Sunday, December 19, 2010

More on the Removal of NPD from newest DSM

Because of the length of the following comment to the last post on this blog I'm presenting it on the front page.  The comments field is limited in terms of space so I'm putting it here.  I'm also putting it here because it deserves front and center placement as a professional opinion on the subject.  It provides some important historical background on the DSM that must be factored into this discussion.


As a psychiatrist with personal experience with NPDs, I fully concur with Anna's views that this change in the DSM is essentially a non-event for all the reasons she enumerated.  Perhaps some additional information about the DSM may be helpful in fully appreciating some of the reasons for its meretriciousness.  (To save some of you from consulting a dictionary, "meretricious" is defined as apparently attractive but having in reality no value or integrity.  I also use this word not unintentionally for its archaic meaning - of, relating to, or characteristic of a prostitute.)

Some of the individuals who first developed the DSM are well known among psychiatric circles to have severe NPD themselves.  The interests of one DSM "innovator" in particular were in statistics and in ways to categorize knowledge generally.  At the time in the 1960s, a dedicated system of classification of mental disorders was lacking.  Previously these disorders were given codes in a manual called the International Classification of Diseases (ICD) along with all other medical disorders.  Seeing an "opportunity," one DSM originator chose to go to medical school and specialize in psychiatry exclusively in order to have the credentials to create a classification system.  Medicine and psychiatry were merely means to another end.  The womb of the DSM resided in an obsessive individual who possessed a prominent dearth of humanity and who by the same token could have easily chosen to classify machine tools, toads or sea shells.  In addition, for the initial DSM there was very little consensus.  It is the product of just a few individuals.  This was the inauspicious inception of the run-away train we now call the DSM.

Another critical point to remember is that the primary impetus for a classification of mental disorders was for research purposes - not for clinical utility.  That is why it is a diagnostic and STATISTICAL manual.  The use of medications in psychiatry began in earnest in the 1950s creating a need to do clinical trials.  A system was needed to enable researchers to group individuals together diagnostically.  One cannot for example do a trial of a drug for schizophrenia without defining the population for which the medication is purported to be effective.  Thus the birth of the DSM and its subsequent revisions has been influenced in no small way by changes in the field of psychiatry and in pharmaceutical technology. 

The pharmaceutical industry is not the only one that has influenced the evolution of the DSM.  Since the 1980s, the health insurance industry has exerted an increasingly formidable influence on the way mental health disorders are viewed.  Because it determines the reimbursement of treatment services, it creates demands on the field for the EXPLICIT purpose of decreasing expenditures.  This industry has clearly had an impact on how individuals are diagnosed.  In stage one, personality disorders were excluded from any reimbursement.  The DSM then responded by creating all sorts of other reimbursable categories into which a psychiatrist could "fit" that patient.  More recently the insurance companies for reimbursement considerations have created strata of severity of mental illnesses in which, for example, major depression, schizophrenia and full-blown bipolar disorder are reimbursed more fully than other less debilitating "disorders" such as adjustment disorders, anxiety disorders, etc.

Perhaps one day a historian will go back and rigorously track the developments in the DSM against the developments in the pharmaceutical and insurance industries.    I am convinced that we will see clear concordance.

And as other industries as well as cultural views continue to pressure and influence how we view behavior, thought and "feelings," the DSM will follow in kind.  One example is "Social Anxiety Disorder" as if there is one person who doesn't get anxious speaking in front of a group of people.  The list of inane diagnostic classifications is endless.

In order to keep ahead of the game, the DSM revisionists employ two other strategies.  The first has always been unspoken and is rarely contested: that all behavior, thought and "feeling" is under the purview of "mental health" and its soldiers, psychotherapists (psychiatrist, psychologists, etc.).  Should tomorrow many people start snapping their fingers frequently, the DSMers would have a classification for that in the next revision.  The underlying problem here is that there is no definition of "mental illness" or "mental disorder."

