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These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 41-year-old is brought in by his sister, who is worried and slightly out of her depth. He has not left his flat in three weeks and has stopped answering his phone, including to her. Six weeks ago he was dismissed from his job — the third he has lost in two years. He agreed to come, she says, only after she turned up at the door.
Clue 2
Since the dismissal his mood has been persistently low. He wakes at four and cannot get back to sleep. Nothing he used to enjoy holds any interest. He has stopped seeing the few people he still saw. He answers questions briefly and without much energy, and describes the last six weeks as a period in which he has felt, in his word, erased.
Clue 3
Asked about the three jobs, the account reorganises itself. Each ended in the same way — a dispute with management about recognition, then his exit. He describes his colleagues as unremarkable people who could not keep pace with him. At each post he had expected to be in senior leadership within months of arriving. He mentions, without any discomfort, that he once presented a colleague’s work as his own, on the grounds that he would do more with it than she would.
Clue 4
Two things become apparent in the room. He warms noticeably when his abilities are acknowledged and turns cold and dismissive when they are not. And when asked directly how the colleague felt, or how his ex-wife felt during either marriage, he does not answer — he returns at once to the unfairness of his own position, seemingly not registering that a different question was asked. His sister confirms the pattern is not new and not confined to work: it is traceable to his early twenties and appears in both marriages and in every friendship she has watched end.
Diagnosis
Narcissistic Personality Disorder
Why the diagnosis fits
This presentation arrives dressed as a depressive episode, and the depressive episode is entirely real — six weeks of low mood, early waking, anhedonia and withdrawal, with a structured screen positive at a moderate-to-severe level. Treating only that would not be wrong, but it would miss why it happened and why it will happen again. The diagnosis is made on what the history reveals once the last two years are laid out end to end. Three jobs have ended the same way, each in a dispute about recognition. He describes colleagues as unremarkable people who could not keep pace with him, expected senior leadership within months of arriving anywhere, and describes without discomfort presenting a colleague’s work as his own. He requires steady admiration and turns cold when it is withheld, visibly so during the assessment itself. Asked directly how anyone else felt, he does not answer the question but returns to his own position, apparently not registering that a different one was asked. Formal diagnosis requires at least five of nine criteria — grandiose self-importance, preoccupation with fantasies of success and power, demands for excessive admiration, entitlement, exploitativeness, lack of empathy and arrogance among them — beginning in early adulthood and persisting across contexts, and this pattern is traceable to his early twenties and appears in every workplace, both marriages and his friendships. The sequence is what makes the two diagnoses separable rather than competing: the grandiosity long predates the low mood and is still present in the room, while the depression dates precisely from a public loss of standing to which he responded with rage rather than disappointment. Two presentations are described, a grandiose form and a vulnerable one marked by hypersensitivity and defensiveness, and he shows features of both. Finally, the risk assessment is not an add-on. Depression commonly co-occurs even though these patients deny weakness, regular screening for suicidal ideation is specifically recommended, and his reluctant disclosure of passive ideation — immediately reframed as not being weakness — is exactly why it must be asked about directly.
Educational reference
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Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.
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