NARCISSISTIC PERSONALITY DISORDER: CHALLENGES OF THE THERAPEUTIC ALLIANCE AND PATIENT RETENTION

Abstract

Narcissistic Personality Disorder (NPD), a Cluster B disorder, is a clinical condition marked by a persistent pattern of grandiosity, admiration-seeking, and empathic deficit. Contemporary literature defines it through two main dimensions: grandiosity and vulnerability, this duality being the basis of severe clinical challenges. This study aimed to elucidate the obstacles to therapeutic alliance and patient retention in patients with NPD. This is a narrative literature review, based on research in the PubMed database, using articles published in the last five years. The results indicate that narcissistic pathology, centered on the difficulty of maintaining realistic self-esteem, sabotages the bond, resulting in high treatment dropout rates (estimated at 63-64%). The main complicating factors include: interpreting therapy as a threat to self-image (shame/narcissistic threat), dysfunction in affective empathy (preservation of cognitive empathy), and low self-awareness. The treatment of choice is long-term psychotherapy (FPT, BMT, Schema Therapy), in which the therapeutic alliance is established as an end in itself. Retention depends on strategies that focus on managing underlying vulnerability, emotional regulation, and building a bond that validates the patient's achievements without reinforcing omnipotence.