The End of Narcissistic Personality Disorder? Say it ain't so!

You may have read this week that the planned release of the next edition of the Diagnostic and Statistical Manual (the "psychiatric bible") DSM V will no longer include 5 of the current 10 personality disorder diagnoses including Narcissistic Personality Disorder (NPI). Does this mean that this disorder no longer exists and that we are now free of those people who are so narcissistic that it adversely impacts their social and occupational functioning (and drives the rest of us crazy)? Hummm.... actually, no! In fact, this is a disorder that seems to be everywhere and getting worse in our culture. There is plenty of evidence that we live in a more narcissistic culture and that many people experience this personality style and disorder.

So, why is it being dropped from DSM V?

I don't know for sure. I am certainly not privy to the backroom private conversations of the leading psychiatrists on the American Psychiatric Association committees making these important decisions but I have to wonder if it might be related (at least in part) to another seemingly unrelated story reported about psychiatry this past week in the national press. You may have heard that the New York Times reported that one of the classic textbooks in psychiatry published in 1999 by two highly prestigious academic psychiatrists and department chairs at Stanford and Miami (one who is the most recent president of the American Psychiatric Association who publishes the DSM) are accused of having their textbook ghostwritten by representative from one of the pharmaceutical companies (for details see my fellow Psychology Today blogger's entry at http://www.psychologytoday.com/blog/mad-in-america/201011/ghostwritten-psychiatric-book-hints-much-larger-problem).

Well, it has been well established that the pharmaceutical industry and psychiatry have had a very close relationship with numerous books, articles, and news reports stating that psychiatry has allowed itself to be controlled, manipulated, and frankly owned by this industry (see the recent acclaimed Daniel Carlat book, Unhinged: The Trouble with Psychiatry - A doctor's revelations about a profession in crisis published by the Free Press). Academic papers published in the most prestigious medical journals have been found to be ghostwritten by pharmaceutical industry representatives with academic psychiatrist being paid handsomely to lend their name and academic affiliations to these projects. The New York Times, Wall Street Journal, and other publications have reported on these exploits in recent years. Having a textbook ghostwritten by the industry represented "a new level of chutzpah" according to David Kessler, former head of the FDA, as reported in the Times.

How are these two recent stories possibly related? My burning question is might the pharmaceutical industry actually be ghostwriting (or at least overly influencing) the new DSM? Narcissistic Personality Disorder is something you can't treat with medications. Drugs don't make selfish, self-centered people more loving, caring, empathetic, and humble. This is true of the other personality disorders being dropped from the new edition of the DSM as well (e.g., histrionic personality disorder). Those personality disorders that will remain (e.g., borderline personality, obsessive compulsive personality) actually are often treated with medications. Hummm, sounds pretty curious.

My concern is that psychiatry has developed a Faustian problem that has been getting more and more press of late. Until they clearly cut off conflict of interest and unethical relationships with the pharmaceutical industry how can they be trusted to be scientists doing what is best for the common good and for the mental health needs of patients? Does the new edition of the DSM reflect the truth of what is and what is not a psychiatric disorder in current times based on the very best and state-of-the-art science and practice or might it only be a mechanism to support diagnoses (or even create diagnoses) that are treated with medications? It is certainly very hard to believe that there is a compelling reason to drop Narcissistic Personality Disorder given how common it is unless why bother keeping a diagnosis that you can't really medicate?

Now I must be very careful since I do not have any inside information about how the American Psychiatric Association ultimately develops their new editions of the DSM. Published reports have talked about the need to alter the way personality disorders are conceptualized which has resulted in the reduction of half of the current prsonality disorders on the books. Ok, but unless the American Psychiatric Association and psychiatrists significantly alter their conflict of interest relationships with the pharmaceutical industry, these decisions that seem to curiously support medication treatments will be highly suspect. To do so psychiatry would have to make hard decisions to no longer accept lavish gifts, trips, and money to support drug company products. They would no longer participate in speaker bureaus funded by the industry. They would no longer be willing to allow their names and institutions to be used on industry articles, textbooks, and other publications in a ghostwriting manner. They would have to agree to the very highest level of ethical behavior avoiding all potential conflict of interests. Can psychiatry be trusted to do the right thing? With more of these stories hitting the press, they may have no choice if they want to save their profession.

What do you think?

Am I connecting the dots or am I paranoid (which is still in the DSM and of course can be medicated)?