Proposed changes in the DSM-V

[CZBZ]

DSM-V

Perhaps some of you heard news stories about the new DSM yesterday? I was listening to an NPR interview about the proposed changes in the DSM-V due to be published in 2013. If you've been reading the 'sometimes' entertaining arguments between psychologists about DSM-V revisions, then you may find it extremely interesting that psychologists are offering the general public a sneak preview of considered changes. I'm not sure if this is a good or a bad thing...nonetheless, the elimination of Aspergers Disorder is causing a slight uproar in the public. It's my understanding that instead of a separate disorder, Aspergers will be part of the Autistic Spectrum.

I was very very interested in news discussions because psychologists are also considering eliminating childhood bipolar disorder. They are replacing this diagnosis with another diagnosis that they believe will improve clinicians treatment for patients with emotional regulation problems as children. Since my nephew was 'diagnosed' with bipolar and recently had his diagnosis changed, I am personally interested in how psychologists are treating his emotional problems.

As I find relevant articles about proposed changes in Personality Disorders, including the narcissistic personality disorder, I'll add links to this thread. If some of you have already discovered informative links, please feel free to refer members to those discussions or articles. For quite some time now, narcissism has been considered an inherent personality trait that is on a continuum. The NPD is often co-morbid with other disorders making it difficult to clearly distinguish what the N's problems might be. Without an accurate diagnosis, treatment may be less effective. Each of the cluster B disorders includes some degree of pathological narcissism which is another reason why having a separate diagnosis of NPD may not be useful or even inaccurate.

Narcissistic traits are a dimension of personality (unhealthy narcissism is notable during stressful situations, corrosive life experiences, etc. though not worthy of a NPD diagnosis). We have talked about the NPI as a measure of narcissism in all human beings, so perhaps this is part of psychologist's reasoning in questioning the NPD diagnosis? I shall continue posting articles while psychologist redefine the Narcissistic Personality Disorder.

The link below will take you to the APA's website where information about the new DSM-V is posted:

The American Psychiatric Association:

Personality and Personality Disorders

301.81 Narcissistic Personality Disorder

This page was excerpted from the APA's website:

General Diagnostic Criteria for Personality Disorder

The Work Group recommends a revised definition of personality disorder and a corresponding revised set of general criteria.

Definition: Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.  

A.  Adaptive failure is manifested in one or both of the following areas:

      1.  Impaired sense of self-identity as evidenced by one or more of the following:

               i.  Identity integration. Poorly integrated sense of self or identity (e.g., limited sense of personal unity and continuity; experiences shifting self-states; believes that the self presented to the world is a façade)

               ii.  Integrity of self-concept. Impoverished and poorly differentiated sense of self or identity (e.g., difficulty identifying and describing self attributes; sense of inner emptiness; poorly delineated interpersonal boundaries; definition of the self changes with social context)

               iii. Self-directedness. Low self-directedness (e.g., unable to set and attain satisfying and rewarding personal goals; lacks direction, meaning, and purpose to life)

      2.  Failure to develop effective interpersonal functioning as manifested by one or more of the following:

              i. Empathy.  Impaired empathic and reflective capacity (e.g., finds it difficult to understand the mental states of others)

              ii. Intimacy. Impaired capacity for close relationships (e.g., unable to establish or maintain closeness and intimacy; inability to function as an effective attachment figure; inability to establish and maintain friendships)

             iii. Cooperativeness. Failure to develop the capacity for prosocial behavior (e.g., failure to develop the capacity for socially typical moral behavior; absence of altruism)

             iv. Complexity and integration of representations of others. Poorly integrated representations of others (e.g., forms separate and poorly related images of significant others)

B.  Adaptive failure is associated with extreme levels of one or more personality traits.

C.  Adaptive failure is relatively stable across time and consistent across situations with an onset that can be traced back at least to adolescence.

D.  Adaptive failure is not solely explained as a manifestation or consequence of another mental disorder

E.  Adaptive failure is not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)

[talia]

I found this interesting, CZ....and am puzzled as I don't really understand....

The following  excerpts were found by clicking on rationale under Narcissistic Personality Disorder.

Five specific PDs are being recommended for retention in DSM-V: borderline, antisocial/psychopathic (possibly with subtypes), schizotypal, avoidant, and obsessive-compulsive.

The other DSM-IV PDs (paranoid, schizoid, histrionic, narcissistic, dependent, depressive, and negativistic), and the residual category of PDNOS will be represented by the use of general PD criteria combined with descriptive specification by personality trait profiles, based on most prominent descriptive features, since the literature lends more support for conceptualizing them as one or more dimensions of personality psychopathology than as types.

[CZBZ]

Not long ago, I began noticing a change taking place when discussing NPD (Narcissistic Personality Disorder).

Psychologists were grouping 'Axis II, Cluster B' disorders instead of differentiating the distinctions between them. This post describes how NPD is currently classified in the DSM-IV.

What has become fairly obvious to a lay person looking at Cluster B personality disorders, is the high degree of pathological narcissism present in each of the separate personality disorders (histrionic, borderline, antisocial, and of course, narcissistic personality disorder). This has made it difficult for people to determine exactly what we're dealing with when we meet a highly narcissistic person.

