The Great DSM-5 Personality Bazaar

By James Phillips, MD | November 7, 2011

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Both the DSM-5 Web site¹ and Psychiatry News² have recently heralded the proposed DSM-5 revision for diagnosis of personality disorders. The end product of much dodging and weaving on the part of the Work Group (eg, narcissistic personality out/narcissistic personality disorder back in), the revision is touted to resolve problems inherent in the DSM-IV treatment of personality disorders: it recognizes the dimensional character of personality traits and disorders, and it moves beyond the dichotomous (present or absent) strictures of DSM-IV diagnosis.

Those accomplishments granted, the news is not all good regarding the new model. A good look at the DSM-5 Web site (I wanted to say a “quick” look, but a quick look will leave you deeply confused) reveals a degree of complexity worthy of the finest medieval scholastic philosophers. If the current version seems disorienting, bear in mind that it was worse. The DSM-5 site notes, remarkably, that “Since its original posting on the APA’s DSM-5 Web site in February of 2010, all parts of the model have been simplified and streamlined in response to comments received and to critiques in the published literature.”³

The site also informs us that “The goal of the new criteria is to maximize their utility to clinicians and benefit to patients.” And the Psychiatric Times articles quotes Drs Oldham and Skodol as saying that “the system will require some training, but that once clinicians familiarize themselves with the criteria, they will find the system easier to use than DSM-IV, more intuitive, and more reliably concordant with the clinical presentation of patients with personality disorders."² Surely they jest—but judge for yourself.

The new list
In this posting I want to focus on the unwieldy complexity of the new Personality Disorders section, but first let me note the revised list of personality disorders. The work group reduced the DSM-IV list from 10 to 5 (and then to 6, when narcissistic personality disorder was reintroduced following objections from the rank and file).

For each of the disorders removed from the DSM-5 list the explanation given is that “The Work Group recommends that this disorder be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.” Anyone wondering how the decisions were made is on his own. For this reader at least, paranoid personality disorder (removed) is a readily identified personality disorder, and easily as worthy of inclusion as avoidant personality disorder (retained).

Doing the assessment
The assessment begins with Criterion A, Level of Personality Function, presumably to be part of every patient’s evaluation. The Levels of Personality Function Scale is a five-point rating scale for two domains of personality functioning—Self and Interpersonal. Under Self are subdivisions of Identity and Self-direction, and under Interpersonal are Empathy and Intimacy. This criterion will let us know whether and to what degree any patient has a personality dysfunction. Aside from issues of uncertain scientific foundation and laborious implementation, this scale is notable for its reintroduction of psychological and psychodynamic features that had been banned from DSM-III. Assessing someone’s capacity for empathy is not the same as checking for sadness or insomnia, and will take considerably more time as well as psychological sensitivity. I can ask someone if he feels sad, but I’ll have to talk to him at some length to determine his capacity for empathy.

Criterion B moves from general personality dysfunction to presence of one of the six disorders. Rather than just naming the criteria for each personality disorder, this criterion uses another architectonic structure in which pathological personality traits are assessed under five broad personality trait domains—negative affectivity, detachment, antagonism, disinhibition versus compulsivity, and psychoticism, as well as component train facets like impulsivity and rigid perfectionism for each of the five trait domains. Needless to say, another scale, the 4-point Personality Trait Rating Form, is administered to score the individual on these traits, and the particular personality disorder is defined in terms of particular trait clusters. (Are you confused? Just remember the reassurance that you will find it easier than DSM-IV.)

To deal with the person with significant personality disturbance who does not reach the threshold for a particular personality disorder, a diagnosis of Personality Disorder Train Specified (PDTS) can be given along with the relevant traits.

