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 selfesteem, 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.

Pathological Narcissism and Emotional Responses to Rejection: The Impact of Adult Attachment

“…Based on these findings, individuals who are high in grandiosity may display more blunted or minimalistic emotional responses during therapy, particularly when recalling distressing interpersonal content. The idea that individuals with pathological narcissism have difficulty describing inner experience in therapy has been outlined elsewhere (e.g., Ronningstam, 2020;Dimaggio, in press), and may indicate an impaired ability to self-reflect. These blunted emotional responses may also extend to interpersonal events within therapy that represent a rejection type experience (e.g., termination of therapy).…”

Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet?

“…The self-as-agent feels more powerless than able to make things happen. Ronningstam (2020b) writes: "As a central aspect of narcissistic functioning, sense of agency influences both self-regulatory and interpersonal functioning, such as attention seeking, competitiveness, and achievements" (Ronningstam, 2020b, p. 91). These hampered capacities are part of the implicit self and thus operate outside of conscious awareness in the adult; they are ego-syntonic.…”

“…. ) but patients may also be characterized by preoccupied attachment status, in which the individual remains angrily or passively enmeshed with attachment figures" (Diamond et al, 2013, p. 533; see also : Ronningstam, 2020b).…”

“…Generally, shame is absent or warded off in grandiose narcissism, whereas grandiose fantasies can alternate with intense shame about needs and ambitions in vulnerable narcissism (Gramzow and Tangney, 1992;Dickinson and Pincus, 2003;Ronningstam, 2005). A more recent explanation for this fluctuation is that some patients with NPD tend toward mental concreteness, a refusal of symbolization or not symbolizing (Ronningstam, 2020b). This certainly has severe implications for the therapeutic alliance, the limitation of latitude for interpretation, and countertransference in the therapist.…”

“…We have already described the phenomenon in which the less patients can reflect upon themselves-an indication of weak reflective functioning-the more pathological narcissism is likely. To the best of our knowledge, little research has been conducted until now that specifically addresses the ability of reflective functioning in narcissistic patients (Diamond et al, 2013, Ronningstam, 2020b.…”