Narcissistic personality disorder is slated for removal from the next edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, to be published in 2013. So notes Charles Zanor in yesterday’s New York Times.
But for some reason, Zanor glossed over the loss of four other personality disorders in the shakeup too — Paranoid, Schizoid, Histrionic and Dependent Personality Disorders. (Schizotypal, Antisocial, Borderline, Avoidant and Obsessive-Compulsive Personality Disorders will remain in the new revision.)
Their intended replacements?
“The Work Group recommends that [these disorders] be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.”
Is this a good idea?
The DSM-5 Personality Disorders Workgroup lays out its rationale for the change, with an emphasis on the research showing that there is a significant co-occurrence of personality disorders — that is, people can often meet the criteria for and therefore be diagnosed with more than just one.
The Workgroup also complains that the existing personality disorder categories have arbitrary diagnostic thresholds — but this is an argument that could be made across virtually all of the DSM’s existing diagnostic categories.
The intended hybrid replacement model has not been extensively tested in clinical practice or in practical research. A handful of studies are used to suggest this model is ready for primetime, yet it appears that the Workgroup used a mish-mash of various theories to justify the change.
For instance, they rely on the five-factor model of personality to justify moving to traits. But then discount one of the five factors (openness) as having no significant relationship to personality. Then, like amateur chefs in their first kitchen of personality creation, they add a dash of two more factors not in the five-factor model — compulsivity and schizotypy (a word I’ve never even come across until today!).
I’m sure you can cook something interesting by taking a part of one recipe and throwing in aspects of two other recipes to come up with your own unique dish. And this may be a good model for creativity in a chef.
But in the world of personality and psychological theory, this seems like a very odd and haphazard way to reorganize the diagnostic system for personality disorders that has been the same for nearly three decades.
I’m not alone in thinking this may not be the best idea the DSM-5 folks have ever had:
“They have little appreciation for the damage they could be doing,” [Dr. John Gunderson told the New York Times. …]
“It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”
He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient. […]
The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians.
Indeed, there are some concerns with breaking disordered personality into what seem like fairly arbitrary dimensions — and more of them — complicating the already complex multiaxial system the DSM already uses for diagnosis.
I think Jonathan Shedler, a psychologist at the University of Colorado’s Medical School, hit the nail on the hear with this quote:
“Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.”
He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”
There is an ongoing disconnect between researchers — who rarely engage in clinical practice — and clinicians — who actually have to use the researchers’ categories and paradigms in daily practice.
Of course, the DSM-5 folks suggest their workgroups have equal and adequate representation of all parties on them. Yet this is a stinging example of where it seems that the clinician’s point of view is simply not being heard.
While practice should not rule out good science, good science should also take into account good practice and what’s done in the real world. Foisting a new trait-based system onto clinicians while removed half of the existing personality disorders from the new edition is likely to cause more problems than it solves.
Read the full article: Narcissistic Disorder to Be Eliminated in Diagnostic Manual
40 comments
I am finding this move by DSM to remove NPD to be almost unbelievable. I say almost because it seems that DSM is whitewashing and cleansing everything of vital importance especially forensically related, from its pages. Where do we see Psychopathy now in DSM? We see it being labeled under the same heading as antisocial personality disorder, and the two are used interchangeably. They are not the same, not all APD are psychopathic, and vice versa, but there is an overlap of symptoms. It doesn’t even seem rational, to not list NPD, one wonders if there is some recognition of the syndrome amongst the ‘committee’ who are re-writing the ‘rule-book’ so to speak.
Try telling all this to the people who have to live with the malignant narcissist, or have been the victim of one over a period of time. They will laugh in your face. Sorry DSM guys, on this one you are making a big mistake.
Narcissistic Personality Disorder out, Introversion In???? What’s this world coming to?
What does this say about the DSM-V PD workgroup members’ personalities?
“The central requirement for N.P.D. is a special kind of self-absorption: a grandiose sense of self, a serious miscalculation of one’s abilities and potential that is often accompanied by fantasies of greatness.” (Zanor, C., November 29, 2010. NY Times, link above)
Or are they in cahoots with the guys on Wall Street?
