As you may have heard, the American Psychiatric Association is in the midst of a revision to its Diagnostic and Statistical Manual of Mental Disorders, used to identify different mental illnesses and assign diagnostic labels to patients. This newest edition, the DSM-V, will be published some time in 2013. Among the more controversial changes is the elimination of five of the 10 personality disorders currently listed, the best known of which is Narcissistic Personality Disorder (NPD).
This revision seeks to move diagnosis toward a greater emphasis on descriptive traits, based on the undeniable fact that individuals diagnosed with one personality disorder often demonstrate traits associated with another. As many clinicians have pointed out, the personality disorders exist along a spectrum. I suppose this refinement in the DSM is a step in the right direction as it appears to treat people a bit more like individuals than categories, but I have a more fundamental problem with the idea of assigning diagnostic labels in the first place.
The fundamental assumption behind the DSM is that its categories of mental illness, with their official code numbers, actually correspond to a discrete syndrome exhibited by real people; in this sense, it is meant to be the psychological counterpart of the International Classification of Diseases 9 (ICD-9) used by physicians to diagnose and label physical illness. In theory, applying the DSM-IV label Narcissistic Personality Disorder should carry the same weight and have as much scientific validity as an ICD-9 code for, say, diabetes. The impending elimination of NPD from the DSM-V proves that such an analogy is fallacious. Can you imagine if the American Medical Association suddenly announced it intended to eliminate diabetes from the ICD-9?
The two code manuals are analogous in one important respect, however: insurance companies require a code from one or the other before they will reimburse for services provided. This is the raison d’etre of the DSM: it exists because providers of psychological services must support claims with diagnostic categories and code numbers, just as physicians must do when they treat physical disease. In my view, the analogy ends there. True, there are certain familiar disorders with a proven genetic component (ADHD) or that present in consistent ways (PTSD); but by and large, people who suffer from depression, anxiety, bipolar disorder or NPD do not fall into neat categories. Each psychological “disorder” (if we should even call it that) is unique to the person, no two of them alike.
[NOTE: SINCE WRITING THE ABOVE SENTENCE ABOUT A "PROVEN GENETIC COMPONENT" IN CERTAIN DISORDERS, I HAVE RECONSIDERED AND WITHDRAW THAT STATEMENT; INSTEAD OF DELETING THAT SENTENCE, HOWEVER, I LEAVE IT INTACT AND REFER YOU TO DR. JEFFREY KAYE'S EXCELLENT AND WELL-RESEARCHED COMMENT FOLLOWING THIS POST.]
If it were only a matter of making insurance companies happy, that would be one thing; unfortunately, the general public believes these diagnostic labels have more validity than they actually do. The average person believes the pseudo-scientific claims of the DSM and readily accept the labels. Sometimes this is because people who suffer from mental illness often feel a great deal of shame; to a degree, they feel relieved to have an identifiable clinical syndrome with an official name and code number because it feels less shameful, especially if the doctor tells them it’s a chemical imbalance that can be treated with
appropriate drugs. On websites that function as support groups for certain disorders — among them autism, bipolar disorder, and NPD — I’ve also noticed a subtle pride in the diagnostic label, as if it grants a kind of distinction. I wonder if any of those people will experience the elimination of NPD from the new manual as a kind of narcissistic injury.
These diagnostic labels also have value for the pharmaceutical companies; if they can develop a drug that has a clinically “significant” effect on a disorder enshrined within the DSM, they stand to make billions of dollars because insurance companies will pay for it. Insurers prefer discrete syndromes with generally accepted modes of treatment, which is
one of the reasons why cognitive-behavioral therapy has become so popular. With its easily defined methods and short-term treatment approach, it gives the non-professional evaluating an insurance claim something he or she can understand and approve. Gone
are the days when psychotherapy was a slow, meandering and completely unscientific journey of self-exploration, an inquiry into the meaning of psychic pain.
One of my teachers in graduate school once told me we therapists needed to stop trying to justify our discipline as if it were a science akin to medicine. I couldn’t agree more. Psychotherapists are more like skilled artisans than scientists or physicians; effective therapy depends more on the psychological fit between therapist and client (the emotional capacities and understanding of the former, the trust and courage of the latter) than following a scientifically-based treatment plan for an identifiable syndrome.
People who’ve experienced good results in psychotherapy understand this, but alas, it’s not a point of view accepted by insurance companies, or even the public at large.
Finding Your Own Way:
Here’s a link to a resource based on the Diagnostic and Statistical Manual-IV. Spend a little time browsing around, visit different diagnostic categories and find out how many of their features apply to you. The experience can be a bit like reading the Physician’s Desk Reference and starting to worry about all the “symptoms” you’ve lately been experiencing. My point is not that you should find the diagnosis that best suits you but to highlight the imprecision of diagnosis. People are unique individuals not categories.
Maybe the new DSM-V will resemble a la carte ordering rather than a prix fixe menu, where clinicians can choose from a whole smorgasbord of symptoms. A little bit of NPD with some histrionics thrown in, and a side order of Asperger’s.