Psychoanalysts do not make diagnoses based on symptoms, but rather psycho- dynamics which can only unfold in the office. In the most general terms, narcissism is a continuum that we all have to more or less degrees. But a narcissistic personality disorder is diagnosed when narcissism is a defense against loss of self-esteem. Patients alternate between grandiose conceptions of self and self-contempt OR grandiosity and raging at others for failure.