This case study outlines the DSM-5-TR diagnostic criteria for narcissistic personality disorder (NPD), illustrating how it may manifest within the context of family and parental relationships.
Related article: Case Study: Narcissism in 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.
Just for fun, Trina stopped off at the psychic booth set up at her children’s school fair. Life in Canberra in the early 1970s was reasonably stable, but Trina knew that, every two or three years, she would have to uproot again as she and the four children followed her diplomat-husband around the globe. Still, life was settling down, so it was with some surprise that she heard the so-called “psychic” tell her that her future would not be a healthy one. “You will have a health problem” the psychic predicted, “not like a cold or flu, but something chronic.” Trina laughed off the reading saying, “What does she know? This is just a money-maker for the school, anyway; it’s not real.” But it was accurate. Trina, 37 at the time, would come to have a mental health diagnosis by age 48, when she would be admitted to the psychiatric hospital, although she was symptomatic many years before that. Considering her personal history, psychiatrists would later comment that mental health issues were almost inevitable.
Trina’s childhood was not an easy one. Her critical, cold mother cared for her physical needs, but was emotionally distant and rarely affectionate. Her biological father died when she was quite young. The stepfather who came along a bit later liked her: so much in fact, that Trina was more than the “apple of his eye”. She also became the victim of his sexual abuse. But that was not the only trauma of her formative years. Her home, like so many others in the Nazi-occupied Netherlands of the 1940s, was appropriated by German military personnel. So, as her body had been violated by her stepfather, her home was now violated by disrespectful, crude Nazi soldiers.
By her 20s, Trina was looking for escape – and adventure. She immigrated to France to nanny for a wealthy family. Trina went for tutoring in French, but got much more; she married the tutor, a same-aged French man whose work would later usher in the somewhat nomadic diplomatic lifestyle. Trina’s married life came with a cost. She only felt safe when she was controlling things, but her husband put up resistance to her domineering ways; their relationship was rife with bickering. The children’s friends would later describe her as “volatile”, flying into a rage for seemingly no reason at all. And her behaviour could be erratic. One day, the children may have been a bit too much too handle. She told them that she was leaving and would not be back. In truth, she probably just needed a few minutes’ break and went grocery shopping, but her 11-year-old son Andre (the eldest child) lined up his younger sisters and instructed them to “pray that Mum comes back.”
Trina had high expectations: of the children and their performance in school, of her husband and his career advancement, and of the diplomatic lifestyle, which afforded her many perks and opportunities. The children were always beautifully dressed. Their home had lovely and rather expensive furnishings. They rubbed elbows with personnel in the highest diplomatic circles (this was important to Trina, as she didn’t want to associate with “low-class” people). Trina would enquire in each new community where she could find the best doctors, dentists, and tutors (for the children), and she used them. A slender woman, she was meticulously groomed, and often remarked if someone were not especially friendly, that that person was probably “just jealous of me or our family.”
While Trina was a dutiful hostess for diplomatic events, she became increasingly prone to periods of depression. Her relationship with her husband suffered, and the children showed many signs of anxiety, stress, and low self-esteem; they would later struggle with issues of anger management and impulse control. Trina’s admission to hospital for psychotic symptoms was the culmination of things that had been “not quite right” for some time. Still, after months in the psychiatric ward and much medication, her symptoms seemed to be under control and she resumed her regular life. But the cracks could not be papered over.
Trina’s relationship with her husband, never close, now became unbearable for him. Her constant criticism, physical illnesses, depression, and suicide attempts took their toll on him emotionally. As they were turning 60, he told her that their marriage was finished. The only problem was that by then she had bowel cancer. He had taken up his final work assignment, back in France. Trina returned with him to France: to a “convalescent home” where she would attempt to recover from the cancer, and the operation for it. Having compassion for her, her son Andre brought her back to Australia less than a year later, allowing her to live with him in his own home.
