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Pathological narcissism constitutes a dimension within the field of personality disorders that includes, in order of progressive severity, narcissistic personality disorder (NPD), malignant narcissism, and antisocial personality disorder. This chapter discusses the history of the psychiatric use of the term, narcissism; clinical characteristics of NPD; etiology of NPD; and differentiating NPD and antisocial personality disorder.

This chapter discusses the following: diagnostic and prognostic implications of the spectrum of narcissistic disorders; the characteristics and treatment of antisocial personality disorder proper, malignant narcissism, and the narcissistic personality proper; countertransference issues; paranoid transference; narcissistic transference; the cognitive style of antisocial disorders; and the effects of treatment.

This chapter discusses the extraordinary plasticity of the term narcissism, arguing that the ways in which 1970s social critics appropriated it for popular discourse shaped its fate in the public realm in the decades since. Linking narcissism to hedonistic consumption and immediate gratification, critics diagnosed a “culture of narcissism” sweeping the nation. They warmed to the concept of pathological narcissism while ignoring the healthy dimensions of the condition that psychoanalysts had outlined four decades earlier. Today another generation of critics charges that Americans are more narcissistic than ever, adducing as evidence too-high levels of self-esteem and ubiquitous self-absorption. Yet the critics’ indictments are not as persuasive as they once were. Narcissism in the public realm is more complex than before, used not only to pathologize but also to discuss complexities of normal behavior.

This chapter describes a case involving severe sexual inhibition in a patient with narcissistic personality disorder. The case highlights how the analysis of oedipal conflicts gradually resolved a severe and extended inhibition of sexual desire that developed in the course of analytic treatment. The enactment in the countertransference of castration anxiety against which the patient was successfully defending himself by projective identification produced an extended stalemate, which was resolved once the countertransference was transformed into transference interpretations.

Pattern is central in the pattern-focused case conceptualization approach. This chapter highlights the five basic treatment challenges for each of the eight common patterns in everyday clinical practice. It first defines pattern and provides a clinical strategy for quickly identifying and differentiating the basic patterns. Then, it describes eight patterns: avoidant, borderline, dependent, histrionic, narcissistic, obsessive–compulsive, paranoid, and passive–aggressive. Each of these patterns is discussed in the following format: pattern description, pattern development, pattern types and triggers, and treatment challenges. Clinicians who understand patterns and can identify them easily in clients are more likely to be able to explain and guide treatment, as well as anticipate treatment challenges.

As a short digression into the world of psychiatric diagnosis, the chapter “Goldwater” discusses the controversy over whether or not mental health professionals should diagnose President Trump with a mental illness, such as narcissistic personality disorder (NPD). The chapter’s title recalls the 1964 U.S. presidential election wherein the results of a survey of psychiatrists were published in an American magazine, concluding that the Republican candidate Barry Goldwater was mentally unfit to hold office. Goldwater later sued the magazine, and the case led to what has become known as the Goldwater Rule, prohibiting psychiatrists from diagnosing public officials from afar. The chapter makes a clear distinction between psychiatric diagnosis, which adopts the language of medicine and illness, on the one hand, and psychological commentary on the other. The latter conception better characterizes what the current book aims to accomplish. Psychological commentary draws from psychological science to develop a personality portrait of a person, without diagnosis and without judgment regarding mental health and illness. Moreover, Donald Trump is much stranger than any psychiatric label can convey.

Psychiatry is unique as a specialty. In the past century, medical technology has advanced at breakneck speed supporting diagnostic refinement, yet this has had limited impact in the area of mental health. It is not possible to diagnose mental illness with a blood test, a radiological investigation, or other such investigative tools. It requires a doctor to hone their ‘end of the bed’ observation skills and develop a sophisticated understand–ing of psychopathology. This familiarity of descriptive psychopathology then needs to be applied in everyday practice to recognize the symp–toms being presented, allowing interpretation of illness states. Similar symptoms can present in different illnesses and their relevance needs to be understood in the context of the history of the person. Psychiatric assessments with well-developed interview skills are the cornerstone of psychiatric practice. This can feel a daunting task to medical students and junior doctors who are well used to the protection of many investigation options at their fingertips. Psychiatric patients are often the most challenging to interview. They can present in ways that confront even the most experienced doctor— highly distressed, aggressive, withdrawn, disconnected from reality, or uncooperative, to describe just a few situations. They may not have cho–sen to see a doctor and may have come willingly or unwillingly due to someone else’s worry about them. These factors often create a difficult starting point from which to engage patients and establish a trusting doc–tor–patient relationship. The reasons for a person’s presentation, especially in the acute set–ting, are often highly anxiety provoking—attempted suicide, threatened suicide, or highly disturbed behaviour. This challenges doctors to remain calm in order to maintain the capacity to manage the assessment without relying on the armoury of procedures other specialties often can. A firm grasp of the MSE and the core aspects of a psychiatric history helps to negotiate numerous potential challenges during the interview. Interviewing and interpretative skills can be developed, akin to a cardi–ologist learning the sounds of different heart murmurs.