I wrote about this miserable state of affairs in this post: Narcissistic Psychopathic Dumplings

People started calling the narcissistic disorder a "psycho-soup" of co-morbid disorders. I have found it to be confusing, especially with the concept of 'narcissistic traits' that are high enough and rigid enough to preclude healthy relationships with other people and yet, their 'grandiosity' (for example) contradicted criteria in the DSM-IV for a NPD. Still, people gave the narcissist the benefit of the doubt and kidded themselves that as long as the N didn't qualify for a NPD diagnosis, there was hope. Sorry folks, even one narcissistic trait that is impermeable to change is enough to make your life miserable and the relationship unhealthy.

The issue, or so it has seemed to me, is 'pathological narcissism' whether qualifying as a personality disorder OR a trait. With current research by social psychologists like Baumeister, Twenge, Campbell and Vohs, narcissism can be measured as a dynamic of every personality, even so-called 'normal' personalities. The higher the narcissism however, the more likely a pathology.

Though I cannot say how psychologists will explain their concept of pathological narcissism and personality disorders, I have a hunch that what's happening is the construct of narcissism as a dynamic. We recently ran a thread about the NPI (Narcissistic Personality Inventory) that measures narcissism by scoring responses on a forced-choice test. This test is frequently used for current research about levels of narcissism in our society. It is a non-clinical measure of narcissism meaning that it does not determine a 'personality disorder' nor the degree of pathology. So perhaps psychologists are viewing narcissism as a component of personality (Healthy or unhealthy?

I will do some googling today just to see what I can find on the web.  


Hugs,
CZ

[CZBZ]

Revising the book on mental illness "Similarly, the proposal to place personality disorders in one category will not be welcomed by patient groups such as The Treatment and Research Advancements Assn. for Personality Disorders, which has championed specific research and treatment for one of these, borderline personality disorder.

"This will be a disaster," said Valerie Porr, founder and president of the New York-based organization. "It kind of trivializes the personality disorders."

Psychology Today:

DSM-V offers new criteria for personality disorders

A roadmap to the proposed changes to personality disorder diagnosis in DSM-V

Published on February 10, 2010

by Jared DeFife, Ph.D. (a clinical psychology research scientist at Emory University and Associate Director of the Laboratory of Personality and Psychopathology)

"...The current system:

Diagnosing disorders in the current edition of the DSM-IV involves two aspects. The first is defining what a personality disorder is. Currently, a personality disorder is defined as a pervasive pattern of "inner experience and behavior" that is deviant from a person's cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control. Deviations in any of the above aspects need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.

The second aspect involves defining what type of personality disorder is present. DSM-IV currently lists ten: paranoid, schizoid, schizotypal, narcissistic, antisocial, borderline, histrionic, avoidant, dependent, obsessive-compulsive, with a catch-all "not otherwise specified category". Each personality disorder had a certain number of criteria, to which you must meet an artificial cut-off. So to be Borderline, for example, you need to have five symptoms out of nine possible symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.

The problems with the existing system are many. First, the different personality types were poorly defined. They weren't based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as "an exaggerated sense of self-importance" were difficult. Don't we all, at SOME point or another, have an exaggerated sense of self-importance? Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met critieria for 3 or 4 others, as well.


The proposed revision:

The proposed revision on the DSM-V website appears quite complicated and has three major facets.

A new definition for personality disorder

First, the definition of what a personality disorder is, in general, has changed. The proposed revision suggests that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects "adaptive failure" involving: "Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning".

There are a couple of things I actually really like about this new definition. The first is the use of the term "adaptive failure". Every one of us has a personality, it's just a matter of how you use it. Your personality features only become a disorder when there is a pervasive failure to adapt who you are as a person to the demands of everyday life. The second is the newly detailed descriptions of failure to develop effective interpersonal functioning. These are fairly straightforward: problems with empathy, intimacy, cooperativeness with others, and inability to formulate a good working understanding or conceptualization of who others are as people.

There are two drawbacks, it seems to me. "Impaired sense of self-identity" is not quite as easily understood as someone who has pervasive failure in their relationships. The proposed revision breaks down identity problems into: poorly integrated identity (e.g. shifting self-states), poor integrity of self-concept (e.g. difficulty identifying and describing parts of oneself), and low self-directedness. The last part is great, and can be easily understood and observed as someone having trouble setting and achieving goals in life, showing a lack of direction, and feeling little meaning or purpose in life. Identity integration and integrity seem a little more "jargony" and a bit more difficult to explain or quantify in the real world.


Five personality types

Instead of the old ten personality types, DSM-V has simplified the system by cutting them down to just five: Antisocial/Psychopathic, Avoidant, Borderline, Obsessive-Compulsive, and Schizotypal types. Each type comes with a narrative paragraph description.

Antisocial/Psychopathic types have inflated grandiosity and a pervasive pattern of taking advantage of other people. Avoidant types are inhibited from forming and maintaining relationships out of fears of humiliation and rejection. Borderline types show intense emotionality, impulsivity, internal feelings of emptiness, and fears of rejection. Obsessive-compulsive types are hyperfocused on details and are excessively stubborn, rigid, and moralistic. Schizotypal types are characterized by odd thinking and appearances or confused states.