The Five-factor model of personality has a great deal of research behind it. It is a much more flexible way of delineating personality strengths and limitations, rather than trying to force people into 5 or 10 rigid yet significantly overlapping diagnoses. Given that the most common personality disorder diagnosis is NOS (not otherwise specified), the DSM personality disorder categories might be said to have very questionable validity with the exception of borderline personality disorder.
The critique of the dimensional approach to understanding personality is absolute bunk!!! Dimensional evaluation is the ONLY logical way of assessing a unique individual’s personality!!! The pigeon-holed diagnoses of the DSM-IV are restrictive at best and indicate limited understanding of the UNIQUENESS of individuals, something you practitioners seem little interested in!!!! But teachers and researchers apparently understand this since we are not dependent on ridiculously specific diagnoses in order to be paid by Big Insurance! Your entire “rebuttal article” is absurd.
Excuse me.
Angry Introvert or someone else:
Could someone please explain to me this comment about “introversion” being included in the Manual for MENTAL DISORDERS?
As quoted by Angry Introvert:
“Narcissistic Personality Disorder out, Introversion In????”
Just because Extroversion is the dominate of these two STYLES in the USA, what on God’s green earth would make it be constituted as a Mental Disorder?
that’s like saying that SENSORS in the Myers-Briggs system have mental disorders while Intuitives don’t or, given the dominance in the USA (again), vice-versa.
It would be appreciated. Thank you.
as i just said in reply to mark-i have had a doctor who let me read the dsm-i was confused as i had been diagnosed as a child-as schizophrenic-with add-(now adhd)-then manic depressive-then borderline personality-and for the past 5 years bipolar 1-that damn little blue book had all the same symptoms listed for each disorder-and subsequent diagnoses and treatment-they might as well close their eyes and stick a pin at random in their bloody dsm-let’s all play a game of psycho-pin the tail on the donkey
Alan’s comment “But teachers and researchers apparently understand this since we are not dependent on ridiculously specific diagnoses in order to be paid by Big Insurance!” is interesting to me since 2 of the “teachers and researchers” on the personality disorders work group may have nice royalties from the psychological tests the SNAP-2 and DAPP-BQ if the trait and facet structure that is proposed goes through. As is noted it is not the Five Factor Model they have proposed for DSM-5, it is a hybrid, hodge-podge of theories thrown together in a compromise which are now referred to as “The Pathological Five.”
How was the Work Group chosen? Were they volunteers who knew each other and what their orientation was going to be regarding the personality disorders? Or were they asked to participate because of their reputations for objectivity and critical thinking? If the first, we’ve got problems, right here in River City; if the second, we need to review their discussions and understand why they came to the conclusions they came to. Maybe they have come upon a system will work well and in retrospect we will see the value of the changes. If not, the number of people who will be adversely affected by the changes will be too many to know or count. Be careful. First do no harm.
Narcissistic out, introversion in? Surely that is not true. What’s wrong with being an introvert? But then again, this is the same manual that used to include homosexuality as a type of mental illness.
Why not make extroversion a disease? Symptoms: loud, energy-sucking, dependent on others for motivation and stimulation, pushy, poor listening skills… oh, I could go on and on…
I was diagnosed with NPD earlier this year because I referred myself to a psych for help in dealing with a large, unexpected career change. I’m not self-centered; I care about my wife and family more than myself, but in order to care for anyone else one must care for their self as well. I don’t have a grandiose sense of self, nor do I have any serious miscalculation of my own abilities for that matter. I know what I’m capable of, but I wouldn’t have known had I not pushed myself to those limitations in the first place. I’m going to keep pushing myself because I have a naturally driven desire to accomplish things and to increase my knowledge of the world around me, which are things that make my family and I happy. Isn’t that what this country is about…the pursuit of happiness? Isn’t that how this country was formed? Isn’t competition a normal human trait? Isn’t that capitalism? Isn’t that why we have been such a successful country? Narcissism is just a BS diagnosis that puts a label on people who are competitive, purpose-driven perfectionists. I am obviously one, but I realize that nothing is perfect; perfection is an opinion. So I’m basically being told that I have a personality disorder for having strong opinions and because of my competitive nature? The board is making a good decision in my opinion…thanks!