Evaluating the evaluation
There is something quite elegant about the DSM-5 Personality Disorders diagnostic system—an architectonic of divisions, subdivisions, and sub-subdivisions. On the other hand, for all their scholastic erudition, the work group have created a monster—a bloated, pedantic, cumbersome diagnostic instrument that will never be used by anyone working in the hurly-burly of clinical practice. Just imagine doing a routine new-patient evaluation and trying to include the personality disorder assessment, each of the first two criteria with its many-item scale, each item to be scored on a 4- or 5-point rating system. It’s hard to imagine anyone having the patience or motivation to use this instrument.

As I indicated above, the DSM-5 Web site assures us that “The proposed system is designed for flexible use to maximize clinical utility.” Who could make such an out-of-touch statement about this instrument, and who could construct such an instrument under the remarkable notion that it will be clinically useful? The answer is simple: experts—or I should say, well-intentioned experts, scholarly psychiatrists who have worked intensively in this area and want to inform the new manual with the benefits of their expertise.

What they lack, of course, is common sense—the ability to limit the implementation of their knowledge to what is practical useful. If we were starting over with the Work Groups, the biggest improvement would be to appoint a number of non-experts to each group—individuals with real-world experience who could say to the experts, this is a brilliant idea, but it’s totally impractical for the ordinary working clinician.

To illustrate, let’s take an example—borderline personality disorder (BPD). Start with the ICD-10, which offers a 100-word description of the disorder, highlighting the main features. The ICD-10 definition would be adequate for most clinicians and in fact reflects how most of us work. It would of course take a fraction of the time as the DSM-5 assessment.

Now let’s move on to DSM-IV. The manual lists 9 diagnostic criteria for BPD. The patient must meet 5 or more of the criteria to warrant the diagnosis. This approach to diagnosis has been criticized for requiring a categorical, dichotomous yes-or-no decision on the diagnosis, eliminating any possibility of a dimensional assessment that would permit diagnosing subthreshold, mild conditions. This flaw in the DSM-IV approach has been the principal argument for the elaborate dimensional approach of DSM-5, which allows the clinician to make the diagnosis along a continuum ranging from mild to severe forms of BPD.

Given the sheer impracticability of the DSM-5 model, what are our alternatives? We could take the simple ICD-10 approach. We could stick with DSM-IV and its flaws. If we wanted to address the flaws of DSM-IV, we could look for a simpler dimensional model than DSM-5. As it turns out, one has just been offered us. In a recent publication⁴ (already noted by Allen Frances⁵), Mark Zimmerman and colleagues have demonstrated in a thorough study of 2150 psychiatric outpatients that one could easily use the DSM-IV NOS category (with traits specified) to create a simple 3-point dimensional assessment with categories of absent, subthreshold traits, and present.

Using this makeshift DSM-IV dimensional assessment for personality disorders, they demonstrated that “There was no difference between the 3-point, 5-point, and criterion count methods of scoring the DSM-IV personality disorder dimensions . . . The DSM-IV 3-point rating convention was as valid as scoring methods using more finely graded levels of severity.” In the case of our example of borderline personality disorder, this method would allow for BPD, no BPD, and mild, subthreshold traits of BPD.

We now have two alternatives to the unmanageable system of DSM-5. We could elect for real simplicity and use ICD-10, or if we want a dimensional component with mild, subthreshold diagnoses, we could use the Zimmermann modification of DSM-IV. Either would allow for quick assessment and spare us the extraordinary time and labor required by the DSM-5 model (The ICD-10 system, with its own NOS category, could easily be modified a la Zimmermann to produce another simple, 3-point dimensional model.).

In the face of these alternatives, it is hard to justify adopting the DSM-5 proposal. One more time, a huge effort by well-intentioned experts that has produced an unwieldy, impractical instrument that will be used by no one.

