Narcissistic Personality Disorder to be eliminated from new DSM?

[CB123]

Here's one guys take on it.  Collusion with the pharm companies?  Hmmm.  Wouldnt surprise me.

http://www.psychologytoday.com/blog/do-the-right-thing/201012/the-end-narcissistic-personality-disorder-say-it-aint-so

CB

[JustKathy]

Collusion with the pharm companies wouldn't surprise me at all, as Ns never seek treatment, and even if they did, there's is no medication that can help them. However, my doctors have tried every antidepressant on the shelf as a way of treating ME. Victims of Ns who suffer from anxiety and depression will continue to suffer regardless of whether or not NPD remains in the DSM, so the pharm companies will continue to profit from the victims. You won't see clinical depression or GAD coming out of the DSM anytime soon.

If I say Narcissist, everybody has a preconceived notion of what that means TO THEM, usually something silly.

I get that reaction too. "Oh, your mother is like Kim Kardashian?" The press has made a mockery of a very serious disorder.

My T told me that my mother also has sociopathic tendencies, so I may start to use the word sociopath instead. I like your idea of "Interpersonal Psychopath Disorder." That term sounds very fitting. It sounds like they don't plan on finding a term to replace NPD, though. The original article suggests that psychiatrists will be taking an individualized approach, so we all may get different responses. Regardless, NPD has been in the DSM for 30 years, countless books have been written on the subject. It's not going to just go away and stopped being discussed, not by victims OR professionals.

[debkor]

I would like to know if they are to change it to (personality disorder) with narcissistic traits .. (would that confuse victims) and they would still think there is (chance for change) and keep Hope! 

What are the other disorder's they are going to drop?  There were 5 but most upset over NPD.  Why is that? 

Love
Deb

[JustKathy]

I'm wondering the same thing Deb. I haven't seen any mention of the other disorders that were dropped. Wonder what they are, and why no one is upset about those ones being omitted.

[Guest]

...other disorders to be dropped, see: http://psychcentral.com/blog/archives/2010/11/30/personality-disorders-shakeup-in-dsm-5/

..Paranoid, Schizoid, Histrionic and Dependent Personality Disorders are to go. So.....what will sufferers of Dependent Personality Disorder do? (Sorry, that *is* a bad joke.)

Seriously, we have a long long way to go in talking about other people's minds, however we might label them.

Isn't Asperger's going to be dropped too?

[sKePTiKal]

Aspberger's - as I understand things - will be rolled back into the autistic spectrum; a subcategory.

I keep thinking about this, obsessive that I am! And it still bothers me and I'm still not sure that if I was asked to vote yea/nay on this, if I could boil it down to something that simple.

A couple of the things:

4 out of the 5 disorders - the "qualifying list of symptoms/criteria" to be diagnosed with the disorder - all are emotionally abusive and can seriously impact people in relationship with them; particularly children who really can't "go NC" without serious repercussions. What are they thinking removing descriptions of specific kinds of abusers??

As far as my limited knowledge of it goes, the DSM doesn't identify any diagnostic/therapeutic set of criteria for ACONs, ACOAs, etc. and yet I know from my experience - and the stories of many of us here (and elsewhere) - that there are certain characteristics we have in common - in large enough numbers to define it as a subset. And more importantly, many of us have needed therapy to start the healing process - expert reparenting, help with depression & anxiety etc that is a direct result of the disorders - specifically, the recognized patterns of effect on others (abuse) - which are being removed, generate. And wouldn't it be easier for both therapist and patient, if these patterns had an "official" set of diagnostic criteria?
--------
I have a hard time understanding - accepting - that a diagnostic tool such as the DSM, would be subject to a revision, which seems to have no more basis than to "not stereotype" or "profile" people - i.e, applying political correctness where it can do real harm. Not all profiling or typing is BAD... there are valid, useful and lifesaving reasons for it, when used appropriately. If it's not broken; don't try to "fix" it.

There are lists of symptoms which are used to diagnose a cold, sinus infection or flu; there are overlaps on those lists as well as significant differences. The lists aren't intended to be a replacement for observation or investigative testing; but they are generally correct a high enough percentage of the time that even ERs and Trauma teams use the same kind of checklists to save time - and lives. Checklists are important ways of organizing information... and the DSM is just one big checklist.

I mean - in human terms - how can we teach people to recognize an abuser without a defined list of characteristics? And what unintended consequences does this begin to create... are the folks supporting the "dimensional" approach to diagnosis really intending to validate and accept people who are untreatably abusive? (and we know they exist) You can't - in reality - pretend these people do not exist, by simply removing the definition of what those people are/aren't.

You can't teach a kid what a bully is, without a defined set of characteristics. So how would they ever know they were being bullied? How do you ever teach the bully, that what they are doing is wrong - and why? Simple punishment doesn't correct the behavior.

