Narcissistic Personality Disorder and Histrionic Personality Disorder To Be Eliminated in the DSM-V: Starbuck’s Diagnostics 101

This article will try to interpret the rationale for the elimination of 5 of the 10 currently recognized DSM-IV-R personality disorders with a specific focus on the Cluster B or “dramatic” personality disorders (NPD, BPD, ASPD and HPD). The New York Times reports in A Fate that Narcissists Will Hate: Being Ignored that:

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition. Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.

The DSM is used by psychiatrists, psychologists, counselors, social workers and other mental health professionals to diagnose different mental illnesses like schizophrenia, bipolar disorder, depressive disorders, anxiety disorders, personality disorders and other behavioral and cognitive disturbances. As stated in the NYT excerpt,  the 5th edition of the DSM is “eliminating” half of the currently recognized personality disorders including 2 of the 4 Cluster B personality disorders; Narcissistic Personality Disorder (NPD) and Histrionic Personality Disorder (HPD).

Does this mean that there will no longer be such a thing as narcissists, histrionics, borderlines and antisocials?

Hope springs eternal, but no. The APA (American Psychiatric Association) seems to be collapsing the existing 10 diagnoses into 5 diagnostic buckets, which means it will probably be even more difficult for the average Joe or Jane to figure out what is going on with their loved one/tormenter. Just because the current members of the DSM committee are doing away with a particular disorder in the Manual doesn’t mean it no longer exists. If only it were that easy!

For example, there used to be a Passive-Aggressive Personality Disorder in the DSM-III, but it was removed from the DSM-IV because women’s groups felt it unfairly pathologized women. This doesn’t mean that these behaviors ceased to exist; it’s just that the APA terminated a specific cognitive-behavioral phenomenon and hid it in Personality Disorder Not Otherwise Specified due to political pressure.

Another example is the APA’s failure to officially acknowledge Parental Alienation Syndrome (PAS) and Hostile Aggressive Parenting (HAP). Numerous studies have been done by credible researchers documenting and quantifying these behaviors. Individuals who have been the target of these pathological and malicious behaviors know full well how real they are. Yet, the APA won’t touch it with a 10-foot pole, probably because it would also assign pathology to a great many women.

Never forget that both the American Psychiatric Association and the American Psychological Association are very political organizations and the DSM is in some ways a manifestation of political infighting, allegiances, prejudices, zeitgeist and feminism. Don’t even get me started on the blatant sexism and male bashing engaged in by Division 35 of the APA; the Society for the Psychology of Women. Apologies for my digression.

What’s staying and what’s going.

I visited the APA’s website to try to understand their rationale for reformulating the personality disorders, but it was the usual mental masturbation that is meaningful only to their planning committees and unfathomable to most practitioners and non-clinical individuals and professions. Currently, the DSM-IV-R recognizes 10 personality disorders plus Personality Disorder Not Otherwise Specified:

  1. Paranoid Personality Disorder
  2. Schizoid Personality Disorder
  3. Schizotypal Personality Disorder
  4. Antisocial Personality Disorder (ASPD)
  5. Borderline Personality Disorder (BPD)
  6. Histrionic Personality Disorder (HPD)
  7. Narcissistic Personality Disorder (NPD)
  8. Avoidant Personality Disorder
  9. Dependent Personality Disorder
  10. Obsessive-Compulsive Personality Disorder

They plan to collapse these 10 into the following 5 buckets:

  1. Antisocial/Psychopathic Type
  2. Avoidant Type
  3. Borderline Type
  4. Obsessive-Compulsive Type
  5. Schizotypal Type

The APA seems to be folding NPD and HPD into the Antisocial/Psychopathic Type; while the Borderline Type shares 2 of the 3 traits I view as being the most sociopathic with the Antisocial/Psychopathic Type: Antagonism: Aggression and Antagonism: Hostility. Aggression is defined as “being mean, cruel, or cold-hearted; verbally, relationally, or physically abusive; humiliating and demeaning of others; willingly and willfully engaging in acts of violence against persons and objects; active and open belligerence or vengefulness; using dominance and intimidation to control others.”

Hostility is defined as “irritability, hot temperedness; being unfriendly, rude, surly, or nasty; responding angrily to minor slights and insults.” I am surprised that Antagonism: Callousness is not included in the Borderline Type, which is defined as “lack of empathy or concern for others’ feelings or problems; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; exploitativeness.”

