by Michael D. Anestis, M.S.
I came across a fairly bizarre article in the Health section of the New York Times recently and feel compelled to comment on it here (click here to read the actual Times article). Written by Charles Zanor, a psychologist in Massachusetts, the article discusses the pending alterations to the personality disorder section of the DSM in the upcoming DSM-V.
As we detailed in an earlier post, the proposed changes in the DSM-V include a shift away from classic personality disorder diagnoses and towards an evidence-based profile approach in which individuals are scored on various levels of a variety of variables (click here to view the DSM-V page describing all changes to personality disorders). Think of it this way:
- Everybody has a certain level of certain variables (e.g., height, intelligence, age). Rather than report a yes-no answer on whether or not we meet a certain level of one of these things (generally speaking), we tend to report specific levels (e.g., five feet tall, 110 IQ, 30 years old). The new personality system will do the same, recording individuals' levels of a number of traits so as to provide an overall view of their global personality.
Why is this important here? Well, first of all, people are making quite a fuss about the DSM "eliminating" diagnoses. In this case, the uproar is about narcissistic personality disorder (NPD). The thing is, it's not being eliminated. If you look at the list of personality traits that will be assessed in clients, you'll see one entitled antagonism, which is defined by the committe as:
"Exhibits diverse manifestations of antipathy towards others, and a correspondingly exaggerated sense of self-importance."
Taking it a step further, each personality trait includes a list of trait facets to be considered. Listed amongst those for antipathy is...wait for it.....NARCISSISM.
That's right, every client should, in theory, be rated on their level of narcissism. In this sense, not only is narcissism not being eliminated from our assessment of personality, it is being included in a profile system that, in theory, will be utilized in assessments of all clients, thereby INCREASING the likelihood clinicians will assess this construct.
Now, I realize that this is still a marked change from the current diagnostic system, but the thing is, there is essentially no empirical evidence demonstrating that the diagnosis of NPD is a valid and reliable idea (which is the reason it is being massively altered) and there is not a single evidence-based treatment for NPD. Massive changes to an idea that has no evidence supporting that it exists in exactly the way it is described (e.g., number of symptoms required) and for which we have no effective treatments does not seem like a horrific idea to me.
In the article, Dr.Gunderson refers to these changes as "draconian," citing the fact that such a massive amount of change within one diagnostic area has never before been done. The fact that it is being done for the first time, however, does not qualify it as draconian. If it flew in the face of empirical evidence, that would make more sense to me, but it does nothing of the sort. Using this same logic, the decision to make DSM-III based upon observable behaviors instead of psychodynamic principles would also be viewed as draconian and there aren't many people trumpeting that idea. The issue here is the accuracy of the changes, not the scope of the changes.
The final aspect of this article that caught my attention and to which I feel compelled to reply is Dr.Shedler's comment that the committe is made up predominantly of researchers who do little clinical work.
- Question #1: on what basis is this claim made (e.g., how many patient hours were accumulated by each committe member?)?
- Question #2: what evidence is there that somebody with a greater level of clinical activity (should his assumption be correct) make more valid decisions regarding diagnostic criteria?
I completely understand folks having reservations about these changes. I certainly have some and I have voiced them in a number of forums (e.g., the DSM-V website, the online forum of Personality Disorders: Theory, Research, and Treatment). That being said, it is important that, when we voice these concerns, we ensure that they actually reflect reality. If not, things like this happen: misinformation spreads in an internationally renown forum and folks argue about something that is not even happening.
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Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
