The fear of what goes up must come down: A case report of vulnerable narcissism.

Pathological narcissism or narcissistic personality disorder is commonly characterized by an exaggerated sense of self-importance, condescending attitude, need for excessive admiration, diminished empathy and exploitativeness. In contrast to these overt attributes, there is a different presentation of pathological narcissism which is underrecognized, as one's preoccupation with hypervigilant, self-effacement and proneness to shame in the context of covert grandiose fantasies. This report illustrates a patient who had this subtype of vulnerable narcissism, and how his defence had been activated to preserve own self agency during a session with the doctor by revealing his paraphilic fantasy.