References
1. American Psychiatric Association. DSM-5 Revisions for Personality Disorders Reflect Major Change: Public Comment Period for Proposed Diagnostic Criteria Extended Through July 15. Press release: July 7, 2011. http://www.dsm5.org/Newsroom/Documents/DSM-5-Revisions-for-Personality-Disorders-Reflect-Major-Change-.pdf. Accessed November 7, 2011.
2. Moran M. 2011. DSM-5 Developers Propose New System for Diagnosing Personality Disorders. Psychiatr News.http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=116625. Accessed November 7, 2011.
3. American Psychiatric Association DSM-5 Development. Personality Disorders.http://www.dsm5.org/ProposedRevision/Pages/PersonalityDisorders.aspx. Accessed November 7, 2011.
4. Zimmerman M, Chelminski I, Young D, et al. Does DSM-IValready capture the dimensional nature of personality disorders? J Clin Psychiatry.2011:72:1333-1339.
5. Frances A. An alternative to the DSM-5 personality proposals. Psychiatr Times. September 29, 2011.http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1959616. Accessed November 7, 2011.

Understanding what make narcissists tick

http://www.escapeabuse.com/npd.pdf
Great guide to print off and take with you when you need it!

Psychology Today article on why men of power cheat

http://www.psychologytoday.com/collections/201107/infidelity-who-cheats-and-why/how-the-weiner-schwarzenegger-and-edwards-sex-scand

The Verdict of Casey Anthony

I must say how unbelievably shocked I am about this verdict.  But we must remember the jury has to take feelings out of it and rely solely on the evidence that they were presented.  Not all that we heard was presented in court.
But still, I must admit I'm having a problem with this.  And she may get to go free with time served.  We just may have to put our belief into Karma.

http://www.psychologytoday.com/collections/201107/is-casey-anthony-guilty/the-verdict-casey-anthony

Are woman narcissist's different than men?

 

20 Identifiable Traits of a Female Narcissist

Posted by Susan Walsh on June 28, 2010 in Politics and Feminism, Relationship Strategies 

Women are attracted to men for a whole host of reasons, and struggle with the question of how to read a guy’s intentions. We don’t want to have sex too soon and lose his respect, but we don’t want to hold out so long that he seeks satisfaction elsewhere. For women, it’s critical to observe a man’s character over a period of time to assess his willingness to enter into a committed relationship.

Character is very important in women too, but men are primarily drawn to women via physical attraction. Their interest in a woman is immediate upon seeing her, and she may wield considerable power over him based on her sexual attractiveness. Women are generally willing to enter relationships, but men worry about finding out down the road that a woman was not who he thought. How can a man verify a woman’s character quickly, so that he doesn’t get caught up in a relationship with a woman who is unlikely to be monogamous over the long-term?

If a man avoids one thing in a woman, he will increase his chances of long-term happiness a thousand fold:

Female Narcissism

It used to be that the word narcissist wasn’t thrown around lightly. We saved it for sociopaths and historical figures like Machiavelli and Napolean.  Female examples were rare, and generally found in fiction: Rebecca of the Daphne Du Maurier novel, Gloria Swanson as Norma Desmond in the 1950 film Sunset Boulevard. In its worst form it is a diagnosable personality disorder (NPD), and historically, 75% of those diagnosed with NPD have been male. However, researchers who have recently studied narcissistic personality traits in the American population say it’s an epidemic, increasing just as fast as obesity since the 1980s, and that much of the growth comes from women. Twenge and Campbell, authors of The Narcissism Epidemic, studied 37,000 college students (2006) in an effort to understand modern levels of self-involvement:

1. In 1982, just 15% of college kids scored high on the Narcissistic Personality Inventory, but that number has risen to 25%, largely due to a greater number of narcissistic women.

2. In the 1950s, just 12% of respondents agreed with the statement, “I am an important person.” By the 1980s, 80% felt special.

3. In 1967, 45% of American students felt that “Being well off is an important life goal.” By 2004, 74% agreed with that statement.

4. Nearly 10% of 20-somethings are thought to have NPD, and it’s estimated that 26% of people now in their twenties will have developed NPD by the age of 65.

Women narcissists often are diagnosed with the subset Histrionic Personality Disorder:

A personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood. These individuals are lively, dramatic, enthusiastic, and flirtatious.

They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others. Associated features may include egocentrism, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behavior to achieve their own needs.