A fine example is just this topic:  NPD.  For years, I frequently have read laying down on my sofa and crossing my legs.  Now I have a knee problem, one that the orthopedic surgeon can directly relate to my bad reading habits.  With proper changes in behavior and stretching, the knee problem is much improved.  So is the case with malignant narcissists.  As this blog pointed out several times, "garbage in, garbage out."  If one goes through life executing malice and then must distort the truth in order to not be caught, one's thinking will become disordered.  That is NOT a mental disorder.  It is the ramification of a habit over which one can exert control.  The DSM makes no distinction between the ramifications of controllable and self-modifiable bad habits versus the ramifications of a process over which volitional control is impossible (e.g., schizophrenia). 

The second DSM strategy is to create categorical buckets so over-inclusive that it is irrefutable.  Hence nearly every "diagnosis" contains a "disclaimer" with language such as, "The present symptoms cannot be otherwise better accounted for by [another] diagnosis."  Or, another sub-category is created to allow for any exception to the rule.  This sub-category is termed "NOS" which stands for "Not Otherwise Specified."  Thus if someone complains of depression of a type that does not fit exactly with the sub-types enumerated in the DSM, that depression is deemed, "Not otherwise specified."

Therefore the DSM "takes all comers."  It is set up in a way that one cannot even attempt to challenge or refute it because it contains inherent escape clauses which are designed only to make it immune from any criticism.  Thus it exists to perpetuate its own existence.  It is a simulacrum; i.e., an image without the substance or qualities of the original.  Simulacra may contain elements of truth (e.g., the DSM's description of schizophrenia), but due to the lack of definition, coherence, mission  and integrity in its core being, its utility is best characterized by where my copy ended up.

One winter, I ran out of firewood...

One postscript.  It may appear that the DSM committee is composed of "academics" and not clinicians.  The distinction today is not very sharp as nearly all "academics" do clinical work.  (I know not a few of them and can vouch for that statement).  In my opinion, psychiatrists have thrown their hands up in trying to understand the "personality disordered" for which, not for nothing, they have little chance of obtaining research funding.  And although they will never publicly admit it, they don't want to even see those "bad and difficult patients" anyway.

The above was contributed by H2tat

Thursday, December 09, 2010

My Two Cents on NPD Being Removed from the Newest DSM

It seems there is some expectation that I have an opinion and need to weigh in on the latest news about NPD and four other personality disorders being removed from the upcoming DSM V since a few people have emailed me about this development. I haven't felt compelled to say anything because I've already stated what my position on psychiatry's labels is. In case you haven't read every word of this blog I'll consent to stating my reaction to the above news. It is more of a non-reaction, really.

Okay, to be systematic about this, the New York Times published an article on November 29, 2010 about the deletion of Narcissistic Personality Disorder from the upcoming DSM. You can find the article here. It is titled, "Narcissism No Longer a Psychiatric Disorder."

Let me state categorically that this deletion in no way affects any of the content of this blog. This blog is established on the authority of eyewitnesses as well as the authority of an objective morality not on the authority of the grand poobahs of psychiatry. I have been unimpressed with the so-called science behind the labeling game of this profession and have stated so on this blog. You know as well as I do that a pen stroke in some stuffy conference room doesn't dismiss the reality of those who are malignantly narcissistic. These pointy-headed academics cannot eradicate the colossal damage narcissists inflict in every realm of human interaction with their decision to shift or erase labels.

Here are a couple quotes from my own blog that should clarify for you how little this news affects my view of anything on this subject. In my article titled, "Narcissist or psychopath....both are human predators" I stated:

Speaking of categorization...I think we would all do well to remember the rather arbitrary lines that have been drawn up for us by the psych community. They are allowed the freedom to re-draw the lines as they deem necessary which only tends to prove the non-scientific nature of the categorization.

Rather a succinct statement for such a windy blogger. But there it is. The labels are not scientific. With this in mind, they can f*&% around with the labels all they want. It won't change a damned thing as far as we are concerned. It will change the way these people are given "treatment", but considering how few actually ever end up in a clinical setting I'm not sure it is going to affect much there either. All this newest deletion of NPD and four other labels does is prove my statement above...once again. Labels aren't science. They are names. What the academic egg heads decide to name a thing isn't going to change my view on those people out there who wreak their damage on everyone in their sphere of influence. Period.

