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NPD removed from new DSM, any thoughts?

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NPD removed from new DSM, any thoughts?

Postby wodienjong » Mon Nov 11, 2013 8:22 pm

I recently read that NPD is one of the disorders they will be removing in the new DSM. This was surprising for me because it seems like there is a lot of literature about NPD. However, I also see how it could be the case that it isn't real, because most of the traits can be explained by other disorders.

Anyone else have any comments on this?
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Re: NPD removed from new DSM, any thoughts?

Postby Esquire » Mon Nov 11, 2013 8:46 pm

NPD is one of the most misunderstood psychological orientations out there. I think the reason is that there are probably very few NPDs who are actually willing to come forward and be studied. Why would someone choose to have their name attached to something with such negative popular connotations? The reason psychiatry knows so much more about Psychopaths is that many Psychopaths end up in criminal custody, and thus are able to be studied. Narcissism correlates, I imagine, with very low rates of criminal activity.
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Re: NPD removed from new DSM, any thoughts?

Postby wodienjong » Tue Nov 12, 2013 7:28 am

Well, I think I've read somewhere before that most psychopaths are narcissistic, so wouldn't that give as access to a lot of subjects for NPD as well?
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Re: NPD removed from new DSM, any thoughts?

Postby margharris » Tue Nov 12, 2013 8:12 am

Narcissistic personality disorder is in the DSM 5. There was a proposal to have it removed to allow for more hybrid type modelling that recognized many people were comorbid with more than one type. The thinking was that clinicians were getting it wrong with distinct categories and subtyping. Due to public outcry the suggestion was dropped. Still the movement is away from discrete classification to a more global understanding of personality disorders. One might expect these changes to filter in over time so that eventually we might see a person diagnosed with a personality disorder with certain specific features or traits and certain problems that can be selected from a comprehensive itemized list. The diagnosis will then be individualized. Those of us raised on labels might not like this approach.

If you notice the work of addx, he often speaks in very fundamental terms that resonate with a defensive thinking that could be attributed to most of the pds. This is the type of approach that dispenses with the label and recognizes the behaviour. Marg
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Re: NPD removed from new DSM, any thoughts?

Postby Nightdrive » Tue Nov 12, 2013 2:30 pm

So perhaps in the future they might do away altogether with the idea of a specific 'personality disorder', and offer treatment based on the individual's particular traits instead? I can see how that would be useful, but surely labels would still be necessary for diagnosis. What would someone be diagnosed with?
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Re: NPD removed from new DSM, any thoughts?

Postby Esquire » Tue Nov 12, 2013 4:47 pm

wodienjong wrote:Well, I think I've read somewhere before that most psychopaths are narcissistic, so wouldn't that give as access to a lot of subjects for NPD as well?


Narcissism and Psychopathy have some overlap, but ultimately are two distinct things. The Narcissist and the Psychopath share certain traits in common, including: lack of emotional range and depth, lack of empathy, the ability to be charming and convince others to like them, highly manipulative, and a view of morality that is quite different from most others (some would say amoral or lack of conscience, but that doesn't quite capture it I think).

But Psychopaths have a lot of traits that Narcissists do not have. Psychopaths are calm under pressure, while Narcissists become highly neurotic under pressure. Psychopaths seem to like hurting things, while Narcissists simply don't care when something else is hurt as long as it doesn't impact themselves. Psychopaths also tend towards criminal activity and are highly impulsive, and usually simply attempt to take what they want without regard to the consequences. Narcissists are acutely aware of every potential consequence of every possible action to the point where it becomes ridiculous.

-- Tue Nov 12, 2013 11:55 am --

margharris wrote:If you notice the work of addx, he often speaks in very fundamental terms that resonate with a defensive thinking that could be attributed to most of the pds. This is the type of approach that dispenses with the label and recognizes the behaviour. Marg


Narcissism is an excellent defense mechanism. It's possibly the best defense mechanism possible. A Narcissist will save himself before he saves 50 other people, and would save himself at the expense of 50 other people. He doesn't bond with anyone, so he can't be hurt, and thus it's hard to emotionally manipulate him. He's far too neurotic to commit crimes, or be impulsive, and he drives the speed limit and pays his rent on time. When blamed for something, he will shift the blame, convince the accuser that they are wrong or crazy, or will create guilt, shame, or sympathy in the accuser to get out of being held accountable. The Narcissist never goes down with the ship.
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Re: NPD removed from new DSM, any thoughts?

