is associated with neurophysiological deficits in emotional empathy, together with intact cognitive empathy, and influenced by a complex interaction between motivational, self-regulatory, and interpersonal processes, as well as by emotional dysregulation and intolerance.
“NPD is associated with neurophysiological deficits in emotional empathy, together with intact cognitive empathy, and influenced by a complex interaction between motivational, self-regulatory, and interpersonal processes (e.g., engagement versus disengagement), as well as by emotional dysregulation and intolerance (49–52).”
From Narcissistic Personality Disorder: Progress in Understanding and Treatment (2022) · cites this paper as [51]
Emotional reactivity and detachment make treatment challenging, often leading therapists to provide non-treatment interventions to avoid triggering intense negative emotions that could result in escalation or withdrawal.
“Both emotional reactivity and detachment make treatment challenging, often leading therapists to provide non-treatment interventions to avoid triggering intense negative emotions that could result in escalation or withdrawal (60, 188).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [188]
Directly acknowledging control dynamics, engaging in open discussions of the patient's emotional experiences, and collaboratively exploring the therapist's contribution have been shown to help stabilize the working alliance.
“Directly acknowledging control dynamics, engaging in open discussions of the patient’s emotional experiences, and collaboratively exploring the therapist’s contribution to them have been shown to help stabilize the working alliance (188, 189).”
From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [188]
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Narrative Accounts of the Self
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- Authors
- Ronningstam, E.
- Affiliations
- Harvard University (US)
- Corresponding author
- Ronningstam, Elsa
- ORCID
- Ronningstam, Elsa
- Venue
- Journal of Personality Disorders
- Publisher
- Guilford Publications
- Published
- 2020-03
- Volume
- 34
- Issue
- Supplement
- Pages
- 80-103
- ISSN
- 0885-579X (ISSN-L)
- OpenAlex
- W3011366893
- Cited by
- 35
- References
- 53
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 4 · 2023: 10 · 2022: 5 · 2021: 7
- FWCI
- 0.43
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Personality Disorders (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- pathological narcissism, narcissistic personality disorder, therapeutic relationship, treatment discontinuation, emotional processing, identity diffusion, sense of agency, reflective capacity, perfectionism, self-esteem, symbolization, treatment options
- MeSH terms
- Emotions, Humans, Narcissism, Personality Disorders, Self Concept
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