Female narcissists focus more heavily on physical appearance that male narcissists. They often overestimate their own attractiveness, and focus on displaying or flaunting physical attributes. Scientists think there may be a link between narcissism and anorexia or bulimia.

In summary, female narcissists see their lives as a running feature film with them in the lead, receiving accolades at all times. Women narcissists in their 30s and 40s who are unhappily single will generally blame their unpartnered state on being too independent, feisty, strong-minded, intimidating and intelligent for most men. They have little self-awareness.

What Caused the Narcissism Epidemic?

There is far less social pressure to demonstrate character than in past generations. Daughters who once would have been disciplined for spoiled behavior are now allowed to dictate the dinner menu, or veto a family move.

The self-esteem movement, which was intended to create happy, friendly children, produced a generation of kids who filled their rooms with “Participant” trophies and congratulated themselves for showing up. In fact, Twenge and Campbell found that 30% of students felt that they should get good grades just for attending class. Indeed, grade inflation at the country’s best universities is a serious problem, and Cornell West was rumored to have regularly given all A’s in his course at Harvard.

During the 1960s, the core American value of individualism began to morph into self-admiration. The human potential movement stressed introspection and self-improvement, intending self-actualization. However, the concept of self-esteem became a shortcut to the hard work of real personal change.

During the 70S and 80s, Americans became obsessed with celebrity culture, and eating disorders skyrocketed.

Today, social media breeds narcissism by constantly encouraging women to post flattering photos, and create online profiles that stress their uniqueness. Facebook, Twitter and YouTube all require self-promotion, bringing out the narcissist in us. Reality shows promote the most ordinary, unimpressive people as special, and we follow their dysfunctional lives with fascination.

As Twenge and Campbell point out, when I was growing up, it was normal to hear the following kinds of  remarks from parents:

Who do you think you are?

Just wait until your father gets home!

Because I said so, that’s why.

My generation became parents and flipped the script. We justified our decisions at great length when our children disagreed with us. We gave up our own interests to spend hours building Lego structures with our kids or ensuring that our little soccer player got all the development she would need to get recruited to play in college someday. Psychologists used to believe that narcissism resulted from emotional damage in childhood at the hands of cold, neglectful parents. However, the data has never supported that theory, and now it’s widely accepted that narcissism grows from inflated feedback. American parents want super-achieving children, and we’ve insisted we have them, even if we have to create the fiction. Instead, we’ve created a generation of Special Little Snowflakes.

Hooking Up And Narcissism

Twenge and Campbell believe that hookups, FWBs and other no-strings relationships are a manifestation of the narcissism epidemic. Hooking up is considered a selfish act, in that it is about self-satisfaction rather than generosity toward another person. When couples do commit to a relationship, they often continue to wrestle for the upper hand, and relationships are often characterized by lack of emotion, antisocial attitudes and an emphasis on physical appearance. In addition, parents pressure their children to achieve, claiming that “love can wait.” That adds to the appeal, at least in the short-term, of no-strings sexual relationships.

“It changes what is normal behavior in dating,” says Campbell, referring to the hookup culture among youth that has left modern-day parents wringing their hands. According to Campbell and Twenge, the rise of the hookup culture and narcissism rates had a convergent evolution—a link they see as significant. “One of the hallmarks of a narcissist is short-term relationships that don’t require a lot of emotional investment,” says Campbell. Adds Twenge: “The current trend right now, especially among younger people, is that ‘I’m going to focus on myself, not on forging an emotionally close relationship.’”

Hannah Seligson’s article Do Narcissists Have Better Sex? for The Daily Beast makes another observation:

In fact, narcissism, even in small doses, has shifted courtship into a high-stakes relationship culture. Now that people think more highly of themselves, expectations of what a relationship should be like have skyrocketed into the realm of superlatives. Twentysomethings not only expect to waltz into high-level career positions right out of college, they also expect partners who have the moral fortitude of Nelson Mandela, the comedic timing of Stephen Colbert, the abs of Hugh Jackman, and the hair of Patrick Dempsey.