Clinicians simply read each paragraph length narrative description and rate on a 1-5 scale how much a patient matches each one (with 4 or 5 being a threshold for diagnosis). Research studies have found that clinicians tend to find this the most useful and comprehensive method for personality diagnosis, improving clinical description and treatment planning from the current system.

 

Personality trait domains and facets

The third and final element of the proposed system is a series of six personality "trait domains". These domains are based on the widely used five-factor model of personality. The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient.

To aid with this, each of the six domains comes with a subset of adjectives, or facets. Disinhibition, for example, encompasses: impulsivity, distractability, recklessness, irresponsibility. While there is a great deal of personality research on these factors, and they are useful for a variety of purposes, their greatest limitation is the sense of vagueness for clinical use.  To compare, it would be like rating someone's level of usual sadness, as opposed to having a coherent syndrome of depression.

That's the roadmap to the new proposed system for personality disorder diagnosis. What do you think? Post your thoughts and opinions below!! For a limited time, you can check out the entire system and provide feedback to the American Psychiatric Association at www.dsm5.org. "





Dr. Elsa Ronningstam, NPD: Facing DSM-V You can download this 11-page pdf HERE or click on the title of Ronningstam's article.




Science Daily: New Proposed Changes "In addition to proposed changes to specific diagnostic criteria, the APA is proposing that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These would permit clinicians to evaluate the severity of symptoms, as well as take into account "cross-cutting" symptoms that exist across a number of different diagnoses (such as insomnia or anxiety).

"We know that anxiety is often associated with depression, for example, but the current DSM doesn't have a good system for capturing symptoms that don't fit neatly into a single diagnosis, said David Kupfer, M.D., chair of the DSM-5 Task Force. "Dimensional assessments represent an important benefit for clinicians evaluating and treating patients with mental illness. It may help them better evaluate how a patient is improving with treatment, help them address symptoms that affect a patient's quality of life and better assess patients whose symptoms may not yet be severe -- leading to earlier effective treatment.""



McMan's Depression and Bipolar Web  "A point that everyone seems to agree on is there is not much to like about the way the DSM defines and classifies personality disorders. In all likelihood, Axis II will receive a major overhaul in the next DSM. The situation is outlined in a 2002 APA publication, A Research Agenda for DSM-V: Summary of the DSM-V Preplanning White Papers. According to the "Research Agenda," 56 percent of psychiatrists and psychologists in a survey considered personality disorders "problematic" and 35 percent regarded personality disorders as "most in need of revision."

Love the personality, hate the axis. What’s wrong is that it is virtually impossible to establish clear boundaries between the various personality disorders (not to mention between Axis I and Axis II), much less arrive at some kind of consensus on diagnostic thresholds. A sign of failure is the NOS (not otherwise specified) diagnosis, which, according to the "Research Agenda," is "often the single most frequently used personality disorder diagnosis in clinical practice." As an alternative to the DSM’s "categorical" approach to personality disorders, the "Research Agenda" discusses a "dimensional" approach that assumes that personality traits are fairly universal. What distinguishes worry-free from worrisome is severity.

The dimensional schema most likely to make it into the next DSM, Dr Paris advised in his lecture, is the five-factor model, which measures for openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Neuroticism breaks down into anxiety, hostility, depression, self-consciousness, impulsiveness, and vulnerability.

The five-factor model would probably complement newer versions of the current categories, resulting in a mixed diagnostic system."



The Future of Personality Disorders in DSM-V? by Andrew E. Skodol, M.D., and Donna S. Bender, Ph.D. "The current proposal under consideration for the DSM-V assessment of personality and personality disorders attempts to capitalize on the strengths of several dimensional models that have been offered as solutions to the problems posed by categories. It consists of five parts: 1) an overall rating of personality (self and interpersonal) functioning ranging from normal to severely impaired, 2) prototype descriptions of major personality (disorder) types, 3) a personality trait assessment, on which the prototypes are based but that can also be used to describe major personality characteristics of patients who either do not have a personality disorder or have a personality disorder that does not conform to one of the prototypes, 4) generic criteria for personality disorder consisting of severe deficits in self-differentiation and integration and in the capacity for interpersonal relatedness, and 5) measures of adaptive functioning. The specifics of this hybrid model and the integration of its parts are being informed by ongoing literature reviews and will be refined through secondary analysis of existing data sets and by field trials using clinicians evaluating real patients."

HAPPY READING!!


 


Hugs,
CZ

[CZBZ]

DSM website: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=19

This page includes four tabs you can click for further information: Proposed Revision; Rationale; Severity; DSM-IV. It's heavy-duty reading, however, you can register for an account and comment on proposed revisions. I haven't yet had time to study the proposed changes but will continue to add links to articles that make it easier to understand.

Prominent Personality Traits: Narcissism, Manipulativeness, Histrionism, Callousness


Hugs,

CZ

[talia]

Thanks for all the links. I am slooowly muddling through as time permits.

