There is a small ferment in parts of the blogosphere and media about some proposed changes in the DSM-V, the fifth iteration of the Diagnostic and Statistical Manual which forms the nosological bedrock of modern American Psychiatry. Tuesday's Science Times reported the story (with a wonderfully misleading headline):
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.
In reality, the DSM-V proposes to offer a series of Chinese menu options to describe characteristics of disordered personalities, an approach as good as any other; in reality there is rarely (never) a pure culture of a disordered personality and most disturbed people exhibit multiple pathological personality traits. The so-called normal person usually has a fair number of mildly to moderately pathological parts of his personality as well, likely a result of having a complex and evolutionarily recent mental apparatus.
As long time readers here may appreciate I have little use for standard Psychiatric nosology. By the time of the DSM-III, any attempts at differentiating Psychiatric disorders by understanding their etiology had been jettisoned in favor of a check list of signs and symptoms that allowed one to, in theory, conduct more reliable research (under the assumption that all Depressions are the same if their superficial symptoms are similar) and direct Pharmacological treatment. In fact, since DSM-III, a good argument can be made that the sole utility of the DSM has been to direct treatment with drugs and facilitate insurance reimbursement. [See Better Living Through Chemistry? Part I for a more in depth discussion of the evolution of the DSM.]
The Last Psychiatrist has an interesting perspective on the proposed changes:
You may have heard the news: "Narcissism is being removed form the DSM."
Narcissistic personality disorder, characterized by an inflated sense of self-importance and the need for constant attention, has been eliminated from the upcoming manual of mental disorders, which psychiatrists use to diagnose mental illness.
That sentence is technically accurate. What's missing, however, is that it would be replaced by something else, a more wordy, symptom cluster description of a personality disorder. You can still "diagnose" someone with narcissistic traits.
However, on the face of it, people are understandably freaked out:
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.
Since he doesn't get Pharma money, there's no need to disclose his megalodon sized bias: his whole career is about measurement tools for narcissism.
And so if you're thinking that the craziness is that psychiatry is the doing away with the concept of narcissism you have fully missed the point: the issue isn't whether narcissism exists or not, the issue is who gets to decide if narcissism exists or not.
His post is worth reading; you will enjoy his description of the vicissitudes of Neurosis. I was struck by his point that many of the changes involved are immaterial but simply reflect the arrogation of power by the people involved. Isn't this the problem with bureaucrats in general? They always make decisions which eventuate in an increased accrual of power and control in their own agencies and they almost always believe they are doing so for the most altruistic of reasons.
When Psychoanalysis lost its position as the authoritative source of understanding of the mind a little noticed effect was the loss of therapeutic humility.
(There were many good reasons to dethrone Psychoanalysis, among them that the treatment is not appropriate for most people and can be harmful to some; however, the fact that drugs offered rapid symptom relief and the illusion of treatment of disease has done a disservice to people in distress and facilitated anew the view that the mind is simply a not too sophisticated machine and that people can be adequately treated as if they are no more than a collection of chemicals that need to be tweaked form time to time.)
Even as the Psychoanalyst is in a position of significant importance to their patients, they spend a great deal of time and energy, including in their personal analysis, attempting to understand the ways in which their own desires can contaminate their treatment and harm their patients. We all want nothing more (consciously) than to help our patients, yet the desire to control others is a deeply ingrained part of the human psyche. Psychiatrist and therapists of all stripes who have never grappled with such issues in their own intensive therapy all at much greater risk of unintentionally weilding power for their own purposes, not always in the best interests of their patients.
Only the most ideologicla openly express their desire to contorl others; such peopel are overtly dangerous andm ust be opposed at all costs. Yet the soft tyrranny of those who gain power for noble and just purposes is just as inimical to the human spriit, if slower to destroy and less overt.
Its a rare individual who can resist the urge to exert power over others in order to do good.
Gollum: SHIRE! BAGGINS!
Frodo: Shire? Baggins? But that would lead them here!
[Cuts to a Ringwraith cutting off a Hobbit's head]
Frodo: [holding out the Ring] Take it Gandalf!
[Gandalf backs away]
Frodo: Take it!
Gandalf: No, Frodo.
Frodo: You must take it!
Gandalf: You cannot offer me this ring!
Frodo: I'm giving it to you!
Gandalf: Don't... tempt me Frodo! I dare not take it. Not even to keep it safe. Understand, Frodo. I would use this ring from a desire to do good... But through me, it would wield a power too great and terrible to imagine.