Intersect between self-esteem and emotion regulation in narcissistic personality disorder - implications for alliance building and treatment

Building an alliance with patients with pathological narcissism or narcissistic personality disorder, NPD, can be challenging and include avoidance, negative reactivity and disruptions. A main contributing factor can be the complex interaction between emotion and self-esteem regulation, which affects patients' ability to engage in a therapeutic alliance and treatment. Recent studies, especially in neuroscience have identified functional characteristic and compromises in self-esteem and emotion regulation related to NPD. Self-enhancement, hyper reactivity and need for control, which patients within the range of disordered narcissism often present, can have different roots and underpinnings that require thorough exploration in the process of building the therapeutic alliance and promote change in treatment. Clinical examples with treatment implications and strategies will be discussed to highlight both internal fluctuations and external features and shifts in narcissistic personality functioning.