[CZBZ]

Two excellent blog posts to read:


Mind Hacks: The Draft of the new psychiatric bible is published



Neuroskeptic: DSM-V, change we can believe in?

[talia]

And another great blog that I liked a lot that criticizes the proposed changes to the DSM-V.

Blog author-
James L. Knoll, IV, M.D. is the Director of Forensic Psychiatry, Associate Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY.

DSM-"V"- for Vendetta
“There is more behind and inside of V than any of us had suspected.”


I more than likely still don't have the hang of inserting a link- if this is the case, the link is as follows;
http://wwwedgeeffect.blogspot.com/2010/02/dsm-v-for-vendetta-there-is-more-behind.html

[CZBZ]

Hi Talia! I promised to link a few more articles about proposed changes in DSM-V criteria (basically eliminating the NPD diagnosis). So get on your elastic waist pants, grab a big bottle of coke, Feed your cat first and make sure there's something to eat for dinner. this is a lot of reading. ha! You may actually enjoy the arguments between psychologists in this first link. Methinks they're about as rotten at direct confrontation as most of us and yes, they are highly opinionated and self-protective. Nonetheless, the internet allows us to see things that were otherwise verboten. YAYA...so now we know the truth. Psychologists aren't gods. They're just people.

I'm still reading about the changes and nothing is set in stone, yet. The psychology Bible is still being chiseled and embellished and edited. Maybe the DSM-V is predicted to be published in a few years but if these folks can't come to an agreement, it may never get published.  Let's go with what we know about NPD and avoid questioning whether or not it's a clinical disorder or merely a matter of perception (or extreme!).

I continue to browse psychiatric sites and forums for further information about the proposed changes. While the DSM committee has invited people to comment, it's probably like having someone who doesn't like you much say, "Let's Do Lunch next Week!" They have no intentions of sharing lunch with you next week or even next year; but it looks good to say that, right?

LOL


Hugs!
CZ

Opening Pandora’s Box: The 19 Worst Suggestions For DSM5

By Allen Frances, MD | February 11, 2010
Dr Frances was the chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

"Perhaps it should occasion no surprise that a flawed process should yield a flawed product. The most fundamental problem is the poor and inconsistent writing. Admittedly, early Work Group drafts are often written imprecisely and with varying quality, but it is surprising that the DSM5 leadership has failed to edit for clarity and consistency. It would be a waste of effort, time, and money to conduct field trials before the new criteria sets receive extensive revision. The poor writing is also a bad prognostic sign, suggesting that the DSM5 text sections for the various disorders may eventually be equally inconsistent, variable in quality, and sometimes incoherent...."

A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences

By Allen Frances, MD | June 26, 2009
Dr Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.
For more on the DSM-V debate also visit www.newscientist.com

"...Why did we go to all this trouble in preparing DSM-IV and why should DSM-V undergo a sharp midterm correction to provide equivalent safeguards by becoming far more transparent, explicit, and conservative? I believe that the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology. First we will explore the excessive ambition, because it has encouraged an excessive tolerance for risk taking.

The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis..."

Setting the Record Straight: A Response to Frances Commentary on DSM-V

By Alan F. Schatzberg, MD, James H. Scully Jr, MD, David J. Kupfer, MD, Darrel A. Regier, MD, MPH
| July 1, 2009
Dr Schatzberg is President of the American Psychiatric Association.
Dr Scully is Medical Director, CEO, of the American Psychiatric Association.
Dr Kupfer is Chair, DSM-V Task Force
Dr Regier is Vice Chair, DSM-V Task Force

"...Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing."

Proposed Diagnosis
Paul Chodoff, M.D.

I would like to suggest a new diagnostic entity for DSM-V. The diagnosis is “the human condition.” Diagnostic criteria would be any combination of the following:

For children: (1) distractability, (2) being fidgety, (3) disobedience, (4) disliking school. For adults: (1) unhappiness, (2) nervousness, (3) shyness, (4) dissatisfaction with one's looks, (5) dissatisfaction with one's sexual performance, (6) getting angry, (7) playing the horses, (8) getting upset when things go wrong, (9) preferring one's own company, (10) showing off, and (11) orderliness.

The advantages of this diagnosis are that it would facilitate insurance reimbursement, dispose of the bothersome problem of comorbidity, and encourage the quest for a drug to cure the disorder of being human.

DSM V--Requiem for a Diagnosis

Written by: Prudence Gourguechon

"...What I've heard from very good sources is that Narcissistic Personality was dropped in the DSM V draft because unlike,say,  Borderline Personality Disorder,which was retained, NPD hasn't been found to have construct validity.  It doesn't hold together, we can't verify that there is a "there" there when we talk about it.  You have to respect that argument.  Can something exist that can't be shown in empirical studies to exist?

But how am I supposed to describe friends, patients, colleagues and movie characters who have a Narcissistic Personality Disorder now that the phrase is going to be axed?"

The Future of Personality Disorders in the DSM-V

Facing DSM-V by Elsa Ronningstam

[CZBZ]

We must have been posting close to the same time, ha!

Thanks for the link and wow, you figured out how to embed the url in the title! It's a pain, isn't it?!!!###**!

I'm reading the blog article right now and thank you so much!


