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Narcissistic personality disorder has long been a particular challenge for psychiatrists and all mental health professionals and carers. Although the Diagnostic and Statistical Manual of Mental Disorders emphasizes the grandiose aspects of the disorder, a deeper understanding reveals that arrogance acts as a defense against inner emptiness and perceived inferiority. To better understand the disorder, we can conceptualize it as the expression of a particular psychic structure called the grandiose Self, which helps us to better understand and intervene in this disorder. This conceptualization lies at the heart of Transference-Focused Psychotherapy, which provides tools to help the narcissistic patient better tolerate the psychic suffering against which the grandiose Self is erected as a defense, and develop a healthier, more authentic Self.