In my blog post titled, "Irresponsible Journalism or Psychologists...or Both" I was talking about the psychoanalyzing of Blagojevich (then mayor of Chicago) going on in the media at the time. The quotes are longer to provide some of the context:

First of all, the so-called professionals love to tell us laypeople that we are not qualified to determine whether or not someone we know has NPD by comparing that individual's behaviors with an checklist. What the article from the Sun-Times illustrates to me is how the 'professionals' are the ones who are unqualified. I think it is highly unprofessional for a psychologist to make pronunciations on someone's mental state to the media when that psychologist has never even met the person in question. They should at least try to uphold some of the standards they hold the rest of us to. They tell us we can't diagnose persons whom we've grown up with or married or worked with for years yet, sight unseen, they can make absolute statements about a person's mental health just from reports they've read in the media and a few pictures of a person? Bah.

This is just one very good illustration of why you should ignore anyone, especially the 'professionals', who tells you that you can't tell whether or not someone in your life has NPD. They don't know Jack themselves. No one knows what NPD is more than someone who has suffered from its predations for years. Eggheads in ivory towers only know NPD from textbooks.

Obviously, I've already expressed how little reverence I have for the labeling game of the professionals. This being the case I'm not affected when they again play with their labels. Whatever. While they're masturbating themselves with their power to pronounce someone mentally ill or "normal" I'm content to know what I know. That is because I know what I know from extensive personal experience. I know what I've seen, heard and lived through, so the labels that are in the DSM, or that aren't in the DSM, don't affect my knowledge or shift my past experience in the least.

I used the label of NPD on this blog because of the ease of communication. It was a convenient label for a couple of reasons. First, because it was an objective listing of behaviors to compare someone's actions to in order to know that we're talking about the same animal. Second, the description of the behaviors and attitudes that this label represented has become rather well known to the general public which means that people who are searching for answers on this subject will usually use the label of NPD. So it made sense for me to use the psychological term for ease of communication and in order to reach as many people out there looking for answers as I could. I didn't use the label of NPD on this blog because I recognize the authority of psychiatry to draw the lines or make the labels correctly in every instance. They had it right with the over-arching description of Narcissistic Personality Disorder so I consented on that basis alone to use their label. They had the label right because it was restricted to describing what is observable about this personality type. Observation is the basis of real science. Therefore I wasn't opposed to using a label that was based on the scientific exercise of what can be observed. Because the label of NPD was a comprehensive, over-arching view of this personality type it has become a good tool for the clinicians out there who have to deal with these people in therapy. This reality tends to prove that the label was an effective description of the scope of behaviors seen in narcissists. Again, another vote in favor of the label NPD.

Even though I am dismissive of the "science" of labels I do recognize the great power this profession wields because of their generally accepted power to label. This profession's ability to apply labels to their fellow human beings has a potentially profound effect on lives. It is a power that is too often misused and can devastate lives. When I apply a label to a person I don't have that kind of power. That is because my labels don't have the authority to put someone into an institution without their consent therefore depriving them of their freedom. My labels can't force a person into therapy. My labels can't deny a person a job or put them in prison. My labels can't make money for innumerable doctors or sell pharmaceuticals. My labels are therefore quantifiably different than those that psychiatry makes. The power to name things is a significant thing when you are called a scientist and have the power brokers of society acceding to your right to make those labels.

All this being said, I suspect that this newest development will not be permanent. The article in the New York Times hints at the internal war that has commenced between the clinicians who actually deal with these people and the academics who largely don't. I'll be mildly interested to see who wins the war. I'm hoping that reality wins. Narcissists are not normal because they exist in large numbers. Narcissists are destructive and often dangerous to others. And by dangerous I don't just mean in the mortal sense. They are dangerous to the emotional and mental well-being of others. They destroy lives without necessarily taking lives. This is not normal. Not ever. The DSM manual may be the bible of the psychiatric world, but it isn't ours. Know what you know and let those in their cloistered halls of academe play their little naming games amongst themselves.