Hugs,
CZ

[talia]

And an opinion/commentary that angered me(perhaps because it encapsulates to a degree my fears with regard to changing NPD in the DSM as it currently stands)

Written by- Prudence L. Gourguechon, M.D.
APsaA President

DSM-V Requiem for a Diagnosis

Excerpt:
What I've heard from very good sources is that Narcissistic Personality was dropped in the DSM V draft because unlike,say,  Borderline Personality Disorder,which was retained, NPD hasn't been found to have construct validity.  It doesn't hold together, we can't verify that there is a "there" there when we talk about it.  You have to respect that argument.  Can something exist that can't be shown in empirical studies to exist?

OMG-talia

[talia]

Oh my gosh....CZ already posted this. I'm losing my mind....LOL!! Okay, well I really didn't like this opinion!!

[CZBZ]

I posted her commentary because her reasoning is not uncommon in the psychiatric field. It's my perception that psychologists dislike the complexity of NPD and BPD or NPD and AsPD traits. They want a more perfect union which might mean using narcissism as a construct of all PDs. I know people dislike pigeonholing someone into a personality disorder that best aligns with presenting symptoms but by eliminating NPD as a categorical disorder, doesn't that mean patients that were formerly defined as NPD must now be pigeonholed into one of the remaining PDs???? I have lots of questions and no answers.

Here's the way my thinking has been about a dimensional versus categorical description of narcissism:

Heinz Kohut presented a model for narcissism that was more conducive to psychoanalytic treatment. Basically, a narcissistic person was not properly mirrored as a child and with proper mirroring, may be able to 'mature' their narcissism to a healthy level. That makes sense. It makes sense in my own life as I've worked with my nephew, trying to do what Kohut suggests to help someone develop a sense of self. Imago Therapy is (in my understanding) the result of Kohut's theories.

However, there is also a need for a categorical description of NPD. This is where Otto Kernberg's theories fit because the improperly mirrored and immature narcissist is irrefutably and irredeemably pathological! What's that cut-off point? When does a narcissist become a pathological? Without the NPD category, I'm concerned that people will make false assumptions about the narcissistic traits they see in a partner (or child or boss or whatever).

Its my sense that social psychologists (who measure narcissism as a dynamic of personality) have gathered enough empirical evidence from college age kids who wanted beer money for filling out the survey, that they've influenced psychologists thinking about narcissism as a dimensional and not a categorical disorder. I believe this is wrong=thinking. It might look good in ivory towers when nine million college kid research articles are spread on their desks but how about real life??? I know the difference between someone who is narcissistic and someone who is NPD but hey, I got my education in the marriage bed, not a University.

I can see big problems for laypeople if they decide to eliminate NPD as a distinct category on the Axis II. A narcissist is not the same thing as a Narcissistic personality disorder, which is a DISORDER of CHARACTER. That makes a lot of sense to the average person. To now be told that NPD does not exist but is a component of other disorders, well, where does that leave us? Looking at all the remaining PDs and picking one that fits best???


CZ

[SydneyFireworks]

I'm only now starting to take notice of all this info about the proposed changes and, to be honest, go a bit ga-ga when reading the more scholarly documents and articles.

My beef is in the naming of the personality disorders - to me they make no sense at all.  If you took a hundred laypeople off the street and asked them what they think they mean, I bet 95 of them would say the same as I would have said before meeting Tosser.  To whit:

Narcissistic person(ality disorder): Someone who is vain and full of themselves.

Borderline person(ality disorder):  Someone who is not quite one thing, not quite the other.  On the border of being (whatever).

Anti-social person(ality disorder):  Someone who isn't sociable - hides away, isolates himself/herself, doesn't have or want any friends.
 
Of course, I (and most of the people I pulled off the street) would be quite wrong. 

I know the DSM-V is not meant for laypeople, but at the end of the day, the experts need to be able to explain these disorders to laypeople so - if they're planning to change the diagnostic criteria, maybe they could also change the names to make them more accurately descriptive and understandable for those of us who have to live/deal with these disordered people.

Sorry to lower the tone of this thread!   

Hugs
Syd

[CZBZ]

That was a great link, Talia. I especially appreciated his concern about lumping AsPD with psychopathy and including NPD in the soup. I had hoped for further clarification of Malignant Narcissism as it differed from NPD proper. Now they're saying NPD proper is not a viable personality disorder and Malignant Narcissism is basically, psychopathy.

The blogger you linked also wrote: "So what do we have to work with now that we can count on? I would assert that it is the lost art of the masters – the art and skill of the clinical interview. From Kraepelin to Freud to Cleckley – it was their rich clinical descriptions that helped us navigate the foreign terrain. But note well that they came across their insights by spending much time listening, observing and questioning patients – a practice that has been subordinated to ten minute med checks, diagnostic coding and billing. "

Now this must be why therapists argue back and forth about the efficacy of longterm psychotherapy. Just like everything in our world today, people want a quick fix. It's like walking into a diagnostician's office and filling out two forms plus an oral yes-or-no test, pick up the diagnosis, go to the pharmacy and maybe get ten sessions of cognitive therapy. And voila, end of mental illness or disorder. ha! Are we microwaving psychotherapy now?

