11/08/2009 05:12 am ET | Updated Nov 17, 2011

Greek mythology tells the story of a great hero known for his personal beauty and contempt for others who make the mistake of falling in love with himself. The gods find their just punishment in having Narcissus gaze upon himself in a forest pool only to discover that his love for himself would have to be unrequited. In despair, he kills himself.

Doctors are ethically not permitted to make diagnoses of people they do not directly know or treat. That means me. That said, I often think the popular press is rife with people who would qualify for this diagnosis were a psychiatrist to have the occasion to see them in consultation. We are offended by their indifference to others. We are appalled by their greed. We are astounded by their behavior which reveals their belief that rules are made for other people, not them. They make for good reading but not good friends (or colleagues or relatives).

Some time ago I briefly had a patient, George, an aspiring financial wizard, who soon fired me as his doctor. He had come to see me after his CEO boss told him he had to go into therapy or he would be out of a job. What was happening with him at work was the same story he had previously written in a marriage that had failed. George's wife had left him after he spent down her savings and became involved with another woman. Did you ever see the riotous movie Ruthless People? (1986: Danny DeVito, Bette Midler)

I asked George why his boss would be so insistent on his being in therapy. He said "...that idiot doesn't know how to manage, and worse he doesn't want to listen to me when I tell him how to do things." I asked him if there might be something valuable he could learn from his boss, or at least not dismiss what he was saying, inasmuch as the CEO held all the cards. That was when I felt what his boss must have felt, namely disdain for me and anything I had to say. Sound familiar? People in power who refuse to listen to anyone else because they know all the answers. People in power who do what they want because their vision ends with themselves.

Several meetings later I tried to caution him that his job was in peril. I suggested that together we might be able to figure out what he could do to save it. He stood up precipitously, called me a fool, and left. I was both stunned by the suddenness of it all but not surprised by his behavior. He did not return my calls and I never saw him again.

Narcissists, as we see from George, feature self-importance, lack of consideration of and empathy for others (many times to the point of exploitation), and have a long trail of troubled and fractured relationships. Psychological theory suggests that early emotional deprivation -- at the hands of parents who were made of the same stuff or from a life without safety or support -- fosters the development of this condition. But explanation is not exoneration. Their inflated sense of self may take them to high places but their grip is tenuous in a world where technical know how (alone) is, sooner or later, not enough.

I dare say that trust is at the heart of human nature. We can forgive honest mistakes but we want to punish those who take us for fools. Jon Stewart joked, and I paraphrase, that the Judge gave Bernie Madoff a choice of 150 years in jail or walking free but unaccompanied out of the courthouse; Madoff chose the former since it was the safer route to go.

"Though the mills of God grind slowly, yet they grind exceeding small;
Though with patience He stands waiting, with exactness grinds He all."

Lloyd I. Sederer, MD is Medical Director of the New York State Office of Mental Health and an Adjunct Professor at the Columbia School of Public Health.