Suicide risk is not reduced by grandiosity. This psychiatric teaching point highlights that narcissistic and antisocial traits can coexist with severe self-harm risk, and that formulation should separate impulsivity, entitlement and planning rather than relying on loose labels such as the dark triad.

In adolescent depression, fluoxetine still has the clearest drug signal, but medication is not the whole plan. Start with psychological therapy, review early for suicidality, and taper antidepressants slowly; TMS may have a role as augmentation for persistent symptoms where services and suitability align.

Persistent aggressive conduct problems with callous-unemotional traits predict later antisocial personality disorder more reliably than isolated animal cruelty. Clinically, adolescent sexual histories must document age gaps and authority roles, because apparent consent does not remove exploitation when power is unequal.