By Prudence L. Gourguechon on 2/10/2010 5:20 PM
 The American Psychiatric Association released its long awaited draft of the DSM V, the latest version of the widely used and influential diagnostic and statistical manual. Many psychoanalysts have been uncomfortable with the symptom checklist approach of DSM III and IV, and likely will be similarly uncomfortable with #5. Nevertheless, most if not all of us in psychoanalysis use the DSM, whichever version is current, frequently if not enthusaistically--in justifying treatment to a third party payer, in presenting a case to a non-psychoanalytic group and even for our own internal understanding and classifying of our patients.
For example, if I come to the conclusion that a patient is suffering from Obsessive Compulsive disorder (DSM IV 300.3) rather than Generalized Anxiety Disorder (DSM 300.02) I alter my approach somewhat, though not my fundamental beliefs. I realize some of my colleagues may not do this, and may take great exception to a psychoanalyst so behaving, but that is not my main point right now.
As Benedict Carey wrote in a story in today's New York Times (the DSM V unveiling made the front page, left column)
The guidebook ...largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self indulgence and self-destructiveness--and, by extension, when and how patients should be treated.
An article in The Economist, published earlier this month, stated
Perhaps most profoundly, the DSM influences how mental illness is understood by society at large. (The Economist February 4, 2010)
On of the biggest changes in the new draft, at least as it struck me, is a reconceptualization of the personality disorders. Much of the work of psychoanalysis and psychoanalytic psychotherapy is done in the land of personality disorders, so it is unsettling when "our" terrain is profoundly altered--or even mildly wrinkled. Sort of like the improbable 3.8 earthquake that I slept through in Chicago at 4 this morning. You don't want earthquakes, even mild ones, where you live.
So, they did away with Narcissistic Personality Disorder (DSM IV 301.81). A diagnostic category that has been part of my thinking as a psychiatrist and then a psychoanalyst for, I don't know, almost 3 decades. I've rarely if ever used that on a form of any kind. But I've thought of people that way. "A [a friend] sure is narcissistic but not an NPD." "B's father is such a classic NPD." "In that movie, C is portrayed as such an NPD but there's a sweetness about him". And so on. I've only given non clinical examples, because they tell the same tale. This is a concept for which my brain has a very real referent. I recognize the entity when I see it and reference it using that name. Like a chair maybe. Or not that concrete--maybe like this "I prefer ethnic food to fine dining." I think I know what I mean by ethnic food, and what I mean by fine dining, and when I talk to you I'm assuming with some confidence that you will know what I'm talking about. But neither concept is crisply defined, and either could be unravelled. Does ethnic food include Italian? Does fine dining mean something about quality or cost or both? The phrase means something to me--and to you--yet it is probably not empirically verifiable as a reliable concept. Let's say those 2 word combinations disappeared from my lexicon--how would I say what I said in that simple short sentence; "I prefer ethnic food to fine dining"? "I prefer the type of food that is typical of foreign countries and served in restaurants usually owned by individuals from those countries, where the prices are pretty cheap, to food served in restaurants that are fancy and expensive, and try to create an eating experience that I experience as pretentious and overwrought."
What I've heard from very good sources is that Narcissistic Personality was dropped in the DSM V draft because unlike,say, Borderline Personality Disorder,which was retained, NPD hasn't been found to have construct validity. It doesn't hold together, we can't verify that there is a "there" there when we talk about it. You have to respect that argument. Can something exist that can't be shown in empirical studies to exist?
But how am I supposed to describe friends, patients, colleagues and movie characters who have a Narcissistic Personality Disorder now that the phrase is going to be axed?
The APA is inviting comments on the DSM V draft:
Proposed DSM-5 draft criteria will be available for review and comment at www.DSM5.org from February 10 to April 20, 2010. Health professionals, mental health consumers and family members are invited to visit the site to review and comment on the draft criteria.
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