Narcissistic personality disorder: diagnostic and clinical challenges.

“Mr. A” is a 42-year-old married man presenting to a private-practice psychotherapist complaining of problemswithhiswife.He is a successful entrepreneur, highly competitive, who describes enjoying social gatherings, where he tends to be the center of attention, as well as challengesatwork,wherehebelieves thathehasa superior ability to solveproblems.Hecomesto treatmentbecausehe is wondering whether or not to stay in his marriage. Mr. A described having lost all sexual interest in his wife during their early years together. Throughout themarriage, he has maintained a series of lovers whom he has housed, supported, and then cut off and replaced. He feels that this arrangementhashadno impact onhis relationshipwithhis wife but wonders if he would do better with someone else. “Mr. B” is a 34-year-old single man with a history of cocaine and alcohol abuse, currently unemployed. He presented to the emergency department complaining of pain following a dental procedure and requesting Percocet (acetaminophen and oxycodone). Although he was initially ingratiating with the attending physician who took his history, when she explained that she would have to speak with his oral surgeon before writing a prescription for anarcotic,Mr.Bbegan to insult andbullyher. The attending spoke with Mr. B’s “girlfriend,” whose contact information he had provided. The girlfriend explained that she had recently broken things off withMr. B because he had been exploiting herfinancially; since being fired 1 year earlier from a high-paying financial job, he had been unable to find employment that met his lofty expectations for himself, preferring instead to live off money from his father and his girlfriend. “Mr. C” is a 29-year-old single man with a history of insulin-dependentdiabeteswhopresents toanoutpatient clinic for treatment of dysthymia and social phobia. He has held a series of low-level jobs that “have not worked out,” and he currently works part-time doing data entry. Mr. C described his mood as chronically “miserable.” Socially isolated and easily slighted, he has no interests, takespleasure innothing, androutinelywonders “whether life isworth living.”When feeling down, he often “forgets” to administer his insulin, resulting in multiple hospitalizations for hyperglycemia. He constantly compares himself with others, feeling envious and resentful, and describes himself as deficient and defective. At the same time, he resents that others fail to recognize all he has to offer. At times he engages in fantasies of his employer publicly acknowledging his special talents and promoting him; at other times, he has fantasies of humiliating his boss with a display of superior knowledge. “Ms. D” is a 44-year-old single woman referred to a group specializing in severe personality disorders. She complained of “refractory depression” for which shewas on medical disability. She had been treated for 10 years with every modality her local hospital could offer, including ECT. She portrayed her previous therapists in scathingly derogatory terms, seeming tofind gratification in their failed attempts to help her. Her group therapist diagnosed her with narcissistic personality disorder based on the gap between her self-image as an extremely gifted but unrecognized author and the reality that she had written almost nothing. Antisocial features consisted of chronic lying, a history of prostitution in her 20s, and “working the system” to obtain disability payments rather than taking onwork that shewas able to do. Therewere no neurovegetative symptoms of depression. When her new therapist raised the possibility of working toward employment,Ms. D coolly declared that shewould kill herself, orhim, ifhe interferedwithherabilitytoobtainherbenefits.