Taking it Personally: The DSM-5 and the Narcissism Controversy

I'm back into mucking out my Augean Stables, otherwise known as updating my mcmanweb site. I have a number of great pieces (at least I think they're great) lined up for this blog, but, in the meantime, from the vaults of "Knowledge is Necessity" (Dec, 2010) ...

A few weeks ago, the NY Times featured a piece by psychologist Charles Zanor entitled, A Fate Narcissists Will Hate: Being Ignored. The long and short of it is that narcissistic personality disorder will be axed from the DSM when the next edition is published in 2013. Imagine how your average narcissist must feel.

The article mentions that retiring the diagnosis has drawn the wrath of clinicians, who view the various committees of the DSM-5 as dominated by academics out of touch with reality. John Gunderson of Harvard, one of the leading authorities on personality disorders, called the decision “unenlightened.”

Actually, overhauling the entire field of personality disorders is probably the only thing those charged with the DSM-5 did right, though with reservations. A little background:

In this post-Freud era of biological psychiatry, “Axis II” personality disorders have been accorded a lot less respect than “Axis I” disorders such as depression, bipolar, anxiety, or schizophrenia. A cynic would say that is because there are no meds for Axis II disorders and they would be one hundred percent right. The upside to this is there has been no big pharma to call the shots. It is no coincidence that the only major reforms to the next DSM occurred in the one realm where pharma is conspicuously absent.

The first obvious change is no Axis I/Axis II distinction. Personality disorders will get the same billing as mood disorders and anxiety disorders and all the rest. The next obvious change is a new “dimensional” component to complement the “categorical” classification of personality disorders, something that should have been done with mood disorders and arguably the whole rest of the DSM.

In its background papers and rationale, the APA and the DSM-5 group note that separating out personality into discrete illnesses has generated no end of end of clinical confusion. Is someone who abruptly breaks off a friendship, for instance, an “antisocial” with no remorse, a “borderline” who can’t cope, or a “narcissist” who cares only about him or herself?

Clinicians typically hedge their bets by choosing more than one, or by tacking on the NOS (not otherwise specified) qualifier.

The dimensional view acknowledges the complexity and subtlety of personality. Instead of asking “which one?” at the expense of ignoring whatever else may be going on, a clinician would be asking “how much” and “how severe?” In a sense, psychiatry is bringing back neurosis, but with some important refinements.

The personality disorders we are most familiar with are grouped into “Cluster B” in the current DSM. They include borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The next edition of the DSM will give narcissistic personality disorder and histrionic personality disorder the boot, and prune out a number of other disorders from clusters A and C as well, leaving us with five “personality disorder types,” including antisocial/psychopathic, borderline, avoidant, obsessive-compulsive, and schizotypal.

According to the rationale provided in the draft DSM-5, three of these types have the “most extensive empirical evidence of validity and clinical utility.”

Here’s where the dimensional component would come in. The draft DSM-5 proposes testing for six “trait domains” that would include:

1. Negative Emotionality (such as depression or anxiety).
2. Introversion (such as social withdrawal and intimacy avoidance).
3. Antagonism (such as callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, and deceitfulness).
4. Disinhibition (such as impulsivity).
5. Compulsivity (such as risk aversion).
6. Schizotypy (involving odd behaviors and cognitions).

These trait domains are based on well-established personality tests such as the five-factor model and Cloninger’s psychobiological model, and would seek answers (note the plural) to such life mysteries as why an individual would abruptly break off a friendship.

Sounds good in theory, but are clinicians too set in their old ways? As the NY Times notes:

Clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Sounds a bit narcissistic to me, wait, I mean - uh - never mind.

Much more to come ...