This debate among the so called experts makes the profession look like a laughing stock. Where is the credibility? The clinicians’ input should have had much more weight. What about those who had previously been diagnosed with one of the 5? Are they suddenly cured? It seems this was not well thought out and they just threw something together called trait dysfunctions. What kind of medical diagnosis would we arrive at if we just looked at the symptoms and had an ala carte way of treatment? Of course individuals are unique, but there are prototypes for rendering effective treatment for a particular “disease” and they can be altered according to the individual’s needs. This situation needs to be amended before the whole profession looks like a joke and the public turns away from getting help. Too bad it isn’t as easy to remove narcissism from the work-group as it is the DSM.
Really baby boomers? There is no such thing as narcissim. Ok.
An ENTIRE generation living off the greatness of their parents and the innovation of their kids who have done absolutely NOTHING to contribute to society, who have shirked all responsibility in favor of fun and feeling good- no wonder it is pointless to continue diagnosing narcissim.
My only solace is that one day we will be running the nursing homes and handing out the diagnosises as you eek out your pointless and unnaturally long lives and you know what? Narcissim is going right back in there! You are like a plague of locusts feeding on fields and then each other until nothing is left for any living thing and then you move on to the next field
wow!
Every generation seems to let succeeding generations down and the new generation all to readily see their faults. Baby boomers have a measure of narcissism and Gen X and Y even more so, in part due to boomers’ failures as parents and the non-accomplishment reality TV celebrity culture that now dominates. Lets hope Gen Z have less to complain about, however unlikely that may be.
“Narcissistic Me” your comment screams narcissism. Just because DSM is no longer acknowledging it doesn’t mean you aren’t one. I feel sorry for your family.
To: Narcissistic Me, posted 12-04-10
You are the very example of why this distinct personality disorder needs to remain in the Manual of Mental Disorders. There is NO comparison to a narcissist, and to not have this specifically laid out in the upcoming manual is to do an injustice and disservice to all. Maybe you have to know one to realize how unique these people are, and the futility of maintaining any type of ‘relationship’ with them. It truly is me, me, me, and what you do to me, me, me. I was watching Beverly Hills Wives, and Camille Grammer is a perfect example of a narcissist. You sir, are a prime narcissist and will never understand your disorder; it is beyond your comprehension and I would urge your family members to run, not walk, away from you.
The guy is married and if there is talk theropy and he can ask for help, he shoud before some-one gets hurt
as someone who has been deeply hurt by a loved one with this disorder, i hope people with NPD are still able to get the help they need. I don’t believe any child dreamt of becoming a narcissist when they grow up.
I don’t understand how it can be just deleted as a diagnosis. While some of the personality disorders scheduled for deletion overlap others left behind, the only disorder left similar to NPD seems to be antisocial.
As a paranoid person(I do know people even moreso) who knows and enjoys some narcissists, I can’t be honestly objective.
But part of me is thinking, “Whew! So despite years of shaming by our doctors/family, we are not really pathological?” A liberating thought.
However, it could just be the big business lobby: All those CEO’s who think they deserve 50X the minimum wage and are also paranoid.
I will follow this debate with enormous amusement.
But seriously, we feel that the more information, the better, so this new prescription for an a la carte analysis is more descriptive, less judgmental and more likely to encourage a precise + succesful treatment.
In the real world, people are different(with many varying responses to(and need for), meds(or even no meds at all); and it is my experience that people don’t really conform to stereotypes.
I believe the new adaptations are showing that the approach of the mental health factions is falling apart. Too long have they developed a theory that sounded rational at first, then forced diagnosis and treatment to conform to that theory. The theories were just repeated sooo many times that people start to believe them as gospel. I especially have seen this when it comes to OCD, bipolar, depression, ADD/ ADHD, and borderline diagnosis and treatments. The theory often is in either adjacent or complete contrast to classic proven theories. Instead, the dysfunction is blamed on “genesâ€, chemicals, or diet. Then “remedies†are created backed by imprecise or unfounded thin science.