There were times when this arrangement worked ok, but Trina – now at loose ends with no husband – made Andre into a surrogate husband, and reacted to his partner (who did not live with Andre) with envy, contempt, and anger. She criticised pretty much everything about the girl: her makeup, figure, clothes, and hair. After all, Trina was cooking Andre’s meals, washing his clothes, and cleaning his house, but it was the girlfriend who was getting all the affection – and sex. One day, after the girl remarked that Andre had made great leaps forward in showing affection since she had begun to date him, Trina told the girl that her son only knew how to be affectionate because she, Trina, had taught him – just in the few years since she had been living in his home (this was incongruent with the girl’s observation that Andre seemed to cringe when his mother tried to hug or kiss him). The claim was similar to those Trina had made earlier that her husband’s career only advanced as well as it had because “I hosted all the dinners for him. I showed him how to do things like setting the table right.”
As the years went on, Trina became more and more demanding of her son’s time and other resources. For instance, she chose a psychiatrist over an hour’s drive away, and demanded that Andre, hugely busy as a doctor, take off a day during the week to drive her to the appointment, wait for her, and drive her back: with time for a coffee and chat in the middle of that. If it was not the psychiatrist, it was another sort of doctor. There was always an appointment to which she needed a ride, as she was always “doing poorly” or needing some medical attention. She hated it when Andre married his partner and Trina no longer lived with him (Trina bought the house from Andre and just stayed there).
When well-meaning friends at the wedding asked her to speak some well wishes for the couple into the camera, she only said glumly, “I’ve lost my son.” No, the friends responded, she had gained a daughter. “No,” she said to the camera, “I’ve lost my son.” When the wedding pictures came in, Trina’s daughter-in-law offered to get a large copy printed and framed of whichever photo Trina wanted. Trina said that she did not want any of the wedding photos. Instead, Andre’s sister had snapped one of Andre and Trina would frame that one.
In reality, Trina did not lose Andre after his marriage. She continued her program of escalating demands, asking to maintain Andre’s services as chauffeur, and requesting four social visits per week as well. When Andre could not always comply due to the pressures of work, his wife did it for him.
Once when the family got together for Christmas at the home of one of Andre’s sisters, they were sitting in the lounge after dinner. It seated six people, although eight were present. Trina insisted she felt poorly, however, and – rather than go to her room – draped herself over the entire three-seater couch, leaving three seats available for the remaining seven people. Most of the family silently sat on the hardwood floor, accustomed as they were by many long years of “knowing” that it was always Mum’s needs that they needed to pay attention to. Sometimes her daughters would angrily remark that “Mum makes everything about her; she MUST be the centre of attention!”, but mostly, they just went along with things.
The most public embarrassments for Andre came when they travelled anywhere. Trina insisted on getting a wheelchair to ride from the plane, down the concourse, to the kerb outside of the airport. She enjoyed being wheeled along by solicitous airline attendants. Other than that, she walked everywhere, as she did not drive.
When her husband (separated but not divorced) was diagnosed with brain cancer, Trina could not bear how the family’s attention turned to their father. Knowing that he did not have long to live, all of the four children made many trips back to France to either visit with him or care for him. Trina was upset at this and proclaimed, “I’m in much more pain than he is; they just don’t know how sick I am.” When this did not change the fact of him getting more of the children’s attention, she attempted suicide with an overdose of pills; she survived.
Throughout the years, Trina had a number of psychotic incidents. The last hospital stay determined that the diagnosis was “schizotypal disorder”, and it was brought under control with medication. But the doctors did not have a pill to reduce Trina’s sense of entitlement or lack of empathy.
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, 2013, pp 669-670).
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 Trina appear to be manifesting?
- Trina’s presentation is somewhat atypical. What is different about her form of narcissism from the more typical presentation?
- Describe the dynamic that appears to be happening between Trina and her future daughter-in-law.
- What role, if any, does Andre have in the escalating levels of demands Trina places on him?
- Why do you imagine Trina chooses not to go to her room when she is feeling poorly at the Christmas family gathering?
- What may be the reward for someone who has a vital need to convince people of how sick she is?
- Trina’s family did not challenge her taking up three whole seats at a family gathering where there were already too few seats. What might have been the reason for this?
Case Analysis
Trina, while generally presenting with narcissistic vulnerability, nevertheless also exhibits most of the diagnostic criteria for NPD with narcissistic grandiosity.