Interestingly, I was lambasted a few months ago for stating on the old Shrink4Men WordPress blog that many narcissists, borderlines and histrionics exhibit sociopathic traits. A group of self-identified BPDs and their cohorts cyber-bullied and harassed me for several weeks as a result of what I viewed simply as a statement of the obvious. It would seem that the DSM committee agrees with my viewpoint, at least in this case.

So, why is the DSM committee doing this and what does it mean?

Starbuck’s Diagnostics: I’ll take a Non-Suicidal Ideation, Non-Substance Abuse and Non-Physical Violence, Half-Antisocial/Psychopathic—Half-Borderline Type with Entitlement, Rage, Meanness and Blame Latte to go, please.

Here’s the rationale for reformulating the Cluster B personality disorders from the APA website:

Considerable research has shown excessive co-occurrence among personality disorders diagnosed using the categorical system of the DSM (Oldham et al., 1992; Zimmerman et al., 2005). In fact, most patients diagnosed with personality disorders meet criteria for more than one. In addition, all of the personality disorder categories have arbitrary diagnostic thresholds, i.e., the number of criteria necessary for a diagnosis. PD diagnoses have been shown in longitudinal follow-along studies to be significantly less stable over time than their definition in DSM-IV implies (e.g., Grilo et al., 2004). The reduction in the number of types is expected to reduce co-morbid PD diagnoses, the use of a dimensional rating of types recognizes that personality psychopathology occurs on a continuua, and the replacement of behavioral PD criteria with traits is anticipated to result in greater diagnostic stability.

I know, shrink-speak is needlessly difficult to understand, so let me break it down for those of you who aren’t fluent in academic, semi-scientific psychobabble. The DSM committee’s reformulation seems to be trying to address a problem many of the Shrink4Men community members and my coaching-consulting clients have raised repeatedly. Namely, that your wife, girlfriend, ex, husband’s ex, boyfriend’s ex, mother-in-law, sister-in-law, etc., seem to have traits from more than one disorder. This is why many practitioners/authors in this field, including myself, explain these disorders as lying on a continuum; different traits manifest under different conditions and in different settings. Not all narcissists behave the same; not all borderlines behave the same and many share diagnostic criteria from one or more disorders.

Essentially, the DSM committee is taking a Starbuck’s approach to diagnosing personality disorders. For example, you take a base beverage like coffee or tea and you can order dozens of variations of it like a half-caff, non-fat, soy, chai, decaff, double espresso, cinnamon, mocha latte with extra sugar or no sugar or specific increments of sugar. Apparently, diagnosticians will now be able to do the same with PDs. New PD diagnoses might look something like this:

Alexa seems to be a Borderline Type with extreme Aggression, Emotional Lability, Separation Insecurity and Hostility, mild Self-Harm and Impulsivity and very little Dissociation Proneness and Callousness. Monica seems to be a Sociopathic/Psychopathic Type with extreme Callousness, Hostility, Aggression and Maliciousness, moderate Deceitfulness and Narcissism and very little Recklessness and Impulsivity.

I suspect that individuals who have traits from multiple types will continue to receive multiple diagnoses. Keep in mind, they haven’t finalized the DSM-V yet, so all of this may change.

Therefore, the APA isn’t really getting rid of NPD and the other PDs, but rather trying to define them with more specificity by using descriptive traits that they can rate based on their presence/absence and degree of intensity. Hopefully, this will eventually make it easier to get an accurate diagnostic assessment of personality disordered individuals for treatment purposes and to know what you’re up against if you’re in a relationship with a PD person—that is if you can get them into treatment and if they they’re unable to pull the wool over a clinician’s eyes.

Criticisms of Starbuck’s Diagnostics

Two of the most strident critics of the proposed PD diagnostic system are esteemed Harvard psychiatrist, Dr John Gunderson, a leading researcher and practitioner in the field of personality disorders and University of Colorado Medical School psychologist, Dr Jonathan Shedler. The NYT article reports Dr Gunderson’s reaction to the changes:

Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how “unenlightened” the personality disorders committee is. “They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment. “It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”

Dr Gunderson’s primary complaint in NYT:

The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians. It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type. And clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Dr Jonathan Shedler states in the same NYT article:

“Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”

The bottom line.

