This case study outlines the DSM-5-TR diagnostic criteria for narcissistic personality disorder (NPD), illustrating how it may manifest within the context of a romantic relationship.
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The story
Disclaimer: This case study contains fictional names to protect the privacy and confidentiality of individuals and entities involved.
Sue first “met” Robert on a dating site in September. He lived in Wales, she in Australia. Over their several months of email and phone contact, romantic feelings increased. Robert said that he would be coming to Australia in January, and that he was hoping to purchase a home. Sue loved how very much fun he seemed to be: charming, jovial, easy to talk to, and so romantic. There was a hint of another side to Robert on Christmas Eve when Sue let him know that, due to plans she and her daughter had to be with her friend’s family, she could not get home in time to ring him at their regular contact hour. He began to get angry over the telephone and the conversation ended “in nastiness – with a big fight.” A short time later, however, Robert resumed telling Sue how much he loved her. She saw little reason to disbelieve it.
When he stepped off the plane in January, he asked Sue to take him to a pharmacy before going home. The long plane ride, he said, had dried out his skin, and he needed to purchase eye and face cream, plus some hair products. Sue was rather surprised to hear that, yet more was to come. Robert took up residence with her in her flat, and Sue noticed that there was suddenly hot competition for the bathroom, as Robert would spend about 40 minutes there every morning. She noticed that his routine included flexing his muscles to make sure they looked ok, and long minutes gazing at himself in the mirror.
On Valentine’s Day they began to plan where they could go for dinner. Robert asked if Sue could arrange an appointment with her hairdresser to get his hair coloured. She did, and even paid for it. Thus, she was disconcerted to hear him complain about the job; he said his hair looked “too gingery” and he needed to go to another hairdresser to get that fixed. They hastily arranged another appointment, but that evening Robert refused to go out for dinner. “My hair just looks too awful,” he said, “We’ll have to get takeaways and bring it home.” Sue was astonished, but – given that he often asked her, “Does my hair look ok?” – she figured that he must just be a very insecure man needing, therefore, even more love.
Other aspects of life with Robert were not exactly what Sue had hoped to attract into her life, either. Robert had complained about her couch immediately upon arriving. It didn’t look good, he said; they needed a new one. Sue promptly bought one. A few weeks later, Robert confided that he needed a new bed as well. Her bed hurt his back, he said. Sue nearly complied, but as she liked the bed, something inside her advised her to hold back on this purchase. It was out of the question for Robert to buy either of these items, or very much at all for that matter, as he had brought only $1,200 with him – the sole amount he had to his name – and he did not wish to work at any of the jobs Sue helped him to find where they lived. The jobs, he said, were “beneath” him, although he did not have many qualifications for high-level jobs. Instead, Robert preferred to spend a good portion of his day working out at the gym, the membership to which Sue obligingly paid for.
After approximately three months of cohabiting, Sue was frustrated and suggested to Robert that he go stay with his sister, living in a nearby community, for a while. He did not wish to do that and, said Sue, “tried to woo me back instead.”
By July the couple were married, but the honeymoon period did not last long. Sue soon noticed that, whenever there were plans to get together with her friends (Robert didn’t have any of his own friends in Australia), he would try to back out of the outing, suggesting that they have “a nice quiet time” instead. He was increasingly resistant to her seeing her friends alone as well. Robert said that he had had a job as a maintenance person for a large property in the U.K. At Sue’s urging, he took up a job packing boxes at a large retail shop during the Christmas rush. As this job was not “suitable” for him, he complained frequently about it. In fact, he didn’t much like packing – or helping for that matter – at all. When Sue’s tenant moved out of the unit she owned, she decided to move back into it herself. She, her pre-teen daughter Marie, and Robert had been living in a rented unit. On moving day, Robert could not be persuaded to get out of bed and help. Just because the removalists were coming at 7:00 a.m. was no reason, he figured, to disturb his slumber and cause him to get up early. Nor did he wish to help pack or unpack any of the boxes. In exasperation Sue said, “Well, just go get a coffee then!” So he did.
Over their time together, Sue had come to know how “everything was always about Robert.” She said he needed to be right, and would become verbally aggressive and be “in my face” if things did not go his way. The turning point, though, was one night when she discovered an odd email in her junk mail folder. It was a picture of a woman sitting on a bed. She called Robert into the room and asked him about it. “Oh, uh,” he said stammering, “That’s a picture of my mate’s wife.” Robert left the room, but came back five minutes later and said, “Actually, it’s the woman he’s got on the side.”
Sue and her daughter had been having a laugh about something unrelated as he walked back into the room. This enraged him, so after making his announcement, he grabbed the computer from Sue and smashed it against the wall, breaking it in half. That action was all the confirmation Sue needed that the relationship was over, and that he needed to go. In crisp tones, she informed him that she and Marie would be going to a hotel that night, and that when they came back the next day, he needed to be gone. As they walked down the stairs to leave, he came running after them. “But what will I do for food?” he asked. “There is nothing in the cupboard; you need to give me money for food.”
