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


  1. This American Live had a segment dealing with the DSM and classifications of mental illness, specifically the removal of homosexuality as a mental illness. Those following the development of the DSM V might find this episode particularly interesting.

  2. Can you please give a link to your original post about the removal?

  3. You can now click on the highlighted words "last post on this blog" and it'll take you there.

  4. A skunk by any other name still smells like a skunk. So it is with malignant narcissists, sociopaths, psychopaths, or whatever they are called.

  5. How very well written, I absolutely agree with you view on this subject.

  6. Anna...

    will we be blessed in 2011 with more blog posts from you..?

    I can only pray!

    Thank you so much for your wisdom and insight!


  7. There is no way to predict that, Don. Keep prayin'. *grin*

  8. I am really confused. My father was a psychopath but does that mean he was automatically a narcissist?
    I always thought my mother was a N too but she is not that mean. Do you have to be really mean to be a N?

  9. All psychopaths are narcissists... but not all narcissists are psychopaths.

    The definition of narcissist doesn't include a scale of meanness. Some narcissists can hide their predatory behaviors behind a veneer of do-good-ism and can appear, on the surface, to be normal people.

  10. Come back to your blog. I miss your postings.

  11. Ahh, it was not the spam-hammer that my comment fell prey to.

    My apologies to blog author!

    - Like your other readers I too will be very interested in updates if you learn more about this topic. It's of interest and can be of consequence also for a lot of people, so it's highly valued when someone with your education bothers to share what you learn and what you think about it.

    Be well...

  12. I am more than half way through reading this blog, Anna I'm so glad you created this blog it has literally been a life saver.

    I just have one quick observation before I continue reading. Did anyone notice that animated movie Tangled that recently came out tells the story of a daughter living with a malignant narcissist!? The movie is a modern adaptation of the Rapunzel story. A woman steals a child and locks it away using its magical powers to maintain her youth, without which she can't live. Narcissistic supply anyone?

    Thanks so much Anna for creating this blog, its been really helpful.

  13. Anna,

    Thank you so much for your blog! It has shed so much light on my life.

    I wanted to pass on some info to you. Is the email address on your profile current? Thanks!

  14. I'm very thankful for this blog. During my very painful and unwanted divorce, I came to the conclusion that my husband (along with his father, grandmother, and possibly sister) was a covert narcissist. We have joint custody of our children, so I can't go completely NC, but I've cut off communication as much as possible and it's helped a great deal. Except for the occasional (but increasingly rarer) outburst of anger toward him for how he's treated me, I'm doing pretty well. This blog, along with the book "The Wizard of Oz and Other Narcissists", have been instrumental in my healing.

    I worry about my children, though. My oldest, who is 13, shows some tendencies toward entitlement and narcissism, and I'm a bit at a loss as to how to deal with that. I'll be reading thru this blog again--and praying a lot.

    God bless all of you! : )


    It looks like they won't be removing it after all!

  16. Help me out here. Both my parents have NPD (imo). I am intrigued by two conflicting thoughts in relation to NPD. On the one hand, nearly everyone in these forums is convinced that 'they can't change'. Don't try. Go 'no contact'. But in this blog, and especially in the above discussion, NPD is described as a 'choice' of habit. Is it really? Do those with NPD have a choice? They have developed their disorder remarkably young, it seems to me. My mother pinpoints it to when she was 2 and forced to abandon her primary caregivers and immigrate. A wound she has never recovered from. How much agency does she have? And can I, her daughter, have any expectation that this otherwise intelligent and politically and socially wise woman can redress her narcissm? Its confusing. I'm also not at happy about the black and white thinking in the ACON community. I don't want to go down that path. But I must admit, that giving myself a break through No Contact is such a relief. I'm very reluctant to re-engage, though I know she (and my father) do have worthwhile qualities. Love to hear more on the abiltiy of NPD's to learn (or not).

  17. Frothi,

    It really isn't important to know for sure whether or not a narcissist can change. If they can, they will have to make the change themselves. We can't do it for them. If they can't, well, either way we have to decide what we can do. We either stay and accept the reality "what you see is what you get", or you go no contact. Those are our choices.

    You really don't need to get hung up on whether or not the narcissist can change, is able to change, isn't able to change... you just need to decide what you must do based on what is. Presuming that 'what is' is what it will likely continue to be is the wisest course. For many, "no contact" is an option, and it is a good option. I also recognize that it can't always be an option for everyone which is when the concept of "limited contact" is an option that can help limit the damage a narcissist inflicts. You don't have to psychoanalyze the narcissist. You just need to make the best decision for yourself going forward.

  18. Thanks :-) That rings true, and gives me something to chew over. Course chewing over is what we seem to be very good at! Which is your point. Thanks again.

  19. my mother is a pathological n. when i was younger i had a fantasy where i dosed her with lsd and she would be able to realize her four children are people not extensions of herself. i realized she is addicted to narcissistic supply and she would eventually fall back into her ways. there would need to be something that made her accept that she is narcissist ,the pattern of her behavior and to try to think differently. i dont think lsd would do that, i think only something perfectly catastrophic would be the needed catalyst. my point is i believe its possible but many n brains are well entrenched in their habits and "redemption" near impossible