Oh look, more political infighting amongst and between both APA factions. Yawn. Only time will tell if this will be helpful or harmful. Although, at this stage it’s unclear whom this change will harm and/or help. If, like me, you’re of the mind that many PD individuals are treatment resistant, these changes don’t really matter. My primary concern is, always has been and always will be helping the targets who are abused by individuals with PDs—regardless of how the DSM decides to classify them.

If the changes help non PD individuals protect themselves and their children in family court, for instance, that would be great. If it helps men and women avoid becoming involved with abusive PDs–super. However, this seems like more political-academic infighting and a new scheme to create diagnoses and treatment plans that Managed Care companies will reimburse. Whatever.

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Dr Tara J. Palmatier provides confidential, fee-for-service, consultation/coaching services to help both men and women work through their relationship issues via telephone and/or Skype chat. Her practice combines practical advice, support, reality testing and goal-oriented outcomes. Please visit the Shrink4Men Services page for professional inquiries.

Citations

  • Grilo CM, Shea MT, Sanislow CA, Skodol AE, Gunderson JG, Stout RL, Pagano ME, Yen S, Morey LC, Zanarini MC, McGlashan TH: Two-year stability and change in schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.  J Consult Clin Psychol 2004; 72:767-775
  • Oldham JM, Skodol AE, Kellman HD, Hyler SE, Rosnick L: (1992). Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity. Am J Psychiatry 1992; 149:213-220
  • Zimmerman M, Rothchild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 2005; 162, 1911-1918


Comments

  1. says

    Well, we can look on the bright side. If it’s not classified as a “disorder” then maybe evil, abusive women can stop using the crutch of “I can’t help how I treat you. I have a disorder.” Maybe they can start taking responsibility for their behaviors, even if it’s forced. Yeah, right. I know I am dreaming about them stepping up to the plate and saying “I treat people poorly because I have learned that by being a manipulative bully who holds people emotionally hostage I can get what I want.” However, if it’s not a “diagnosis”, then maybe others around them will stop enabling them and excusing their bad habits of abuse.

    • Verbal says

      Also, disordered women will no longer be able to use the dismissive, “I don’t have a personality disorder. You’re the one with a personality disorder.”

  2. Anonimos_Non says

    Pardon my rambling, but it here goes:

    It is our ability to name things that allows us to make distinctions and gain power over our environment and circumstances — science requires that we have precise ways of communicating. Further, clinicians and legal authorities either should adhere to, be guided by, and insist upon evidence-based practices and standards. To me, consolidation of Personality Disorders in the DSM V is tantamount to Psychiatric “Newspeak” http://en.wikipedia.org/wiki/Newspeak . I agree with you completely that consolidation of Personality Disorders in the DSM V mean that “it will be even more difficult for the average Joe or Jane to figure out what is going on with their loved one/tormenter.”

    My intuition tells me that the “Starbucks” approach to such diagnoses will likely backfire and be detrimental to men caught up in the legal system — especially cases where such men are up against those with High Conflict Personalities. IMHO, rather than consolidate such PD diagnoses, it would be better to document and codify the relationships and potential co-morbidities between apparently separate medical conditions and/or personality disorders. For example, as Dr. Randy Sansone has mentioned in his article, “Fibromyalgia and Borderline Personality: Theoretical Perspectives” In: Focus on Fibromyalgia Research ISBN: 1-60021-266-2 Editor: Albert P. Rockne, pp. 127-141 © 2007 Nova Science Publishers, Inc. :

    “POSSIBLE RELATIONSHIP MODELS

    If future empirical studies confirm, among a minority of fibromyalgia patients, a
    relationship with BPD (Borderline Personality Disorder), what might the explicit relationship between the two be? To address this question, we might consider several theoretical models.

    Independent Co-Occurrence Model

    This model proposes that fibromyalgia and BPD actually have no genuine relationship to one another. Their association, or comorbid occurrence, in an individual is simply one of random chance. In other words, they independently co-occur.

    Common Causality Model

    This model proposes that both fibromyalgia and BPD share a common etiology (i.e. they are caused by the same phenomena), but have slightly different presentations and disease processes in the same individual. In other words, both originate from the same cause, but develop into somewhat different diseases.

    Spectrum Model

    This model proposes that fibromyalgia and BPD share similar etiologies as well as
    similar courses. Indeed, the two are not really distinct from one another, but are actually versions of the same disease phenomenon—i.e., they both exist as closely related spectrum disorders.

