New approach means less attention for disorder, writes MUIRIS HOUSTON
“Anyone who goes to a psychiatrist needs his
head examined”
– Sam Goldwyn
THAT EXAMINATION, at least where personality disorders are concerned, is about to become much narrower in 2013. The 5th edition of the bible of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is about to eliminate five of the 10 personality disorders listed in the current edition. Narcissistic personality disorder is to be no more.
The non-clinical picture of narcissism differs from the professional one. It has led to quips such as “A narcissist is someone better looking than you are,” attributed to Gore Vidal, and the comedian Eddie Izzard’s: “That’s what narcissism is all about; looking in the mirror every day and thinking, ‘Damn, I’d like to shag myself.’”
In fact, the self-absorption of narcissistic personality disorder is of a different order than that referred to by vernacular usage. First diagnosed by analyst Heinz Kohut in 1968, the disorder involves a grandiose sense of self of such magnitude as to bear no relation to the person’s actual abilities. Coupled with this is an insatiable need for attention, recognition and praise.
Worryingly, some experts believe a disproportionate number of pathological narcissists work in influential occupations such as finance and medicine. The disorder is thought to affect about 1 per cent of the population. It tends to present clinically when the person is in their early 20s and is more common in men.
What are the current DSM criteria for narcissistic personality disorder? A patient diagnosed with the illness must display at least five of the following nine criteria:
1. A grandiose sense of self-importance.
2. A preoccupation with fantasies of unlimited success, power, brilliance, beauty or ideal love.
3. A belief that he or she is “special” and can only be understood by, or should associate with, other special or high-status people.
4. A requirement for excessive admiration.
5. A sense of entitlement – unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations.
6. Exploiting personal relationships – taking advantage of others to achieve his or her ends.
7. A lack of empathy and an unwillingness to identify with the feelings and of others.
8. Enviousness of others – along with the belief that others are envious of him or her.
9. A tendency to arrogant, haughty behaviours or attitudes.
There is no cure for narcissistic personality disorder. Psychological therapies such as cognitive behavioural therapy are used to try to ameliorate some of the victim’s behaviours.
Although by its very nature, psychiatry is a more fluid science than other branches of medicine, it seems strange that a diagnosis can be done away with completely. Critics say the committee tasked with updating the personality section of DSM is top heavy with academic types who perhaps lack sufficient exposure to seeing patients on a daily basis.
And they are worried patients will suffer with the pruning of personality disorders from 10 to five. Apparently, it’s part of a move away from a “prototype” approach to diagnosis in favour of a “dimensional” approach, which focuses on making a general diagnosis of personality disorder before describing the principal traits associated with a particular patient.
Those of an anti-psychiatry persuasion will presumably be tickled pink at the notion of eliminating half an entire diagnostic category by committee. It certainly has a Kafkaesque ring: moving pieces of a diagnostic jigsaw so dramatically risks the credibility of psychiatry itself.
But perhaps the greatest losers will be the pathological narcissists themselves, who will have to face being ignored – a fate worse than death for someone in need of extreme admiration.