Psychologists want to Fix the problem because Insurance demands a reliable 'fix' or they won't pay and most people would like to believe that ten sessions with a psychologist would cure their behavioral and relational problems. They don't want to spend years working on the self either.

Let's face reality though. I wanted a ten-session fix for an infidel husband, too. I also wanted a ten-session fix for each of my kids and one for myself and for Christmas, I'd buy a Therapy Gift Card for both my parents but not more than $500 for the whole program. maybe that's part of the lure for self-help week-end retreats? I remember my X saying that he wanted to take the weekend to find himself. He's likely very typical of people today.

And i've been working on family problems for twenty-five years now. Well, if there's one thing I've got, it's patience.

Hugs,
CZ

[CZBZ]

Hey, Syd! You make a great point and yes, this new classification bugs me to pieces. We have finally made headway on narcissism as a pathology (not just conceit) and now they're gonna eliminate it as a personality disorder???? It's like taking ten steps forward and being pushed to the back of the line! There are so many books, so much help, so much support for people so they can learn about NPD and avoid investing their lives in a pathological relationship. what happens to all that work? To the intensive and very reliable information of NPD theorists who have worked with this disorder almost exclusively? I imagine they're mad as hell. 

Even if NPD is far more serious than vanity, at least people get the general idea that it's all about the narcissist. Now we're gonna tell 'em the mirror is broken? There is no such thing?


It's so ludicrous it's almost laughable.

I have an article by Kernberg on my nightstand. I'll read it tonight and hope I kept the url. He discusses the change in the NPD diagnosis.  It's true---we know a lot more about NPD now than we did in even twenty years ago, but it's not fair to pull the rug out from under our feet right when people were starting to understand the seriousness of this disorder.

Just rantin' tonight.....

CZ

[eyes_up]

WoW! Axe NPD ... So, I can tell you what was flowing through my mind as I read that. This is about the people who do not want this disorder and it established characteristics to be knowable and discernible
Just who are those people... HA HA HA HA HA ... Narcissist. the people who are above the psychologists.

Why would I say this?

Because ~

The NPD axe will be heading in the direction of powerful (narcissistic) figures. When it is more publicly known/understood it will change peoples minds. Those in power do not want this , of course not.

It was so many years ago when I listened to a history on Freud. I have written about this on WoN before and here it is again. The point of the history note was in revealing that Freuds original findings were not published because Freud himself knew that he would not be the public figure he is today. His original findings, which of course are all written down and then what was presented was different in order to hold his position.

The subject changed had to do with domestic violence and violation. It had every thing to do with human rights specifically female. He knew his finding would not be acceptable. His original writings talked about
how the female nerosis and issues were based on physical and psychological violations BUT what got handed to the public was "penis envy" and thatis why women were experiencing the emotional / psychological problems such as hysteria, various nerosis etc.

I should have recorded the radio show. It blew me away since what it was saying , again , is do not allow anything that will seriously disrupt the present flow and do allow the crimes to continue.

That is what I see happening here. Since NPD is has a certain amount of flow in the media it needs to be stopped. There are too many rich and powerful meN that want to keep their positions and the psychologist need theirs as well.

This is what I see happening and the only reason is because The knowledge of NPD will uncover and that is not the objective of those in power.

This also reminds me of the story of the electric car. If you have seen the movie you will know what I am talking about.

So, the term NPD just disappears... no longer in the media and it all begins to soften for the essentially well organized criminals, perpetrators, the thieves, liars, manipulators etc. Since narcs don't fit into psychopath perfectly, well, of course the NPD issue is blocked and deadened.

Again to set it up blaming the victim. That is what I see.

When Freud claim that women suffered from various neurosis and metal illnesses and the notion, just a creative notion, that on has "penis envy" it blames the victim. This will be happening again. I find this to be equivalent and parallel the same theme and even subject when it gets down to it as in the Freudian era. The lie lives on because people are forced to exterminate it. This is definitely what I think.

eyes

[CZBZ]

You bring up a valid point, Eyes. First let me say that my interest as a victim is with other victims. My interest is focused on helping people resolve any issues they have after being 'used' by a narcissist. I'm also dedicated to providing information that will help people understand the pathology and stop taking the narcissist's behavior too personally; i.e. it's all about the narcissist, not you as a person.

Psychologists are interested in treating a client's personality problems, encouraging them to heal whatever the diagnostician has determined to be 'The Problem.' There is a definite conflict of interests here. I am not interested in curing the narcissist because I am not a psychologist. I am interested in curing the narcissistic infection in people who are otherwise 'normal'.

What I have read repeatedly is that psychologists dislike the NPD diagnosis because it stigmatizes a client. Clients dislike being labeled NPD and psychologists perceive this as counterproductive to a client's perception of 'self' and ability to heal. But to me, the NPD diagnosis is most useful for people who are harmed by the narcissist and let's face it, the narcissist is NOT suffering. We are.

If the NPD diagnosis protects people from someone who appears to be competent, confident and 'normal', then it serves a greater purpose in protecting other people from inevitable harm. To me, that is a 'greater good' than how the narcissist feels about being diagnosed with a stigmatizing disorder.