I think this move to remove these categories, simply blurs the lines even more and unavoidably provides an unwarranted acceptance of certain behaviors under a dispersed collection of personality attributes. That could prove to be - in 3-D reality - quite dangerous - even life threatening - to people in relationship with those kinds of non-typed "patients".

Sorry this is so long and kinda rehashes things yet again. I had to put down the pieces that I can't get to "fit together" and make sense.

[Dr. Richard Grossman]

Hi Hops (and everyone),

This is such a great discussion with so many terrific points made, I didn’t want to butt in…But here are some of the important questions being raised:

What is the purpose of the DSM as far as personality disorders are concerned particularly the ones such as NPD that are very difficult if not impossible to treat?  Are they useful to clinicians—or just insurance companies?  Should it matter, DSM-wise, if the personality disorders are useful to those who have been afflicted by parents, spouses/significant others, siblings, friends, etc. who have the disorder—if the purpose of the DSM is simply for professional use?

And concerning narcissism in particular:

Isn’t the trait a continuous variable with human beings having very little (many of the the chronically depressed) to some (healthy narcissism) to a lot (such that it dominates interactions with other people)?  And if it is, where is the diagnostic cutoff point?  And furthermore, given the continuous nature of the trait, and given that most people have some, anyone can call anyone else narcissistic and be correct.  (Anyone want to read or re-read Dawkins’ The Selfish Gene?!!!)


Furthermore, some people with high levels of narcissism exhibit other personality disorder traits.  Such that diagnoses are at some times almost random:  “Borderline Personality Disorder with Narcissistic and Paranoid features” or is it “Narcissistic Personality Disorder with Borderline and Paranoid features”?

Furthermore, different people have different narcissism meters.  I am extremely sensitive to it—and have always been (the reason I started this site).  But other people I know, including clinicians, don’t see it, hear it, feel it around them.  Instead, they see other aspects of people’s personalities—perhaps those aspects that particularly bother them.  Having trained in the Harvard Medical School and psychoanalytic community, I felt that narcissism abounded.  But others didn’t see it, feel it, question it—or it simply did not matter that much.  And I always thought to myself:  what if the clinicians are diagnosable?  Then the world is truly mad!  (One of the 10 minute plays I submitted to the Boston Theater Marathon this year is on this theme.)

I’ll stop here, and perhaps offer some of my own personal answers to these questions later on…

Richard

[Guest]

Dr G
I often think to myself:  the clinicians are diagnosable. I mean it. Not that I know, or know of, many (thank goodness). But then so are many people in positions of 'authority': by the nature of the job, nutters are attracted to positions of power.

We don't like black and white thinking but heck, sometimes the world divides easily for me between Givers and Takers. It's an easy distinction for me, but then I don't overly crave fame or power etc. But then we're all 'takers' in a competitive survival of the genes way. Or are we?

If the DSM is used in law (as it is, by professional expert opinion?) then I guess it matters to the victims...or maybe not. The most important thing is behaviour, not the diagnosis label, I would think. Oh and justice too!

Humans are necessarily nuts though. If we weren't, we wouldn't survive.

[sKePTiKal]

I'm looking forward to your thoughts about the questions you posed, Dr. G!

I'm still flip-flopping around about how I feel and what I think about all this... so I'm not sure I'm even making sense to myself. Every time I think I've nailed it down... I remember something that was pivotal in my own experience or something someone else struggled with that required being able to hold up a "bad guy" - to be able to work through it and get past that level of understanding about ourselves.

Having the NPD spectrum of characteristics officially recognized in the DSM, enabled a lot of us to realize that we weren't the bad guys like we thought we were and freed us to proceed to the next level after "explanation and processing/understanding of what happened to us" to healing and seeing the possibility that one can eventually let go the concept of "bad guy and victim".

What changes in the therapeutic relationship if the "bad guy" is no longer so easily identifiable or definable?

[mudpuppy]

And furthermore, given the continuous nature of the trait, and given that most people have some, anyone can call anyone else narcissistic and be correct.

We all have some level of money, from two mites to wheelbarrows full of it. That doesn't stop us from noting correctly, that Carlos Slim is rich, but it also doesn't mean we have any conception of what it's like to have his wealth.

And I always thought to myself:  what if the clinicians are diagnosable?

Present company excepted, the few I've known have been.

Furthermore, some people with high levels of narcissism exhibit other personality disorder traits.

That would appear to be the primary good of the proposed new approach; assessing these people more accurately. It probably is not a good thing for those people, and their victims,  whose traits fit neatly into one of the current classifications.

Anyone want to read or re-read Dawkins’ The Selfish Gene?!!!

Not really. Apparently many evolutionary biologists who merely seek knowledge rather than celebrity or a soapbox have little use for many of Dawkin's ideas or his polemics.