Has grandiose self-importance and exaggeration of achievements. Her statement to her son’s partner that it was she who taught Andre (and only in the previous several years) to become affectionate is incongruent with Andre’s partner’s experience when observing her and Andre. Similar is Trina’s claim that she was the chief reason her husband’s career advanced: through her clever setting of the table at diplomatic dinners she hosted. At best this is an overstatement.
Believes that she is “special” and unique and should only associate with other high-status people. Trina’s insistence on having only the best doctor, dentist, or tutor for her family and her desire to associate only with the upper echelons of diplomatic staff exemplify this criterion well. Her desire for “special” status was also reflected in her insistence on being wheeled in a wheel chair from the plane when she could walk quite well.
Requires excessive admiration. Trina’s narcissism is of the vulnerable type, so while she did wish for admiration, what shows up more strongly in her patterning is the quest for “special status” through others’ recognition of how sick she claimed to be. Being seen as really ill but battling on was the best way that she could garner kudos – a form of admiration – from the family and others. Hence, her unwillingness to go to her room when she felt poorly at the family Christmas gathering. She believed that she could elicit more sympathy (admiration) for her pain by making a bid to be the centre of attention (shown by taking up half the available seating in the lounge).
Sense of entitlement and interpersonally exploitative. Nearly all of Trina’s behaviour shows a sense of entitlement and interpersonal exploitativeness. She was hugely exploitative in expecting her consummately busy but dutiful son to be her sole chauffeur for all appointments, and then becoming a client of a (presumably high-status) psychiatrist who was over an hour’s drive away. Occupying multiple lounge seats when there was not enough seating was equally exploitative, showing a sense of entitlement. When her son married and would no longer live with her, she felt rage at the loss of opportunity to live with (and continue to exploit) her son, and angrily expressed this into the camera. She also turned down the opportunity to share in the wedding through her rejection of the offer of a framed photo. Even early on, when she abandoned her children temporarily, it is likely that her sense of entitlement made her believe that she shouldn’t have to put up with noisy, active children.
Lacks empathy. The biggest evidence of this criterion was Trina’s huge upset when her estranged husband was diagnosed with brain cancer. Rather than feeling sorry for him, she felt sorry for herself, as she had now lost the special status of “family sick one” – and all the commensurate attention through visits and calls of the children. Trying to commit suicide was a means of attempting to recapture attention. She also felt little empathy for her overworked son through the years, as he struggled to meet both his work demands and also her continuing ones. Similarly, she felt no empathy for the joy of Andre and his wife coming together in marriage.
Is often envious or thinks others are envious of her. This criterion was demonstrated through Trina’s interpretation over the years that, if she did not get along well with someone, it was because they were envious of her. Her jealousy of her daughter-in-law, who received much of Andre’s affection, and her harsh criticisms of the girl, were evidence of envy.
A more complete understanding of Trina’s disorder can be gained by also considering her relationship with others in her life. One might well ask why no one challenged her selfish occupation of three seats in the lounge at the Christmas gathering, or why her son continued to give in to her escalating levels of demands. For one thing, Trina’s children were accustomed to her volatility and capacity for flying into a rage at the slightest provocation (shown, for example, the day she abandoned her children for engaging “normal” child activities, such as being noisy or active). Her children were used to her relentless bids to be the centre of attention, so it didn’t feel abnormal to them. Andre felt a sense of duty to his mother. The children’s lack of challenge to her at the Christmas gathering and other times shows that they acted in at least a somewhat self-defeating manner, forming a natural complement to Trina’s ongoing demands – springing from narcissistic entitlement – for more than her fair share of resources.
Trina’s heavy criticism and attempted exclusion of her daughter-in-law were ways of: (1) going into denial about her son’s relationship, and thus, her potential loss of place as “the special woman” in his life; (2) expressing envy of the daughter-in-law; (3) denying the demise of her own marriage, and her concomitant sense of entitlement to a husband; (4) unconsciously trying to make Andre into that husband. Trina’s plea that the family notice how she was much sicker than her estranged husband shows her increasingly desperate quest for the “reward” of being “special” in the only way she could: through being sick.
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.