In the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders , the bible of psychological dysfunction produced by the American Psychiatric Association, it looks as if the association will drop narcissistic personality disorder as a recognized psychiatric illness, as this article in the New York Times reports . This is creating all sorts of controversy in the field as academic researchers (who are mostly the ones proposing the changes) and clinicians (who are mostly the ones opposing it) fight over what a personality disorder is. Dropping narcissism is not analogous to what happened when the APA stopped classifying homosexuality as an illness. In that case, there was a recognition that behavior once labeled sick was simply a normal variation of human experience. But as anyone who’s had a spouse, parent, or co-worker with narcissistic personality disorder can attest, no matter how the DSM-5 constructs or deconstructs the diagnosis, personality disorders are real, and can be a crucial way to understand the destructive behavior of someone who has one.
The new proposal would remove five personality disorders-narcissistic, paranoid, dependent, schizoid, and histrionic-and replace them with a methodology that instead describes people in terms of traits. In a commentary objecting to the new approach in the September issue of the American Journal of Psychiatry, a group of clinicians writes, “A clinically useful approach should focus on types of people, not types of ratings scales.” They acknowledge the proposed revision offers one significant improvement in that it would assess people for the severity of their unpleasant behavior. This is particularly important for narcissism. We all have a dose of it – without it why bother to get out of bed and try to make your mark on the world? But it is in the matter of degree that someone goes from the egotistical to the pathological. Another aspect of the struggle over this reassessment is the fact that insurance companies rely on the DSM as a way of deciding on reimbursement. Insurance companies hate personality disorders-they can be intractable and are generally not amenable to pharmacological fixes. If narcissism is dropped as a recognized personality disorder, the irony is that this will please no one more than the narcissistic. They already know they are not the problem, it’s everyone else who is sick.
Photograph of narcissus by Wikimedia Commons.