So.....what will sufferers of Dependent Personality Disorder do? (Sorry, that *is* a bad joke.)

I thought it was a pretty good one.

mud

[sunblue]

Maybe I'm just extremely sensitive to this issue but for me there is no gray on this issue: in my view, NPD needs to be in the DSM.  It is only in the defining and labeling (even when those are working definitions and imperfect labels) of behaviors that results in the study, funding and treatment of disorders that emanate from a series of behaviors (in this case, those of the Narcissist.)  And my perspective is that one can say that ANY set of behaviors or type of mental illness can be viewed on a continuum---from depression to schizophrenia to bipolar disorder to narcissism.  By no longer including it in the DSM, the medical community is shouting out the message that Narcissism, as a set of behaviors, should not be taken seriousl---not in the Narcissist or those who victims of Narcissists.  Indeed, by excluding it, those of us who have sought or seek treatment for other conditions resulting from lviing a life in the Narcissist's world are being marginaliized.  I, for one, was extremely relieved and comforted when one psychologize I sought out pulled out his worn DSM and read off the characteristics of NPD.  Finally, there was documentation---and a medical one at that---that explained that what I was experiencing was real...and that there was an explanation for why the toxic people in my life behaved in the way they did. 

Diagnosing and treating mental illness is far from an exact science.  But just because some behaviors or disorders are more difficult than others to identify, diagnose and treat doesn't mean they are not valid, honest-to-goodness illnesses that should be studied, understood and treated.  Let's face it.  If a set of behaviors does not have a bona fide definition tied to it that is accepted by the general medical community, it will be dismissed, ignored and marginalized.  In the case of Narcissism, when that occurs, its victims will be further hurt and the Narcissists themselves will have little to no chance of improving their condition. 
If anything, Naricissism, at the far end of the continuum, seems to be rampant today.  It needs to be included in the DSM and more widely understand by both clinicians and the general public.  Treating it, diangnosing it and defining it may be a work in progress but it is one that must be pursued if we are interested in avoiding thelifelong damage Narcissism causes.  Clinicians aren't perfect and this disorder isn't one size fits all.  But to turn their back on this widespread and oh so damaging disorder would be detrimental to those suffering from it or because of it.  My advice to the clinical community?  Try harder.  Dig deeper. Work to better understand it and move the needle forward.  Now's not the time to give up.  The repercussions are just too all encompassing and damaging.  We can all attest to that on this board.

[sKePTiKal]

Mud - I've been thinking about what the defining characteristic might be on that N-continuum... and where to set it with an eye toward having a datapoint to use, to assess with some higher probability of correctness, the diagnosis of N.

What is one defining trait of NPD, that separates the disordered folk from those at the less engaged end of the spectrum (those that are simply Nish)? If we could say what this one (or more) thing is - and where it "crosses the line" from healthy to unhealthy - then we'd have that datapoint, which in fairness would only be a starting reference point. There would have to be a lot more "evidence" gathered... but it would suffice for a definition in the DSM, to "know one when you meet one". A definition need not prohibit the dimensional approach to treatment and to my way of thinking, works to support a basic working definition of NPD (vs "just" N) with much more detail.

I keep coming back to the idea of boundaries and control over others. An NPD at the fully engaged end of the spectrum may acknowledge that boundaries exist for them - but not see any reason whatsoever to respect other people's boundaries - because the NPDs goal in life is control over others, in support of the N's delusion of being more perfect, smarter/all knowing or more powerful than others. I think all the other things derive off of this - lack of empathy, sadism, etc. Someone with N-tendencies may still (when it suits them) actually respect some boundaries, in some situations. It's that delusion that one can control others, and that this is a good thing, that stands out for me as the difference between NPD and N.

I think this is recognizable enough - like your Carlos Slim example - to "know" when someone's NPD or when they merely have N tendencies... when they're comfortably well off versus wealthy.

MAYBE... It feels like I'm still missing a vital, probably obvious piece of the picture. But it simply doesn't make a lot of sense to me to remove a category/disorder... simply because people disagree on where to draw a line separating healthy/unhealthy. It's like the deal with categorizing grief as depression! Of course one's depressed when there's a loss in one's life... but there is a common sense distinction between "ordinary - natural" depression and the more serious levels of it, that persist and invade all areas of one's life. It's common sense - because it's simply obvious.

I don't know if my idea for a definition "works"... what does everyone else think? Remember the idea is to separate N from NPD... to "say" what the difference is.

