“Narcissistic Personality Disorder” Gets the Good Boot

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013) will feature five, instead of ten, personality disorders.  Among the casualties, and the most controversial of the cuts: narcissistic personality disorder.

They’re slimming the psychiatric menu?  Isn’t that vaguely un-American?  Aren’t we about endless proliferation, about 36 available variations, and growing, of shampoos and deodorants and tackle boxes and yoghurts and chairs?  Isn’t this endless capability of catering to every idiosyncratic niche of sufficient number what makes America great?  Isn’t that why a quarter of the world’s economic activity takes place in the United States?

From the bargain bleachers, watching professional psychology politics, I feel good and I cheer.  My team is the one doing the cutting.  Not my team because I really understand what they’re doing.  Just the town of Occam where I was born.

Paring the list of official personality disorders doesn’t mean there are no narcissists after all.  It just means the way narcissists are diagnosed and, if they need it, treated, is a little more open-ended.  Psychologist Charles Zanor, writing in the New York Times, describes the warring camps as the dimensional approach versus the prototype approach.  The new dimensional approach is “a method of diagnosing personality disorders that … makes an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient.”  In other words, fewer threshold categories, and a mess of individual profiles.

The “prototype approach that has been used for the past 30 years” uses more threshold categories with clusters of traits (like “narcissistic syndrome”) and “matches patients to that profile.”

How could that difference possibly matter?  Think of it this way.  You want a burger with bacon, cheese, mushrooms, no onions and no lettuce, extra mustard, hold the mayo, goodfriggingod no ketchup, and extra pickles.  Two restaurants.  One features “Burgers,” and lets you pick all your preferences.  The other features six different kinds of burgers, no substitutions.  The burger you really want isn’t one of them.  The latter restaurant is more efficient.  They train their staff to do six burgers, and they do them very well.  The first restaurant caters to you, even though it’s chaos in the kitchen dealing with sixty-five million different burger combinations.

How brilliantly American the dimensional approach.  More mistakes happen in the restaurant that lets you choose whatever you want, but most of these mistakes are incidental (forgot the extra pickles), and easily corrected.  American culture ravenously uses mistakes, eats them for breakfast.  American soldiers thrown into World War I were initially terrible, lessons were quickly learned, and Americans became a decisive force for victory.

At issue in the Great War between the dimensional and prototype approaches is the comfort of the clinician, the psychologist treating this or that patient.  Yes, it’s easier for the prototype psychiatrist, less uncertain, to have a fixed menu, and proceed accordingly.  And yes, I suggest, it’s better for the dimensional psychologist to dwell in uncertainty a little longer.

The human brain is wired to loathe uncertainty — no less the brain of the typical clinician.  But maybe the best clinician possesses “negative capability,” what the poet John Keats described as the capability “of being in uncertainties, Mysteries, doubts without any irritable reaching after fact & reason.”  That is to say, the longer the clinician can bear the mental agony of not categorizing, of resisting the sirenic tug of the formulaic decision tree, the better, on balance, the result.

I say the foregoing with great sympathy for the clinicians.  Their decisions to adopt this or that framework do not occur in a vacuum.  Unlike the theoreticians, they deal with patients, very real and often very frightened human beings, who demand answers, and who themselves experience the agony of uncertainty and profoundly wish it dissipated.  That is precisely the appeal of the prototype approach.  You are this, and here are the steps we must take.

That doesn’t mean I get my burger the way I want it.  American pragmatism drives toward the greatest satisfaction.  John Dewey credited John Keats’ “negative capability” with influencing his driving American philosophy of pragmatism, because you never know for sure, but you persist.  (Keats may have been comfortable without the latter, but we’ll never know.)  It’s hard work, personality disorders, but you persist.

Yes, let there be fewer categories, fewer decision trees, and fewer easy pharmacology solutions.  Let it be uncertain a little longer.