Narcissistic personality disorder to be eliminated from Diagnostic and Statistical Manual of Mental Disorders

From The NY Times:

Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species.

Not that they face imminent extinction — it’s a fate much worse than that. They will still be around, but they will be ignored.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition.

Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.

Most nonprofessionals have a pretty good sense of what narcissism means, but the formal definition is more precise than the dictionary meaning of the term.

Our everyday picture of a narcissist is that of someone who is very self-involved — the conversation is always about them. While this characterization does apply to people with narcissistic personality disorder, it is too broad. There are many people who are completely self-absorbed who would not qualify for a diagnosis of N.P.D.

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. It is the difference between two high school baseball players of moderate ability: one is absolutely convinced he’ll be a major-league player, the other is hoping for a college scholarship.

Of course, it would be premature to call the major-league hopeful a narcissist at such an early age, but imagine that same kind of unstoppable, unrealistic attitude 10 or 20 years later.

The second requirement for N.P.D.: since the narcissist is so convinced of his high station (most are men), he automatically expects that others will recognize his superior qualities and will tell him so. This is often referred to as “mirroring.” It’s not enough that he knows he’s great. Others must confirm it as well, and they must do so in the spirit of “vote early, and vote often.”

Finally, the narcissist, who longs for the approval and admiration of others, is often clueless about how things look from someone else’s perspective. Narcissists are very sensitive to being overlooked or slighted in the smallest fashion, but they often fail to recognize when they are doing it to others.

Most of us would agree that this is an easily recognizable profile, and it is a puzzle why the manual’s committee on personality disorders has decided to throw N.P.D. off the bus. Many experts in the field are not happy about it.

Actually, they aren’t happy about the elimination of the other four disorders either, and they’re not shy about saying so.

One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.

Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how “unenlightened” the personality disorders committee is.

“They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment.

“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.

This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile.

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.

It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type.

And 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.

Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “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.”

Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients.

Given the stakes, the blow-back from experts in personality disorders should come as no surprise.

Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching.

Right now, this much seems clear: It is way too early for the narcissists to give up their seat on the bus.