For example, this guy Freud came up with this model of a personality that seemed to work. “If Id and Super Ego are in complete indecisive conflict, the result is anxiety and eventually depression.†SO, the professions answer is to produce a drug that incapacitates the Super Ego. Great, no more anxiety and depression. Then everybody sits around scratching their heads trying to figure out why some many people are displaying manic type behaviors. Instead of somebody saying, “hey, what is there something causing these behavioral traits? We do have a decade of research from people like Milgram, Pavlov, and other less known pioneers. Why not incorporate what they taught us?â€
It seems that there was a book written in the late 80’s called “I Hate You, Don’t Leave Me. Understanding the Borderline Personality†(I am sure there are many other books) in which an entire chapter was dedicated to “the Borderline Society†where an explosion of these behavioral traits and the resulting problems were predicted. Yet nobody is standing up and saying, “Hey, all this divorce, single parenting, joint custody, both parent working, day care raising is causing us to loose our feelings of security.†Instead, they will adjust the way things are labled and create a new drug to treat it.
I am a system designer, Not a mental health professional. If we approached system design the same way we approach mental health, we would still be riding horses.
Insightful comment.
We do seem to be creating problems in each new generation with increasing numbers of people with certain personality problems. Rather than simply trying to fix those sufferers up with drugs and therapy we really do need to start thinking about why some of these problems seem to be becoming more prevalent.
After being tortured by a malignant narcissist for 2 decades, I find it horrific that this diagnosis will no longer exist. Removing this as a disorder is so dangerous for the victims and survivors. We need a way to spot them and avoid them. Without the diagnostic criteria and literature available on the disorder, I may have very well lost my life. Is there a contact number or address for this work group making the decisions? If enough people scream loud enough about this, maybe it can be changed.
I don’t know whether to laugh or cry… I googled NPD to try to remember if my therapist (who is treating me for PTSD stemming from child abuse) said my abusive mother was NPD or BPD… and after reading both definitions and deciding, oh yeah, he said NPD, I stumble upon this. Guess that’s why I can’t find it in the DSM online??? What a disservice to those of us horribly abuse, manipulated, lied to and the target of the physical rage of someone with NPD. I’m afraid GenX and Yunite might be right… this is just more BS lowering the bar and making the very tormentors feel good about themselves. Sounds like a really arbitrary, convenient move – kinda… narcissistic, even? And yes “Narcissistic Me” – you are NPD. My God, the word “Me” is in your name on here!! Besides, your comment smacks of self-adoration, feeling “special” and entitled to pursue your self-declared “talents,” probably at some huge sacrifice to your family (I bet you don’t even live with them right now.)… Of course, this is all just a hunch (rolls eyes…) Get the help you need and listen to the doctor before you lose everything. My mother is losing her adult child little by little, and she doesn’t even know it. If I could tell her, I would but I tried before and she explodes (how unexpected :-/)… NPD destroys relationships, scars victims at the will of their abuse (like their children) and is ABSOLUTELY pathological. If it doesn’t keep the title NPD, it will resurface as something else. Make the name disappear if you must, but the disorder will not!!
And by the way, if my childhood abuser suddenly doesn’t have NPD, does this mean I can stop seeing my therapist, because I suddenly don’t have PTSD? Lunacy!
Re: Lilia \ MCP \ Guessallarewinners
Tisk, tisk – tisk…
=]
This kind of shows the politics in mental health. Now i won’t generalize there are psychiatrists and psychologists out there who do it for the passion and to make a difference in the lives of people. Whether they have a psychotic illness, or just mild symptoms of a personality disorder or stressful time of life. But eliminating whole disorders which those diagnosed came under a list of the specific behaviours to extreme labelling them as that disorder is a bit of a slap in the face to them & psychology just being another business.
