The Latest Personality Disorder?

When does narcissism become a pathology?

Posted Mar 30, 2009

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My weekend reading included two fascinating, completely different articles on celebrity egos. One marveled at the outsized political ambitions of several mediocre actors and asked why, as entertainers, they no longer seem to know "their place." The other, less cutting but no less devastating, concluded that such celebrities have a personality disorder we should be taking very seriously. Hollywood in this respect is but the tip of a massive iceberg.

Both outcomes deserve our attention, though for different reasons. When film stars imagine a movie role entitles them to broker peace treaties in the Middle East (are you listening, Richard Gere?), one needs to ask quite urgently: When exactly did acting in a B-movie equate to the complex stakes of political diplomacy? Indeed, when did we decide as a culture that the difference between acting and political expertise is, for celebrities, irrelevant?

In the second article, which appears in Slate, author Emily Yoffe asserts: "This is the cultural moment of the narcissist." She has of course an embarrassment of riches with former Illinois Gov. Rod Blagojevich and a hilarious line in a New Yorker cartoon about the prospect of narcissist greeting cards ("Wow! Your Birthday's Really Close to Mine!"). But Yoffe's article quickly swerves into a stern bid to recognize "Narcissistic Personality Disorder," or NPD, which she calls a "pathological state when it overwhelms a personality." The problem she encounters, as the subtitle of her article makes clear, is that if narcissism is a pathology, "Why does everyone seem to have it?"

One line of inquiry would chalk up a list of probable causes, with an empathy-deficit right at the top, perhaps due to withholding or hovering parents. Another would declare that by "everyone" Yoffe really means everyone she knows and reads about in the United States. I'm more interested in the wavy, uncertain line between healthy self-assertion and apparently "pathological" narcissism, because that line vanishes the moment we state that everyone has the same affliction.

Yoffe sounds reasonable-enough when she notes, "NPD is one of fewer than a dozen personality disorders described by the American Psychiatric Association." And these "include anti-social personality disorder (these people are also commonly called 'sociopaths' or 'Bernie Madoff') and borderline personality disorder (think of Livia Soprano)."

But, all humor aside, these "disorders" raise enormous diagnostic questions when you examine them closely and study their history. As recently as 1980, the APA defined Histrionic Personality Disorder by explaining: "Individuals with this disorder are lively and dramatic and are always drawing attention to themselves." Doesn't that sound eerily reminiscent of the celebrities we began talking about—indeed, a working definition of just about any actor or performer? "They are prone to exaggeration," DSM-III continued, "and often act out a role, such as the 'victim' or the 'princess,' without being aware of it." To crown it all, the APA warned: "Such individuals are typically attractive and seductive," though it declined to explain why.

Then there's Passive-Aggressive Personality Disorder, now relegated to the appendix of the DSM, which for decades has included as official psychiatric symptoms "procrastination, dawdling, and 'forgetfulness.'" Note the scare quotes around that last illness, especially the next time you can't find your car keys. "A housewife with the disorder," explains DSM-III, p. 328, "fails to do the laundry or to stock the kitchen with food because of procrastination and dawdling." In 1987, for the revised third edition, the APA decided that it hadn't gone far-enough and added that such a person "becomes sulky, irritable, or argumentative when asked to do something he or she does not want to do." I'm glad that clears up any remaining diagnostic confusion.

As these examples show, there's a litany of reasons to question how the APA came up with its own definitions before its diagnostic bible began applying them to hundreds of thousands of Americans. In the case of Passive-Aggressive Personality Disorder, as I noted recently in Theory and Psychology, amazingly the organization simply copied memos issued by the U.S. War Department. Military psychiatrists at the end of World War II were so concerned about soldiers shirking duty by willful incompetence that they asked the War Department to issue a memo in 1945, trying to outlaw aggressiveness "by passive measures, such as pouting, stubbornness, procrastination, inefficiency, and passive obstructionism."

Oddly enough, this exact sentence appears in the first edition of the DSM, published in 1952. Indeed, many other personality and psychiatric disorders in DSM-I began life in this way. With what effect? By 1966, Stefan A. Pasternak observes, Passive-Aggressive Personality Disorder had become a common diagnosis, accounting for more than "3% of hospitalized patients in public mental institutions and over 9% of outpatient clinic patients." Since "dawdling," "procrastination," and "pouting" were the illness's official symptoms, it's a wonder the numbers weren't higher.

I've reviewed much of the unpublished literature that documents the creation and revision of these so-called disorders, including all the heated debates about "Borderline Personality Disorder" and where the threshold for that controversial disorder should fall. The correspondence raises more eyebrows than it answers complex puzzles about our personalities.

So when I read in Slate that "NPD is a little-studied condition" and that "a chilling lack of empathy" is its hallmark, I worry that another round of memos will soon circulate, asking for greater psychiatric recognition of the apparently "epidemic" problem, with consequences just as serious as before. If the American Psychiatric Association can call "pouting" and "dawdling" symptoms of a disorder that has applied to 9% of outpatient clinic patients, just where is the organization going to draw the line next time?

Christopher Lane, the Pearce Miller Research Professor at Northwestern University, is the author most recently of Shyness: How Normal Behavior Became a Sickness. Follow him on Twitter @christophlane