As requested, Robert was gone when they returned, but the reminders of him were everywhere. Knowing that they had a problem with ants, Robert had sprinkled sugar (which ants love) up and down all the window sills of the flat. He had put sugared popcorn all throughout Marie’s sheets. He stole Sue’s work laptop computer and some of her most valuable rings.
Later, he would send texts accusing Sue of having had an affair, and making remarks such as that she was “fat and old-looking” to him when he first got off the plane (Sue is three years older than Robert: attractive and slender), and querying why she didn’t “look more like your friend.”
The “icing on the cake”, however, was going to her bank account a few days later and discovering that Robert had taken out most of the money in it: $10,000. Sue immediately rang his sister who lived nearby. She was horrified. The sister rang Robert’s mother in the U.K., who was also upset at the news. When Sue finally spoke over the telephone to Robert, his only remark was, “Well, Sue, you should have kept your mouth shut. Then I could have had my residency, and you could have kept your money.” Robert believed that he deserved the money, because, after all, he had “left a job in the U.K. to come to Australia for you, Sue. Not only that, but my legal team say that I should have been paid for my domestic services of tidying the flat and occasionally cooking while we were married.” In fact, Sue had thrown him out and declared a legal separation only a month or two before their one-year anniversary, at which stage Robert would have been granted permanent residency.
The following year, Sue was contacted by a woman living in her community. The woman had met Robert on the dating site where Sue had first met him. He had returned to the community to marry this woman; they had used the services of the same marriage celebrant that Robert and Sue had used. This woman, in tears now, had kicked Robert out after only three months. Sue immediately rang the Immigration Department and let them know about Robert’s ongoing tactics for establishing residency in Australia. She can laugh about the whole saga now, calling it “the most ridiculous thing I ever did in my life,” but at the time it hurt.
Narcissistic Personality Disorder: Diagnostic Criteria
The DSM-5-TR identifies NPD as “a pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
- Has a grandiose sense of self-importance, exaggerating achievements and skills and expecting to be recognized as superior without commensurate achievements
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- Believes that he or she is “special” and unique and can only be understood by, or should associate with, other high-status people (or institutions)
- Requires excessive admiration
- Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
- Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
- Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others
- Is often envious of others or believes that others are envious of him or her
- Shows arrogant, haughty behaviours or attitudes.” (American Psychiatric Association, 2022).
Narcissistic grandiosity versus narcissistic vulnerability
The above symptoms describe well the typical presentation of NPD: that is, a person showing narcissistic grandiosity. Another, less typical, type of NPD identified is that of narcissistic vulnerability. Narcissistic vulnerability involves the conscious experience of helplessness, emptiness, low self-esteem, and shame (as opposed to the underlying, but often unconscious presence of those states in narcissistic grandiosity). Such patients may present as long-suffering and intractable in their psychic pain, yet at the same time, their condition provides them with the “special status” that they are loath to give up. The vulnerability is also linked with the use of social avoidance to cope with threats to the self; the person withdraws in shame when his or her ideal self-presentation is not possible or the much-needed admiration is not forthcoming (Pincus et al, 2009).
Self-Defeating Personality Disorder (SDPD)
The diagnostic criteria for SDPD (from the DSM-III) are as follows.
- A pervasive pattern of self-defeating behaviour, beginning by early adulthood and present in a variety of contexts. The individual may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:
- Chooses persons and situations that lead to his or her disappointment, failure or mistreatment even when better options are clearly available to him or her
- Rejects or renders ineffective the attempts of others to help him or her
- Following positive personal events (e.g. new achievement), responds with depression, guilt, or a behavior that brings about pain (e.g., an accident)
- Incites angry or rejecting responses from others and then feels hurt, defeated or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
- Turns down opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)
- Fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so (e .g., helps fellow students write papers, but is unable to write his or her own)
- Is uninterested in or rejects people who consistently treat him or her well (e.g. is unattracted to caring sexual partners)
- Engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
- The behaviors in (a) do not occur only in response to, or in anticipation of, being physically, sexually or psychologically abused.
- The behaviors in (a) do not occur only when the individual is depressed. (Kass, 1987)
Case Questions
Some of the questions posed by this case are below. Take a few minutes to read them and think about what you believe the answers should be before going on to the analysis.
- Which of the DSM-5-TR diagnostic criteria for NPD does Robert appear to be manifesting?
- What was probably Robert’s strongest motivation for marrying Sue?
- Sue recounts the warning signs she had at Christmas Eve when Robert became quite angry over her not being able to call him at the usual time, and then when he stepped off the plane and “needed” to go to the pharmacy to purchase moisturisers and hair care products. What is likely to have been Sue’s motivation for ignoring those signs and proceeding with the relationship?
- Sue ultimately shows her healthy side: the steely part of herself that refuses to tolerate abuse and has good enough boundaries to get rid of the abuser: with no looking back. Initially, however, she was seduced – as the vast majority are – by the narcissist’s charms. Can you identify any incidents where Sue’s response may have fanned the flames of Robert’s narcissism? Hint: you may wish to consider this question in the context of self-defeating behaviour.