    Predisposition Model

    In this model, one syndrome precedes the other. In doing so, the first heightens the risk of developing the second. In this case, one would suspect that BPD is the forerunner disorder, which then subsequently heightens the risk of developing fibromyalgia.

    Whether any of these relationship models accurately describes the comorbidity of
    fibromyalgia and BPD is unknown. However, the spectrum model is appealing. Regardless, these models provide an interesting panorama of possibilities for future research.”

    We humans begin creating (and destroying) everything around us through our words. I concur with Dr. Gunderson’s assessment that a “careful dresser” can all-too-easily become a “dandy” or “clotheshorse” at the caprice of a clinician, psychiatrist, psychologist or others with an agenda. In their efforts to be precise and accurate, they may end up being more arbitrary and prejudiced. In any case, the changes apparent in the DSM V scare me precisely because of the politics involved, the infighting amongst DSM committee members, the profit motives on the part of insurance and pharmaceutical companies, and the potential for abuse by legal systems that are increasingly biased against men.

  3. Cousin Dave says

    I’m inclined to go with Dr. Shedler’s statement: this makes a sort of sense from a research standpoint, where you want to be able to precisely quantify characteristics. But from a clinical standpoint, I can see where it will cause great difficulty in making or understanding a diagnosis. One possible fallout from this is that it will make it much harder to get insurance to pay for treatment for a (formerly) Cluster B personality disorder, since the disorder can’t be tied to a specific syndrome name in the DSM. The ironic consequence is that, for the few NPDs who actually seek treatment for their condition, it will make treatment much harder to get.

  4. dietrich says

    Interesting, but it’s important to remember that these ideas and formulations are still in embryo.

    Personally, I think compacting the PD category is a good thing. Certain PDs are rarely, if ever, diagnosed. In 13 years of working in clinical settings, I’ve never seen someone diagnosed as ‘schizotypal’. Dependent, avoidant, and schizoid PDs are also very, very rare.

    It makes sense to cluster them together, as there is significant overlap, but I agree that rating multiple traits is tedious and trivializes the process of diagnosis.

    • moundbuilder says

      I believe ‘schizoid’ has been thought to possibly be the same thing as Asperger’s, which is on the autism spectrum. If the two are one in the same that possibly it does make sense to drop that from the list of personality disorders. Since autism spectrum issues are developmental, as I understand it, then it doesn’t seem to consider that a matter of personality disorder, if ‘schizoid’ and Asperger’s are one in the same.

  5. Jazok says

    I’ve been thinking about this and am leaning toward it being a good thing. The old categories seemed to insist on placing someone in a bucket. Disorders aren’t a continuum, only aspects of them are.

    I believe EVERYONE has traits which could be classified individually as a disorder. The question is how they add up, overall.

    In the quest to figure out what to do about my marriage, it’s become clear that my wife has several strong straits in the current borderline personality disorder “bucket”, but has no indication in others outside of normal human behavior. One thing that you have to be very careful about is not assuming that because a person shows traits A, C and F, therefore she must have B, D and E and begin seeing what you want to see.

    • Ming_on_Mongo says

      Some of the newer research in neuroscience is actually providing evidence of more of a “continuum” approach, due to the phenomenon of common affected areas of the brain. For example, it’s become well-known that all the former “cluster B” disorders share a common absence of empathy. But it’s also been discovered that this capacity for empathy is located in a specific portion of the brain, the pre-frontal cortex. What’s more, the frontal brains of Psychopaths, the most serious of the cluster B’s, have been found to match those of people suffering frontal brain damage. “Continuum” indeed!

      But if we’re going to reduce the number of “buckets” for adding “characteristics” to, then it would seem that at least one basic and essential bucket should be Narcissism, which is already well recognized, and is often used as a starting point for so many other “co-morbidities” (BPD, ADD, OCD, Depression, etc.).

      Although how “convenient” at a time of increasing encroachment by “science”, that this new psychiatric paradigm, will now more than ever require an individualized, “private” opinion, albeit one more resistant to “outsiders” second-guessing the DSM!