Hugs,
CZ

[eyes_up]

Agreed

Why i write above is because I do not think these  changes are absolutely clean.

As far as being stigmatized... If ya can tell me I am PTSD or tell a BPD etc then why is narcissist saved the stigma.

I know that my therapist waited a 3.5 years to tell me what he was essentially primarily treating me for. buy the time he told me I was in the head space to deal and didn't feel stigmatized.

Every one is stigmatized  more or less when labeled and fact is... every person on the person can be labeled. People for the most part are neurotic. Just depends on how dysfunctional the neurosis is.

My therapist explained to me the ins and out about label. It seems pretty stupid to experience a bunch of traits and not be able to say ... well, heck you have experienced trauma. Well, what ever. Stigmatized the narc. Why is a narcissist spared the stigma? How bout every one else?

I just think that their is a another reason why narcissism is losing ground as a personality disorder. NPD seems serious enough in terms of the behavior. i think it would be an important message that a person might suffer from the inability to empathize. As in ... there is a serious part missing.

So rather than burden a narcissist with  stigma that every Bipolar person apparently is not exempt from is in order. That doesn't make a lot of sense to me.

 I think stigma is a nice way of saying.... we don't want to label a N person because narcissist hold positions and are successful / functional (matter of importance) in all other fashions there fore it isn't that bad and narcissist want to remain high functioning and with out question.

 Lack of empathy doesn't create  an obvious dysfunction there for a narcissist should not have to bare the label of dysfunction.

I think that if people stopped servicing narcissist the disorder would be really obvious. What covers a narcs behind and sickness are the people that are infected/affected.

Altogether it strikes me strange bone that narcissist get spared stigma  yet no one other disorder is spared. hmmmm like I said there is something more to this.  

Folds can all just go back to old fashioned terms such as jerk and mind-cluck cuz really that is what people have to deal with regardless of whether the DSM ever makes progress. This is the base reality. It's not like NPD was created when the DSM was created. It isn't even important if it is a personality disorder on ground level. what seems to matter the most is that people are prepared to deal with what exists and that simply means self awareness, self connection, boundaries, self care and the ability to differentiate.

I also agree that people look for a quick fix... that would be the other subject I picked up on with in this thread. the idea of self/adult development being some thing that happens in a year or less. Kinda silly really.

So much for the DSM. I wonder if the label NPD would really actually affect people and their choices?

eyes

[CZBZ]

Narcissism will be measured as a dimensional trait. In other words, the Degree to which narcissism is manifest is measured. There is no 'cut off' point like there is with a categorical diagnosis. According to clinical measures, you either ARE a narcissist or you AREN'T and this determination is based on fitting five of the nine criteria in the DSM-IV.

The issue that most psychologists have with the existing criteria is that it isn't adequate in describing other subtypes. I go along with that perception. We have talked many times about 'covert' narcissism' which is just as pathological as the Overt Narcissism described in the DSM-IV. also, what about the malignant narcissist? When people read Sam Vaknin (a diagnosed malignant narcissist) they may assume that all narcissists are 'malignant', which they are not. malignant narcissism is a syndrome of NPD, far more akin to psychopathy and/or antisocial disorder.

So yes, there are justifiable reasons for examining narcissism as a dimension of a personality disorder and further clarifying malignant narcissism from the everyday garden variety narcissist.

What has surprised me is the bold move to eliminate NPD as a personality disorder. It's times like this when I'd love to be a fly on the wall of a psychological convention. LOL! One can only imagine what kinds of arguments those pros are getting in to. I'm guessing they throw around 'diagnoses' every bit as well as the layperson is accused of doing.

The stigma of NPD is that it's incurable. (I also think psychologists pussy-foot around the narcissist because if they tell their client his mind is disordered, he might jump over the desk and strangle them.) ROFL... With PTSD and now even BPD, psychologists are able to treat and even cure what used to be considered incurable. A.J. Mahari writes about being diagnosed with BPD and now she is no longer considered 'borderline'. DBT and other treatments have shown such positive effect that it's almost better to be diagnosed with BPD than NPD.

It's rather interesting to watch this drama unfold, though. In a society that is becoming more and more narcissistic (in fact, self-admiration is almost required these days), wouldn't it be strange to say the whole culture was 'disordered'?  


Hugs,
CZ

[talia]

It's always been my hope that awareness and education about NPD would increase. With the elimination of NPD as a disorder I fear that the opposite will happen. My concern is that a decline in interest/research/education/awareness will adversely affect those that are impacted through intimate relationships with NPD'rs. It's crucial to the well being of those affected to have validation, understanding and support. NPD does exist and these character disordered individuals can cause great harm and havoc in the lives of others. Intimate relationships include parents, children, husband/wife, boyfriend/girlfriend, sibling, co-workers and even a boss,etc...One better know what one is dealing with when up against a NPD'r in court. My finding a therapist who was knowledgeable about NPD had much to do with my healing.

As confusing as the label NPD was and even though it took me ages to wrap my head around what it meant(and I, by no means, understand it all), it is what finally made sense of the behaviors of the person I was involved with that prior to him were foreign to me.