How to Identify a Female Narcissist

Physical Appearance

1. She dresses provocatively, flaunting sexually suggestive body parts.
2. She focuses attention on makeup and hair, even for the most mundane tasks or events.
3. She is overly confident about her looks. Research shows that narcissists are no more attractive than other people, but they believe they are much better looking than other women.
4. She places high value on brand names, and feels entitled to wear “the best.” She frequently purchases new clothing, and does not distinguish between wants and needs.
5. She is more likely to have plastic surgery, most commonly breast augmentation.
6. She enjoys being photographed, and often asks others to snap her picture. She enthusiastically shares the best pics of herself on Facebook or other social media sites. She will sometimes invest in a professional photographer for a portrait that she uses on Facebook or for online dating.

Personality/Character

1. She insists on being the center of attention, and is often the most charming person in the room. Narcissists are very outgoing and excel at marketing themselves.
2. She often seeks favorable treatment, and automatic compliance. She believes that she is special, and that she deserves fame, fortune, success and happiness.
3. She is highly materialistic.
4. She is prone to envy, though she presents as supremely confident. She seeks opportunities to undermine others, and enjoys sharing confidences about how the two of you are better than others.
5. She is convinced that others are envious and jealous of her, and often uses this excuse for her lack of real, intimate friendships. When her friends enjoy successes of their own, she finds ways to punish them by downplaying their achievements.
6. She lacks empathy, and even common courtesy at times. She puts others down, including you. She does not hesitate to exploit others.
7. She is very competitive.
8. She believes that she is intellectually superior to her peers.
9. She blames others for problems. Narcissists don’t believe that they make mistakes, and lack the ability to process shame.
10. She displays a haughty attitude when she lets her guard down or is confronted. She will act impatient, arrogant and condescending. She will often excuse her own shortcomings by claiming that others are pressuring her or expecting too much of her.
11. She is dishonest and often lies to get what she wants. She will never admit this.
12. She is “psycho:” She engages in risky behaviors, has an addictive personality, and is prone to aggressive behavior when rejected. (Note: This is most common with Histrionic Personality Disorder.)
13. She is unpredictable in her moods and actions. You have trouble figuring out what she wants and where you stand.
14. She is capable of short-term regret, and will apologize profusely if backed into a corner. However, she will quickly rationalize her behavior and return to narcissistic patterns.

A woman doesn’t need to have all 20 of these traits to make a lousy relationship partner. If you can check off even a few of these characteristics, you should head for the hills at 60 mph. The six traits related to physical appearance should be apparent immediately, or within a short time of meeting.

Narcissistic personality traits can be difficult to detect at first. Narcissists always make a strong showing right out of the gate, and it takes time for them to reveal their negative qualities. They will only do so when feeling threatened or that they are not receiving “their due” in some way.

Based on the women of all ages I have known in my life, I think 10% is an accurate estimate of the number of narcissists in the female population. That’s a lot of women who could make you miserable if you’re not careful.

Please don’t date one. I beg you not to fall in love with one. And never, ever marry one.

The Prosecution rested in the Casey Anthony Trial -- Sad Girl/Big Liar?

The prosecution has rested after four weeks of testimony. Although many have described the forensic evidence presented as circumstantial; few have questioned the powerful impact of the testimony about Casey Anthony's character. The prosecution has painted a picture of Casey Anthony as a liar and "a party girl" who killed her daughter because the toddler was interfering with her carefree lifestyle. The prosecution tried to prove premeditation. Experts testified about duct tape found on the mouth area of the child's skull and searches for chloroform found on the family computer.

Casey Anthony is charged with murder in the first degree. She has entered a not guilty plea and her attorney, in his opening remarks, told the jury that the child died by drowning in the family's backyard pool. It is up to the prosecution to prove, beyond a reasonable doubt, that Ms. Anthony planned to kill her daughter.