  6. Dave M. says

    I dated a single mom in 2000. She had a difficult situation with her ex and had to take a psychological evaluation. 2 weeks later she called and said “they said I have a Narcissistic Personality Disorder.” She went on to say that, it says I have this trait and that trait naming off 4-5 different traits. It was like a light going off over my head, as she was all those things. My daughter’s mom is a Borderline Personality Disorder and I know 2 Histrionic Personality Disorders. To eliminate these is an injustice to people who gain insight and knowledge of people we run across and are involved with in our everyday lives.
    They are making a big mistake in the DSM-V as far as I’m concerned.

  7. TheGirlInside says

    I tend to think it’s a good thing.

    From this site and other reading (not to mention personal experience), I see the dirorders as ‘degrees of psychosis.’

    Meaning, Histrionic may be the mildest, moving on to
    Borderline, then even worse / more destructive
    Narcissistic Personality Disorder*
    then the most dangerous: Antisocial / sociopath

    Like different articles of clothing, sewn using varying patterns, yet all cut from the same cloth.

    Also, I think it’s good that they will be able to ‘make a salad’ of different tendencies…from my limited education of psychology, I understand people are often diagnosed with Mental Illness X with Y and Z tendencies.

    On a personal note, I believe most of the above mentioned personalities are simply different ‘recipes’ of a**hole. Just as there’s about a billion different ways to make equally delicious chocolate chip cookies…there’s about that many different ways of being an A #1 A-hole.

    *One thing that bugs me about the ‘official’ symptoms / diagnostic critera for NPD, is that they define how a narcissistic thinks (per the DSM-IV):

    1. a grandiose sense of self-importance
    2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
    3. believes that he or she is “special” and can only be understood by, or should associate with, other special or high-status people (or institutions)
    4. requires excessive admiration
    5. has a sense of entitlement, ie unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations
    6. is interpersonally exploitative, ie takes advantage of others to achieve his or her own ends
    7. lacks empathy and is unwilling to recognize or identify with the feelings and needs of others
    8. is often envious of others or believes that others are envious of him or her
    9. shows arrogant, haughty behaviours or attitudes

    in order to truly diagnose a narcissist by those criteria, you have to know what they are truly thinking…and there’s no way for anyone else to know that. Annoying.
    Dr. Tara, thankfully, cuts through the psychology-speak to give us real-life applicable defining characteristics.

    • Ming_on_Mongo says

      Having been married to an NPD/BPD (clinically diagnosed), seems to me that all those symptomatic ways of “thinking” do manifest as pretty specific (and not so pleasant) “behaviors”! And as I’m sure anyone who’s had any significant experience with them can attest, after awhile you acquire pretty good “antennae” for picking up on all the “cues”.

      Among the ones I find easiest to notice is the “entitlement”, where they very quickly indicate some way in which the typical “rules” or common courtesies don’t apply to them somehow, due to some special “circumstance” or “condition”. Also the well-known absence of empathy, and I think also a lack of humor, are others, although you have to be able to have a little more experience around them to detect that.

      But if you suspect it, one easy way I’ve found is to simply bring up the general subject of narcissism (social, clinical or otherwise) and observe what happens. An “N’s” strong need for “control” will soon surface, along with their hyper-sensitivity to any perceived criticism (because it’s always all about ‘Me”… even when it isn’t)! So they’ll often be the folks who seem curiously “uncomfortable” or “annoyed” with the whole subject, which they’ll quickly try to control via “re-framing” the discussion, usually thru some haughty and dismissive explanation, or else with what’s basically just a solipsistic argument (“it must be so, because I think it is)! ;-p

  8. Jdog says

    If you have been a victim of a narcissist or psychopath (or borderline), you probably will react differently to this decision than someone who has an academic interest.

    Unfortunately, the word “evil” tends to spring to mind with NPD, ASPD, and BPD.

    The distinction I’ve always thought helpful is those narcissists/psychopaths who go to prison and those who don’t (the socialized vs non-socialized) – now they are all being lumped together more closely. The “white-collar” types are far more dangerous; we meet them in the office and marry them and they do so much to destroy others.

    It is extremely frustrating to see “narcissism” popularized in a non-clinical way and see in the popular press how we live in a narcissist culture, when someone with a true disorder does untold damage in their relationships and communities. For that reason alone, a single “narcissistic personality disorder” is extremely useful. The better we can distinguish behaviors, they better they can be recognized and dealt with. Collapsing them seems to be a way of running from the clinical realities of these disorders.

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