December 1, 2010

Narcissism Out Of The DSM-- And Into The Open

nothing to be said

Jay Mohr, popular comic and actor, did a phone-in to the Opie & Anthony radio show and told this story (I recite from memory):

So I'm shooting Hereafter, and there's a scene where I walk up these flights of stairs, I fumble for my keys and my next door neighbor is supposed to hand me my mail, and it's a letter from Matt Damon and blah blah blah. 

So all she has to do is hand me the letter and say, "here's your mail."  But she's some San Francisco wannabe actress, and she's decided she's going to get her Oscar on this movie.  So she comes over, all dramatic, and she says, "so, ummmm, hi.... You want your mail?... Looks like you got a letter here...."  And she hands it to me, but then she pulls it back at the last second, because she wants to be a cunt, and I reach for it, she pulls it out of my hand again.  So finally I just grab it, and she says, "well, enjoy your mail."

So Clint Eastwood (the director) is down at the bottom of these three flights of stairs watching all this on the monitors, and you hear him say, "goddamn it!"-- he doesn't even yell cut-- and he starts coming up the stairs, he's like 9000 year sold, coming up, puffing, really slowly.  Finally he gets up to the top and he looks at her and he says, "honey, I can't begin to tell you how much this movie isn't about you.  If I could have hired just your goddamn arm, I would have."

You may have heard the news: "Narcissism is being removed form the DSM."

Narcissistic personality disorder, characterized by an inflated sense of self-importance and the need for constant attention, has been eliminated from the upcoming manual of mental disorders, which psychiatrists use to diagnose mental illness.
That sentence is technically accurate.  What's missing, however, is that it would be replaced by something else, a more wordy, symptom cluster description of a personality disorder.  You can still "diagnose" someone with narcissistic traits.

However, on the face of it, people are understandably freaked out:

One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.

Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how "unenlightened" the personality disorders committee is.

"They have little appreciation for the damage they could be doing." He said the diagnosis is important in terms of organizing and planning treatment.

Since he doesn't get Pharma money, there's no need to disclose his megalodon sized bias: his whole career is about measurement tools for narcissism.

And so if you're thinking that the craziness is that psychiatry is the doing away with the concept of narcissism you have fully missed the point: the issue isn't whether narcissism exists or not, the issue is who gets to decide if narcissism exists or not.

You break it, you bought it.


Here's a metaphor.  When The Oscars, defying all logic and sanity, choose Sandra Bullock as best actress-- a woman who Gwyneth Paltrow (Shakespeare In Love) once used as an example of the kind of actress she didn't ever want to be (Demolition Man-- anyone see the irony?) the strength of that choice isn't that her performance in The Blind Side is even good but that I, me, a guy who watches movies, believes that The Oscars are nuts for choosing her: they have tricked me into thinking that their decision has any relevance.

I realize it matters to the actors' future salaries and sales and blah blah, but these annual terrible picks reinforce to me that they should have picked something else.  But why should they have?  As a reasonably educated person I recognize that people have individual tastes; but that there are some things that make a work of art better or worse; but neither of those things are the purview of The Oscars-- they only make me think it's their domain.  In other words, who cares what they think?  But while I have no problem dismissing the relevancy of the Super Bowl victor, it still infuriates me that the Oscar goes to X, and that's because they've beat me.  I know they don't have any say about what is good.  And yet I'm furious, every single year.


You want a historical example, here you go.  No one gets diagnosed with obsessional  neurosis anymore.  People do, however, get called obsessional and neurotic by regular people.

What happened is that a term that highly educated and philosophically precise people used all the time was turned into a vernacular label; and the power of "diagnosis"-- read: labeling-- seized by the new emperors of psychiatry with a different paradigm.

The person in the chair is still recognized to have a pathology: but one group is dismissed by the other group as being mean, pejorative and unrigorous: "we don't call it that, that has no construct validity, it's better described as this."

Never mind that the new terms have no more validity than the old terms, and are equally invented.  That's not the point, diagnosing the patient isn't really the point, the point is that the DSM is the authority.  They've made it that the burden of proof of disagreement is on you, not them.  They gain the credibility not by improving the diagnosis, but merely by altering it.  And so you all say, "well, I think they're wrong, but they must have had some scientific reason that I don't fully understand..."

And you're stuck.  You're left suspecting that there is something really, really wrong, but since it's not bipolar and it's not a unicorn you're left wondering if you're not just a prejudiced ass.  Worse, the only one you can turn to for "support" is Freud, et al, which immediately gets you labeled as a nut.

Yet you can't help but see it-- so you tentatively try to dress it up in the least disparaging way you can, and turn to psychiatry for a little help, but:

"Well, we all know there's no such thing as hysterical neurosis.  Allow me to offer an equally arbitrary but nonetheless reliable construct that puts all the power of labeling in our hands."

Wait, that's not what I was going for...


Let's go back to that telling scene in Hereafter.  To the extent one can make a judgment on a single anecdote, let's agree that at that moment the actress was behaving narcissistically.  Psychiatry, however, would not have a quick way of discussing this (and, truthfully, it didn't a year ago either.)  But by not having a useful description of it, that behavior is no longer  psychiatry's problem.

Added bonus: it's yours.