Postby MirageInTheMirror » Tue Nov 12, 2013 7:38 pm

I think the changes made to the DSM-V for personality disorders make for a significant improvement over the previous diagnostic criteria. The previous definition focused too much on a list of externally observed behaviors, and the new changes shift that focus to something closer to the root disordered thought patterns that make up a PD.

General Criteria for a Personality Disorder (DSM-5)

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains or trait facets.
C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).


The two basic factors that all personality disorders share are 1) a reduced sense of self and 2) a disability in interpersonal functioning. These two factors together are defined as personality functioning impairments. The different named personality disorders each display these basic personality functioning impairments through one or more personality traits out of a given list of 25.

Impairments of Self (Identity and Self-direction) and impairments of Personal Functioning (Empathy and Intimacy) are rated on a scale of 0-4, with a level of 2 (moderate impairment) being diagnostically significant.
Self
Identity
0 Little or no im-pairment - Has ongoing awareness of a unique self; maintains role-appropriate boundaries-
1 Some impairment - Has relatively intact sense of self, with some decrease in clarity of boundaries when strong emotions and mental distress are experienced-
2 Moderate impairment - Depends excessively on others for identity definition, with compromised boundary delineation.-
3 Severe impairment - Has a weak sense of autonomy/agency; experience of a lack of identity, or emptiness. Boundary definition is poor or rigid: may show overidentification with others, overemphasis on independence from others, or vacillation between these.-
4 Extreme impairment - Experience of a unique self and sense of agency / autonomy are virtually absent, or are organized around perceived external persecution. Boundaries with others are confused or lacking.-

Self-direction
0 Little or no im-pairment - Sets and aspires to reasonable goals based on a realistic assessment of personal capacities-
1 Some impairment - Is excessively goal-directed, somewhat goal-inhibited, or conflicted about goals.-
2 Moderate impairment - Goals are more often a means of gaining external approval than self-generated, and thus may lack coherence and/or stability.-
3 Severe impairment - Has difficulty establishing and/or achieving personal goals.-
4 Extreme impairment - Has poor differentiation of thoughts from actions, so goal-setting ability is severely compromised, with unrealistic or incoherent goals.-

Interpersonal Functioning
Empathy
0 Little or no im-pairment - Is capable of accurately understanding others’ experiences and motivations in most situations-
1 Some impairment - Is somewhat compromised in ability to appreciate and understand others’ experiences; may tend to see others as having unreasonable expectations or a wish for control.-
2 Moderate impairment - Is hyperattuned to the experience of others, but only with respect to perceived relevance to self.-
3 Severe impairment - Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering.-
4 Extreme impairment - Has pronounced inability to consider and understand others’ experience and motivation.-

Intimacy
0 Little or no impairment - Maintains multiple satisfying and enduring relationships in personal and community life-
1 Some impairment - Is able to establish enduring relationships in personal and community life, with some limitations on degree of depth and satisfaction.-
2 Moderate impairment - Is capable of forming and desires to form relationships in personal and community life, but connections may be largely superficial.-
3 Severe impairment - Has some desire to form relationships in community and personal life is present, but capacity for positive and enduring connections is significantly impaired.-
4 Extreme impairment - Desire for affiliation is limited because of profound disinterest or expectation of harm. Engagement with others is detached, disorganized or consistently negative.-


Here is also a quick list of the 25 different personality traits associated with personality disorders. They are grouped into the five basic categories of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. (Obviously these are traits that anyone can have, but to be diagnostically relevant it is combined with the personality functioning impairments as described above.)
Negative Affectivity
1. Anxiousness
2. Emotional lability
3. Hostility
4. Perseveration
5. (Lack of) restricted affectivity
6. Separation insecurity
7. Submissiveness
Detachment
8. Anhedonia
9. Depressivity
10. Intimacy avoidance
11. Suspiciousness
12. Withdrawal
Antagonism
13. Attention seeking
14. Callousness
15. Deceitfulness
16. Grandiosity
17. Manipulativeness
Disinhibition
18. Distractibility
19. Impulsivity
20. Irresponsibility
21. (Lack of) rigid perfectionism
22. Risk taking
Psychoticism
23. Eccentricity
24. Perceptual dysregulation
25. Unusual beliefs and experiences


Finally, considering all these aspects of the Personality Disorder in general, the DSM-V defines Narcissistic personality disorder as such:
Narcissistic Personality Disorder (DSM-V)

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain
B. Pathological personality traits in the following domain:
1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert;
self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).


The wording has changed significantly, but the essence of the Narcissistic Personality Disorder definition remains the same.
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