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The news that the DSM-V will likely omit narcissistic personality disorder as a diagnosis has created some controversy among clinicians. On one hand, it seems absurd to throw away a classification that describes traits and defenses that we see all around us. Everyone knows someone—hopefully not one of our patients—who has a narcissistic personality structure. Narcissistic defenses are commonplace, and show up everywhere from the boardroom to the locker room. If the disorder is so easy to recognize, and the term describing it is so apt, why would we remove the term from our nomenclature?
On the other side sits the argument that narcissistic personality disorder isn’t real psychopathology. Narcissists are really just unpleasant people who are full of themselves and get rather perturbed when you tell them so. Just because they aren’t nice doesn’t mean they are crazy. In fact, some would suggest that self-esteem is a trait with a bell-shaped distribution—and people at the very high end look pretty much like classic narcissists. Is thinking too much of yourself while seeking fame, praise, and power a sign of deep illness? By that standard, many of our politicians and captains of industry are candidates for an Axis II diagnosis.
Perhaps the biggest problem with keeping narcissistic personality disorder in the DSM is that we don’t really know how to treat it. With all due respect to Kernberg, Masterson, and Kohut, there is no treatment for narcissistic personality disorder that has any empirical support. There is no evidence that we have found anything that reliably works with these folks. (Except age—the problem seems to lessen as people get older and beaten down by life.) The purpose of diagnosis is to point clinicians to a reliable treatment. Otherwise we are simply drawing a circle around arbitrary groups of symptoms and having fun giving them labels. The exercise may be intellectually satisfying, but it hardly advances clinical science.
If we consistently applied the standard that a diagnosis should always connect to a treatment specific for that disorder, we would have to throw many more “disorders” out of the DSM. Of course, doing so might be a good idea since the DSM is such a poor instrument for helping us choose appropriate or effective treatments. That, however, is a long conversation for another time.
—Matthew McKay, PhD
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New Harbinger will be attending the following professional conferences in 2011- we'd love to see you!
March 23-27, Psychotherapy Networker (PTN)- Washington, DC- booth 100-102
August 4-7, American Psychological Association (APA)- Washington, DC
November 10-13, Association for Behavioral and Cognitive Therapy (ABCT)- Toronto, Ontario, Canada
The Dialectical Behavior Therapy Diary
Real Behavior Change in Primary Care
Psychology Moment by Moment