What brings individuals with narcissistic personality disorder to a psychiatrist’s or psychotherapist’s office? A range of symptoms and precipitants, which revolve around a threat to or breakdown of the person’s defensive grandiosity, generally lead to the initial consultation.

The spoiling or impoverishment of interpersonal relationships, resulting from the narcissistic individual’s exploitation and lack of empathy, may lead to the loss of the admiring other and a painful sense of rageful emptiness.

For example, a highly successful 27-year-old banker who had already earned his first million had developed a false story about his upbringing in a foreign country. The story evolved from a series of nondelusional “slidings away from the truth,” which are frequently used by narcissistic patients to support their grandiosity. Fully aware of its falsehood, he elaborated on the story to friends and acquaintances, as well as to the woman with whom he lived and planned to marry. On introducing her to his family, however, his duplicity was (predictably) revealed, and he entered treatment ashamed and panic-stricken after the loss of his admiring girlfriend. Although he acknowledged that her anger with him was justified, he was shocked with self-righteous fury when she actually decided to leave him.

A professional or creative setback also may threaten the grandiose self-image of a narcissistic individual and bring him or her to treatment. For example, a 35-year-old physician who was viewed by his seniors as having a promising second career in medicine (after having left a promising first career as a humanities professor before the tenure decision) sought treatment for feelings of depression and hypochondriasis after failing his specialty board examination. He had not prepared for the examination because he had considered it beneath him, and he felt contemptuous of his peers who had spent time preparing. He could not believe that he had failed and was enraged at the examiners. This was the first academic failure he could recall, and he felt deeply ashamed and exposed by it. He withdrew into reveries of revenge and sexual conquest. He avoided the mentors he had once idealized and began to blame them for his failure.

The stress of aging or illness and the attendant loss of beauty, strength, or cognitive function can undermine narcissistic fantasies of invulnerability and limitless power. It may lead to an empty, depleted collapse on the one hand or a frantic search for compensatory thrill-seeking on the other, both of which are described in the classic “midlife crisis”. Later-life crises, such as one experienced on the eve of retirement, also may reflect narcissistic pathology. For example, a 62-year-old married man was referred for depression by his internist after a month-long course of fluoxetine had failed to improve his symptoms. He was a successful self-made businessman, married with grown children, but for almost a year he had experienced a general lack of zest, anhedonia, and a sense of detachment from his loving wife. His appetite and sleep were undisturbed. On closer examination, his mood was not depression but pessimism tinged with bitterness and resentment, an affective tone frequently encountered in narcissistic individuals. He was bitter that he had never pursued a dreamt-of career as a theater actor. He had a narcissistic decompensation rather than a clinical depression.

Each of these vignettes describes a crisis that brings an otherwise well-functioning, socially successful individual to treatment as a result of narcissistic injury. Although the presenting clinical situation is suggestive of narcissistic personality disorder, further life history and the nature of the transference often are necessary to confirm or rule out the initial diagnostic impression.