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Narcissistic personality disorder matters because grandiosity in these patients hides a fragile self-esteem that shatters easily under criticism. It is a Cluster B ('dramatic/erratic') personality disorder, a lasting pattern of grandiosity, a need for admiration, and a lack of empathy for others. For example, imagine a man who dismisses a colleague's achievement as trivial, then reacts with rage when his own work is mildly criticised. In practice, that swing from apparent superiority to wounded anger is the clue to the underlying fragility.

Core features include a grandiose sense of self-importance, preoccupation with fantasies of unlimited success, a belief in being special or unique, a need for excessive admiration, a sense of entitlement, interpersonal exploitativeness, and a lack of empathy. Self-esteem is often described as fragile, so mild criticism can trigger disproportionate anger or withdrawal, sometimes called narcissistic injury. Say a patient becomes coldly dismissive of a friend for forgetting their birthday, treating it as a personal insult rather than an ordinary lapse. In practice, recognising this fragile core, not just the outward grandiosity, explains why these patients react so strongly to seemingly minor slights.

• A man reports inflated self-worth and contempt for others. What most helps decide between narcissistic personality disorder and a hypomanic episode?
• After being passed over for promotion, a man with narcissistic personality disorder becomes acutely suicidal. Which mechanism best explains this?
• How is a narcissistic presentation coded under the ICD-11 personality disorder system?

• Antisocial personality disorder, rights-violating, deceitful or aggressive behaviour, unlike narcissistic personality disorder's grandiosity and need for admiration.
• Histrionic personality disorder, attention-seeking through shallow, dramatic emotionality, rather than narcissistic personality disorder's claims of superiority.
• Narcissistic injury, disproportionate anger or withdrawal after criticism, unlike ordinary embarrassment, and reveals the fragile self-esteem beneath the grandiosity.
• Borderline personality disorder, identity disturbance and fear of abandonment, whereas narcissistic personality disorder centres on entitlement and lack of empathy.

• Superficial or strained friendships occur in both, so this does not separate them.
• A treatment trial is not a diagnostic test, and delaying diagnosis on that basis is poor practice.
• Intelligence has no bearing on either diagnosis.
• No acute neurotransmitterA chemical messenger that nerve cells release to signal to the next cell.Read more → mechanism of this kind explains the reaction.
• Nothing in the presentation suggests a psychotic illness.

• Extract the defining phenomenology, duration, severity and functional-impact clues.
• Match the pattern to the most specific diagnostic or assessment construct.
• Actively test the closest look-alike against the missing or contradictory clue.
• Choose the precise term rather than a broader category that is merely compatible.