Case Formulation
Mark suffers from covert narcissistic personality disorder (Pincus et
al., 2014), with traits of avoidant personality disorder, and from
recurrent depression. He experiences envy, anger and contempt towards
“luckier ” others, because they have reached success or could
access to resources he thinks were out of his reach. Consistent with the
diagnosis, Mark is prone to guilt (Dimaggio, 2022; Kealy et al., 2023).
He spends a lot of time thinking about what he would like but cannot
get, he thinks often about his past failures and this rumination paved
the road to depression. Mark indulges in fantasies of sabotaging the
others, tends to lie for the sake of grandiose self-presentation; he
avoids social interactions so to not run the risk of getting busted as
the charade he thought he was.
Mark longs to be free and autonomous but, from an early age, he over
complied with the demands to take care of his sister. Over time, Mark
gave up fancying any future consistent with his core wishes and now he
is unable to detect any vital aspect in his soul. After his father’s
death, Mark’s mother completely weighted in on him, making requests for
support and help. If Mark just did what he wanted, she become angry and
accused of being mean and selfish. When facing his mother’s suffering
and complains, Mark experienced guilt of the so called
“altruistic ” type, meaning the trigger is the idea that one is
enjoying something at the expense of another, or while another is
suffering (Gazzillo et al, 2017). As an adult, Mark begins to think he
has no right to do something for his own well-being as that could damage
the others: “If I walk away from home, I am bad and selfish. I
better give up so no one will suffer nor criticize me ”. As a result of
these ideas, he gives up with the exploratory motive and this is another
reason for his recurrent depression.
His never-ending commitment to care for his mother and sister, made Mark
loose opportunities for personal and professional growth. As a result,
he finds himself trapped into an “anonymous and boring job ”.
Mark has had to squelch the drive toward education, career, and
achieving high social status. Mark sees himself as a loser and considers
the others as luckier and more able to enjoy life, and for this reason
he is envious and belittle them. This is why Mark has never built
healthy and lasting interpersonal relationships in his entire life. He
somewhat realizes being responsible for his isolation, but he cannot
control his tendencies to criticize, derogate and humiliate others.
Mark harbours grandiose fantasies, where he portrays himself as having a
successful top-level job allowing him to travel worldwide. Again, as
typical of covert narcissism, grandiose fantasies suddenly leave room to
a sense of failure as he realizes the life he actually lives. He is
self-critical in particular when he acknowledges having lied either for
the sake of grandiose self-presentations or in order to spend time on
his own without caring for his sister.