You can’t eliminate physical disorders so why mental disorders ? I do know most people have narcisisstic or most women can have histrionic tendencies and more times then not they have another disorder and the symptoms from those PD are just running comorbidly with them. But what if there are people who are just those and so obviously and are harming the lives of others, or themselves ? They will still need to be treated as what they were and undergo therapy for that.
Mental disorders are so frequently handed out to people because in this day and age and society everyone has symptoms of mental disorders and stress. Everyone has anxiety or feels down at times or can become selfish. But i think thats more the diagnosis been given out to easy rather then needing to eliminate disorders.
Although i do agree with the fact everyone has narcisisstic tendencies. We all need our self esteem boosted at times, we are all selfish and walk some kind of vain image, we all daydream at sometime or envy something. Maybe not once our life is satisfied or fufilled… but when younger it is so easy to do. Look at society and its standards set so high or the amount of famous celebrities that take the spotlight. We are constantly tempted with how to win money, what to buy for ourselves and what we can do for ourselves etc.
But i think when it becomes so bad a person has no control over hiding their daydreams, they care for nobody at all not even family or friends or know how to change their personality around appropriate situations, or they start hurting people to get what they want without caring then its bad and it needs therapy or controlling.
It appears that the APA has reversed their decision to drop NPD from the DSM V; http://www.dsm5.org/Newsroom/Documents/DSM-5-Revisions-for-Personality-Disorders-Reflect-Major-Change-.pdf.
The press release if dated July 7, 2011.
So does this mean that Narcissists, Paranoids, Schizoids and other such most crazy people will be considered sane? This is indeed disturbing, more so for people living with such personalities. Where do they go now or do these relationships end right away without any hopes of recovery?
The problem with this disorder is it has been overused in the military. It is the first thing they label patients when they walk in the door. I do know this disorder exists because I have seen it in people. Although you don’t tell people that have seen a lot of death that the reason they are depressed is because they don’t care about anyone but themselves. This disorder is a life long issue not a temporary issue and it has been used to diagnose people with temporary depression problems and than used as a way too not have to treat the patient.
There is a difference between histrionic or narcissistic tendencies and having a Histrionic or Narcissistic Personality Disorders. To be diagnosed with these disorders, you must have at least 5 of the characteristics from the DSM-IV-TR.
I assume to be diagnosed as Introverted or Extroverted Personality Disorder from DSM-V you will also have to have a certain amount of the characteristics. A lot of disorders everyone can relate to at times. However, a disorder is usually something that affects someones life daily.
However, I’m not sure Histrionic and Narcissistic Personality Disorders should be removed.
I’ve been interested in personality disorders since the early 70’s when I started work on a psychiatric ward and realized that there is something inherently wrong with how the term is used. Later in my career I learned about dimensional models and saw that they are inherently far more accurate than the DSM “pigeonhole” model.
The problem I have with the new proposed changes is the extent to which they rely on Millon’s Big Five. Millon’s Big Five has no supportive theoretical underpinnings, nor is it derived from clinical experience, but (unless I am mistaken) is based instead on surveys of what the normal population sees as “abnormal.” I think that approach is highly idealistic to the point of being hopelessly naive.
The Personality Circumplex model has far greater accuracy and flexibility, as far as I am concerned. It’s one drawback is that it takes time to learn. I am disappointed that clinicians are not interested in taking the time to learn a clearly superior model, but would prefer to cling to the familiar. Narcissistic? Obsessive Compulsive? Clingy and Dependent? No, I didn’t apply any of those pigeonholes to clinicians, did I?
I agree with what they are doing anecdotally when I look at myself I have 2 big issues that explain me however I could easily be interpretted another way by other therapists because the DSM IV has a lot of characteristics for each personality disorder that can fall into/lead into another diagnosis. My question is are they deciminating those characteristics that are common in the remaining PD’s ? An example it is easy for one to see A BPD and think NPD however the BPD can be either low functioning or high functioning. If they can truely tell me what came first the chicken or the egg I would truely appreciate it.
Nice analysis John. Too bad they don’t wait until they’ve got a nice body of decent research results before inventing these categories (which is what they seem to be doing).
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