In the pursuit to provide greater diagnostic stability to clinicians because "mentally translating personality traits back into syndromes or disorders is cognitively challenging" (Gosh, can't we just put together a NPD for Dummies manual for 'em??.j/k!) by eliminating NPD as a PD in the DSM seems to me to be the wrong way to go....Reformulate it, clarify it, add to it......but DON'T eliminate it. Should less research/education/awareness/understanding of what malignant NPD is come about as a result, the consequences can only be negative.

Just one more comment to use as a comparison. There are 80 different types autoimmune disorders. A person may have more than one autoimmune disorder at the same time. Diagnosis is difficult as symptoms are shared, etc....It takes time, diligence, research and dedication. It's not easy. Seems as if the psychiatric community responsible for the proposed changes want an easy way out/ easy fix instead of doing the hard work that is needed and necessary. Is simplifying/streamlining something so hugely complex as a PD possible?

Wonder what Sam Vaknin thinks and if he'll suffer narcissistic injury by being booted out of the DSM??...LOL:)

[CZBZ]

I found this link to a brief article about changing the name of BPD to prevent stigmatizing clients. It offers a little insight into concerns about the label NPD.




"...Back in 1952, when the APA's diagnostic manual first appeared, it was a thin, spiral-bound edition that offered sketches of such '50s-sounding traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a chapter-and-verse authority on everything pertaining to mental health. Somehow it acquired those pretensions in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested.

"Inadequate personality wasn't quite dropped from DSM-III; it was allowed to merge with "atypical, mixed, or other personality disorder," which is, if anything, even more nebulous. Among the more hair-raising mental illnesses also added to the manual were avoidant personality disorder, oppositional defiant disorder, and social phobia. The latter's symptoms to this day include fear of eating alone in public and concern that "one will act in a way … that will be humiliating and embarrassing." ...Conceivably, we might by 2012 reach a point where the APA is defining more than half the country as mentally ill." Bitterness, Compulsive Shopping, and Internet Addiction, The diagnostic madness of DSM-V  by Christopher Lane



"...The existing data suggest that NPD occurs frequently enough that DSM-V should continue to include it in some fashion. Nevertheless, there are a number of limitations in the existing data that should be addressed for DSM-V. First, most research on NPD has not examined the concordance between DSM-IV criteria and the essential features of the disorder as seen in clinical practice. Recent research by Westen and colleagues (Westen et al., 1999) has begun looking at this process and if replicated suggests that DSM-V broaden the criteria set to include assessment of controlling behaviors, the tendency to engage power struggles, and the more competitive aspects of the disorder..." ~ Pages 42-43, Narcissistic Personality Disorder Kenneth N. Levy, Ph.D. ( http://levylab.psych.psu.edu )

For some reason, I can't link this article, but here's the google page where it's listed: http://www.google.com/search?hl=en&q=DSM-V+elimination+of+NPD&aq=f&aqi=&aql=&oq=

13-page PDF discussing changes in the DSM-V classification of NPD

[CZBZ]

Interesting article by George Will on the DSM:


A 'Cure' for Character

"...This DSM defines as "personality disorders" attributes that once were considered character flaws. "Antisocial personality disorder" is "a pervasive pattern of disregard for ... the rights of others ... callous, cynical ... an inflated and arrogant self-appraisal." "Histrionic personality disorder" is "excessive emotionality and attention-seeking." "Narcissistic personality disorder" involves "grandiosity, need for admiration ... boastful and pretentious." And so on.

If every character blemish or emotional turbulence is a "disorder" akin to a physical disability, legal accommodations are mandatory. Under federal law, "disabilities" include any "mental impairment that substantially limits one or more major life activities"; "mental impairments" include "emotional or mental illness." So there might be a legal entitlement to be a jerk. (See above, "antisocial personality disorder.")..."

[SusyP14]

Interesting article by George Will on the DSM:

A 'Cure' for Character

My mother, who completed her psychology training close to 50 years ago still calls Personality Disorders - Character Disorders.  It tends to throw me off when we are talking about the subject, so I guess that is old school. 

What I did not like about this article was the implication that a disorder is the same as character defect.  The term disorder is there to imply permanency.  It is not getting any better, nor will it ever get any better.  It is on the same line as mental retardation.  Does George Will expect someone that mentally retarded to change?  Then don't expect a disordered person to change either.  I think the article exposes what most of us think, until we are face head on with what it means to tangle with a disordered person.

[honeybearII]

I think what bothers me about all this, is that there is no statement about the CONTINUUM of these disorders.  We talk about that a lot here, and in our experience of survivors of NPD, I think the issue of continuum has to be addressed.  There are people with very mild NPD who manage to create a pretty good life overall if they find someone willing and able to live with them.  Then there are the ones on the other end of the spectrum who eventually become physically and/or emotionally abusive. 

A personality disorder is rather like classifying cancer or other diseases.  There should be a kind of Stage 1, Stage 2, etc. classification for many of these personality issues because if you are dealing with a Stage 1 narcissist, that is entirely different than being in the clutches of a Stage 4 psychopath although they both might be diagnosed with NPD.

Honey