Case Analysis
It appears that Robert suffers from full-blown narcissistic grandiosity, with typical presentation. His many selfish, exploitative acts provide ample “fuel” for a diagnosis of NPD:
Has a grandiose sense of self-importance, exaggerating achievements and skills and expecting to be recognized as superior without commensurate achievements. Robert consistently complained about the menial nature of the jobs available to him, although he was not qualified for higher-level work. He worked very little of the time he was with Sue, and then only at her urging. He also showed grandiosity in complaining about her furniture, even though he had no means to buy alternative furnishings.
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. We cannot know exactly what fantasies Robert may have had, but we can infer from his hurtful remarks about Sue as “old and fat”, from his angst about his face and hair, and from his habit of gazing at himself in the mirror for long periods of time that he was preoccupied with thoughts of ideal beauty.
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other high-status people (or institutions). Sue’s regular hairdresser was not deemed skilled enough for Robert.
Requires excessive admiration Again, we can infer from Robert’s excessive concern with his appearance (the hair, the compulsive gym attendance, the muscle-flexing and mirror-gazing) that he was motivated by desire for admiration.
Has a sense of entitlement, i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations. Robert especially excelled at demonstrating entitlement and exploitativeness (the next criterion). He felt entitled to come to her home and – without contributing any money towards rent, food, or anything else – complain about the quality of the couch and the bed. He believed that he was entitled to gym membership, to all of Sue’s exclusive time that he wished to have, and to a high-status job. If such a job could not be attained, he was entitled to not work. At the end of the relationship, he felt entitled to take Sue’s money because he was being deprived of residency and, in any case, he was entitled to be paid for the small amount of time he contributed to domestic chores such as housecleaning and cooking.
Is interpersonally exploitative, i.e. takes advantage of others to achieve his or her own ends. There was little that Robert did in his 16 or 17 months with Sue that was not selfish advantage-seeking. From getting her to pay for everything to his very motivation for marrying – to gain Australian residency – he was crassly exploitative.
Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others. Robert showed from early on that he was unable to even recognise others’ needs, let alone be compassionate towards them. On Christmas Eve the fight occurred because he could not understand the emotional importance to Sue and her daughter of celebrating the evening with her friend’s family. On Valentine’s Day he failed to recognise the importance to Sue, newly in relationship with him, of going out for a meal on the special day set aside for lovers. He never seemed to get how it would have been appreciated if he had contributed something towards the welfare of their newly-formed household. His hurtful remarks to Sue about his perception of her appearance and his deliberate sprinkling of ant-attracting sugar around the flat showed not only lack of empathy, but also strong vindictiveness.
Shows arrogant, haughty behaviours or attitudes. Robert’s attitudes towards work and his refusal to help on moving day were only two examples of the arrogance that permeated most of his interactions.
It is not surprising that Sue “overlooked” the warning signs in the beginning. When starting a new romance, it is natural to want to have it work out, to hope that this love will be the “love of our life” that we have been fantasising about. The truth of the saying “Love is blind” certainly applies here. Sue, in hindsight, would probably rather that she had not paid for absolutely everything for Robert – especially items such as the new couch, when she was happy with the old one, and the gym membership, which he used to become even more narcissistic. It was this excessive sacrifice on her part – plus somewhat allowing him to isolate her socially – that may have reinforced his escalating narcissistic demands.
Still, Sue did not perfectly exemplify the complementary position of the self-defeatist stance. If we use as a guide the now-DSM-excluded Self-Defeating Personality Disorder, we see that Sue’s behaviour in the relationship fits only one or two (not the required minimum of five) of the diagnostic criteria: (1) She did choose a person/situation that led to “disappointment, failure, or mistreatment” (although the DSM – III requires that she needed to have had “other options open to her” when choosing the mistreating person; Sue may not have seen other options at the time); and possibly (2) “Engages in self-sacrifice…”. The problem with saying that Sue’s behaviour shows this second criterion is that the rider on the criterion adds that it must be sacrifice “unsolicited by the intended recipients”. In fact, Robert actively solicited her generous gestures. Thus, we see an extreme narcissist who came to be in relationship with a compassionate and somewhat self-sacrificing woman who nevertheless was too healthy to allow the relationship to continue for very long.
This case study was extracted from Mental Health Academy’s course, Case Studies in Narcissism. This course – a case study companion to Narcissism: The Basics and Treating Narcissism Iin and Around Your Clients – provides an in-depth look into several case studies of pathological narcissism.
References
- American Psychiatric Association. (2000). Quick reference to the diagnostic criteria from DSM – IV – TR. Washington, D.C.: American Psychiatric Association.
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.
- Kass, F. (1987). In response: New controversial diagnoses: Self-Defeating and Sadistic Personality Disorders. Jefferson Journal of Psychiatry, 92 – 96.
- Pincus, A.L., Ansell, E.B., Pimentel, C.A., Cain, N.M., Wright, G.C., and Levy, K.N. (2009). Initial construction and validation of the pathological narcissism inventory. Psychological Assessment, 21 (3), 365 – 379.