[mudpuppy]

Hi  PR,

Doubt there is one defining characteristic of someone with NPD.
The grandiosity is one that seems pretty exclusive to them and psychopaths but it's also pretty hard to measure or even demonstrate to an outsider in and of itself.
The incessant lying and control freakishness are not exclusive to NPD and are sometimes shared by people narcissistic but without full blown NPD.
The one thing that might meet your criteria is the lack of empathy, but again that is pretty hard to measure or demonstrate to any third party. However someone with N traits but who also has empathy is certainly different in kind not just degree from the soulless, heartless thing that is an NPDer, who seems to me have crossed some type of bridge to another world of self absorption and indifference to others. To me the lack of empathy is synonymous with or a symptom of the utter lack of a conscience with these people. The lack of a conscience seems pretty similar in practice to the Anti Social PD and psychopathy, the only difference seemingly being the NPD's aversion to committing overtly violent acts. Instead they prefer control through primarily emotional and psychological abuse rather than the physical type although usually the ASPD and certainly the psycho are quite good at the psychological side of things as well.
  I've never been entirely sure where NPD ends and psychopathy begins and am not convinced there is a real difference, unless one defines it precisely as this line of physical violence. And I'm convinced that people with NPD only forego violence as a means of self preservation and would not have the slightest qualms about regularly knocking heads together if they thought they could get away with it, as can be seen in those who practice child abuse but no other violence, which is much easier to get away with and hide and carries much less risk of the victim's retaliation than violence toward an adult. Perhaps we could define NPD as psychopathy with a broad yellow streak? Or maybe psychopaths are NPDers who have learned to shed their inhibitions brought about by their overriding concerns of self preservation.

mud

[Guest]

Mud I'm finding I agree with most of what you say above.
Re " lack of empathy, but again that is pretty hard to measure or demonstrate to any third party." - but perhaps with MRI proof of differences in brains, especially regarding empathy and fear responses (of psychopaths in particular), we might be getting towards a way of measuring?
"people with NPD only forego violence as a means of self preservation " - is it possible that psychopaths don't care about self-preservation but feel similar to NPDs about violence, that is: they see no difference between themselves and 'others' so...if they're going to be violent (NPDs) they imagine that *they* will feel the violence?? Possible? And psychos just don't care how they might feel? Hmmm.

[sKePTiKal]

CB: I agree with you, that even without a name or DSM classification of just how my momster is disordered, that any T would be able to see the results of that kind of primary relationship on me. I think where I was going with all that was summed up succinctly by Hops - about the power of a "name". I am afraid that without a name for these people, that in the collective conscious, the model/pattern/concept will cease to exist... yet the momsters & popsters & abuse will continue their destruction, unacknowledged by society. Starting with the psychological community.

Thanks mud, for your thoughts! I admit that I'm going through what might be a futile "thought exercise". Where are the tools to quantify the criteria (and can we identify enough criteria that is consistent across many kinds of Ns?) of what an N is? Maybe Guest's suggestion of MRIs in identifying faulty neuro-wiring... but I'm not sure it's evolved to that point yet.

Your comment about yellow streaks, does give me another idea, tho. It tied in with the criteria of control over others - and that is, that I think NPDs are literally scared to death to feel anything, so instead they manipulate others into emotional states... through what I'll just call psychological warfare, for now... so that they can at least "see" what the emotions might look - might feel like. It's almost as if, in their quest to preserve their inner delusion of perfection... they dare not sully themselves with an emotion. It's too viscerally human. So they create the conflicts, wield anger or control like a club, trespass boundaries... all to externalize emotion so that they can then laugh at it, put it down, or put it under a microscope & study it... because it's completely foreign to them. They don't care that this is mean; it's how they continue existing. Like a form of self-preservation. They have to act on something outside themselves to "be" - to exist - to feel "real".

But, perhaps, that's only one form of NPD; maybe that's not even NPD...  I truly don't know. But like a lot of people, I would consult the DSM to find out where that description "fits" best. The DSM isn't simply an encyclopedia of symptoms for mental health professionals, anymore. It's become accepted as the authoritative dictionary of disorders and is how people have been able to mainstream ideas into popular culture about BiPolar, Depression, etc. Perhaps, that's not what it was intended to be... and there are certainly dangers inherent in the attempts to classify someone's behavior and "stick a label on them" by the general public. A quick tour through all the support boards on the 'net returns a lot of comments about the DSM this... the DSM that...

So the cat's out of the bag already... In a way, awareness of and attempts to understand mental health issues is a really good thing - overall and long term. I just don't see that popular culture can sustain a conversation or discussion long enough to deal with the subtleties or complexities... to do more than label - correctly or incorrectly. And the DSM is the tool that enables them to do this. So, taking away that "name" for this particular kind of disorder is, I'm afraid, going to lessen awareness of NPD and only add to overall confusion about where healthy N stops and turns into abusive NPD.

I'm not sure it should, but it does matter to me.

I've talked myself inside out & in circles, on this and I can't wait to read what Dr. G has to offer on this topic!