I watched a good deal of the trial on television and was struck with the family drama unfolding in the courtroom. Although this case is primarily focusing on scientific forensic evidence, the psychological and family dynamics issues are impossible to ignore. I posted a blog a few weeks ago about my impression of the initial testimony given by Cindy Anthony, the defendant's mother.


Altogether, Cindy Anthony testified for the prosecution three times. During the third time she was called to the stand, she was asked about objects found at the crime scene. She identified remnants of items from their home -Caylee's t-shirt, her Winnie-the-Pooh blanket, and a laundry bag. The prosecution's goal was evident, Cindy Anthony's testimony would link the child's body to the Anthony home.
It wasn't Cindy Anthony's testimony that made the biggest impression on me. It was what occurred as she left the stand. She looked at her daughter and seemed to mouth, "I love you." That seemed to me a huge gesture of support. Her daughter's response, on the other hand, was raised eyebrows. I can not make any definitive conclusions about what her expression meant, but Casey Anthony certainly did appear to have a positive response to her mother's gesture. I was struck with their brief interaction and wondered whether the jury did as well.


The jury has been sequestered throughout the trial and have not heard the extensive press coverage about the Anthony family. They did, however, hear the defense attorney's defense strategy. Druing his opening remarks he told the jury that his client's father and brother sexually abused her. George Anthony has denied these accusations.

The jurors have also had ample opportunity to observe the family interactions. The jail visits between Casey Anthony and her parents and brother were videotaped. The prosecution played these videos during the trial. In one meeting that occurred before Caylee's body was discovered, the video shows Cindy Anthony trying to calm her daughter, calling her "sweetheart," all the while asking for information about what the defendant knew about the toddler's disappearance.

As I watched this video I wondered - What did Cindy and George Anthony know? I also wondered what they psychologically did not want to know. Did they suspect that their daughter was involved with Caylee's disappearance? Did they believe her story about the child being kidnapped by "Zanny the nanny"? Did they, perhaps not on a conscious level, know their granddaughter was dead?"
We do not know, and may never know, what Casey Anthony's family knew. It is important not to rush to judgment. After learning of the child's disappearance, they were under incredible pressure. For months they searched for information about her whereabouts. I saw many photos and videos of them addressing the press, wearing t-shirts that read "Have you seen me?" over Caylee's picture.

Many people have focused on the psychological make-up of Cindy, Casey and George Anthony and the dynamics of the Anthony family. Some have described conflict between the defenant and her mother. Others have questioned whether Cindy Anthony was an over involved or possessive grandmother. In one video she describes Caylee as not only being Casey's baby, but "belonging" to everyone in the family. She also describes her daughter as her "best friend."

After Caylee's body was found and Casey Anthony was arrested, the grandparents were frequently criticized. The criticism became more vituperative over time. News reports have shown the family home with many "No Trespassing Signs" posted. Crowds at the curb yelled comments including, "Baby killer." As I watched images of the grandparents, I could appreciate how they were facing perhaps the worst of all family tragedies, the knowledge that their beloved granddaughter was dead and the possibility that their daughter may have killed her.

Latest from our resident Narcissist

Dedication of a song to ?
How do you sleep?  by John Lennon
So Sgt. Pepper took you by surprise
You better see right through that mother's eyes
Those freaks was right when they said you was dead
The one mistake you made was in your head
Ah, how do you sleep?
Ah, how do you sleep at night?
You live with straights who tell you you was king
Jump when your momma tell you anything
The only thing you done was yesterday
And since you're gone you're just another day
Ah, how do you sleep?
Ah, how do you sleep at night?

Ah, how do you sleep?
Ah, how do you sleep at night?

A pretty face may last a year or two
But pretty soon they'll see what you can do
The sound you make is muzak to my ears
You must have learned something in all those years
Ah, how do you sleep?
Ah, how do you sleep at night?

Narcissist says:
"Dedicated to .... You know who you are.  ha! Karma got you again!"

Whom ever this is aimed at I truly pray for....