Abolish Narcissistic Personality Disorder (NPD) in DSM V?

Uploaded 12/4/2010, approx. 5 minute read

My name is Sanda. I am the author of Malignant Self-Love, Narcissism Revisited.

In 1997, three years before the current version of the Diagnostic and Statistical Manual was published, I proposed to abolish the diagnostic category of narcissistic personality disorder altogether. I suggested that since at the root of all personality disorder there is a common psychodynamic process, all personality disorders should be united into a single diagnostic category.

So a person would be diagnosed with personality disorder, with certain emphasis or certain traits. Personality disorder with narcissistic emphasis, personality disorder with antisocial or psychopathic emphasis, and so on and so forth.

Close to 15 years later, a committee that is now compiling the next edition of the Diagnostic and Statistical Manual, Edition 5, seems to have taken notice. They propose to abolish a few personality disorders and lump all of them together into a single diagnostic category. That is a welcome development.

The Diagnostic and Statistical Manual, the current edition, the fourth edition, text edition, is published in the year 2000. It describes access to personality disorders as deeply ingrained, maladaptive, lifelong behavior patterns.

But the classificatory model that DSM has been using since 1952 is harshly criticized as woefully inadequate by many scholars and practitioners. The DSM is categorical. It states on page 689 that personality disorders are qualitatively distinct clinical syndromes, but this is by no means widely accepted.

As we saw, the professionals cannot even agree or must constitute normal, and how to distinguish normal from disordered or abnormal. The DSM itself does not provide a clear threshold or a critical mass beyond which the subject, the patient, should be considered mentally ill or mentally disordered.

Moreover, the DSM's diagnostic criteria are polythetic. In other words, suffice it to satisfy only a subset of the criteria to diagnose a personality disorder in a patient.

Consequently, people who are diagnosed with the same personality disorder may share only one criterion or even none. And this diagnostic heterogeneity, this great variance, is unacceptable, not to mention non-scientific.

Elsewhere, I've dealt with the five diagnostic axes employed by the DSM to capture the way clinical syndromes such as anxiety, mood and eating disorders, general medical conditions, psychosocial and environmental problems, chronic childhood and developmental problems, and functional issues interact with personality disorders.

Yet, the DSM's laundry lists obscure rather than clarify the interactions between the various axes. As a result, the differential diagnosis that are supposed to help us distinguish one personality disorder from all others, this diagnosis, differential diagnosis, are vague. They are equivalent.

In psych parlance, the personality disorders are insufficiently demarcated. This unfortunate state of affairs leads to excessive comorbidity. In other words, multiple personality disorders are very often diagnosed in the same patient.

For instance, people with antisocial personality disorderare also very often diagnosed with narcissism, narcissistic personality disorder, or borderline personality disorder. This is an unhealthy cocktail, a mixture which proves that the DSM is unclear, equivocal, ambiguous and vague.

The DSM also fails to distinguish between personality, personality traits, character, temperament, personality style, and full-fledged personality disorder. It does not accommodate personality disorders induced by circumstances, reactive personality disorders.

For instance, Millman's proposed acquired situation of narcissism, whereby someone is rendered narcissistic for a limited period of time or into life circumstances.

The DSM also doesn't efficaciously cope with personality disorders that are the result of medical conditions, such as brain injuries, metabolic conditions, or protracted poisoning. The DSM had to resort to classifying some personality disorders as not otherwise specified.

In other words, this is a catchall, meaningless, unhelpful, and dangerously vague diagnostic category.

One of the reasons for the dismal state of the taxonomy is the dearth of research and rigorously documented clinical experience regarding both the disorders and various treatment modalities.

The DSM's other great failing is that many of the personality disorders are culture-bound. They reflect social and contemporary biases, values, and prejudices. They do not reflect authentic and invariable psychological constructs and entities which have withstood the laboratory test. They reflect the biases and prejudices and value judgments of the psychiatrists and psychologists who set on the committee that compose the DSM.

The DSM-4 distances itself from the categorical model and hints at the emergence of an alternative in the DSM-5, the dimensional approach.

It says on page 688, an alternative to the categorical approach is a dimensional perspective, that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and also into one another.

Now that's a helpful approach because it reflects reality far better.

The new scientist issue of December 2009 had this to say, one aim of the workgroups compiling the DSM-5 is to cut through these scales.

They are streamlining diagnosis by removing various subtypes of schizophrenia, for example, and they intend to address the confusion created by the fact that many people with one condition meet the criteria for other disorders as well.

The DSM-5 task force is expected to propose a series of dimensions to be considered with a patient's main diagnosis. As well as deciding whether someone has, say, bipolar disorder, doctors will determine whether they are suffering from problems such as anxiety and sleeping disturbances and assess them on a simple scale of severity.

According to the deliberations of the DSM-5 committee, the next edition of this work of reference, due to be published in 2013 or 14, will tackle these long neglected issues, the longitudinal course of the disorders and their temporal stability from early childhood onwards, the genetic and biological underpinnings of personality disorders, the development of personality psychopathology during childhood and its emergence in adolescence, the interactions between physical health and disease and personality disorders, and the effectiveness of various treatments, top therapies, as well as psychopharmacology in treating personality disorders.

Whatever happens, the DSM-5 is bound to be a major improvement over the murky state of things with regards to personality disorders in the DSM-4.

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