Who, me, a narcissist?
Many experts are considering a redefinition of the personality disorder
Everyone knows a narcissist — either from life, politics, or fiction.
The friend who only thinks about herself. Political despots like Stalin or Mussolini. Fictional Mafia leaders Don Corleone and Tony Soprano, or characters like Gordon Gekko from the movie “Wall Street’’ (representing a few real-world figures who work at that address).
Now, the group that defines mental illness in America is thinking about redefining narcissism.
Nothing’s been decided yet, but there’s a good chance that narcissistic personality disorder will cease to be a mental illness of its own and will instead be folded into other personality disorders, making it a trait of someone with a broader problem.
The labeling issue may seem arcane, but it matters to patients who want a name for their problem, to family members for whom a label can help them better understand their loved one, and to doctors who have to call it something in order to get reimbursed for treatment. It also matters to insurance companies, which generally require that a diagnosis fit a condition as officially defined by the American Psychiatric Association.
In a sense, narcissism has been done in by its own success.
Because so many narcissists are thriving — at the expense of the rest of us — it’s hard to classify “narcissism’’ as a disability. Growing up with a narcissistic parent or marrying one can be disabling, but, almost by definition, many narcissists go through life without realizing the harm they are doing to others.
A narcissist is someone who has an unrealistic sense of self-importance, a lack of empathy, and a “conviction of being different and special and entitled that is so profound that they feel it’s only natural people will admire them and want to do whatever they want to do,’’ said Dr. John M. Oldham, chief of staff at the Menninger Clinic, a psychiatric research and treatment center in Houston. “Corporate America is filled with people with a lot of this kind of problem.’’
Oldham said he once had a patient with narcissistic personality disorder who came in for help after his son attempted suicide. Oldham worked for several years with the man, whose behavior had clearly played a role in his son’s misery, getting him to face up to his problem. He eventually recovered.
But most narcissists fail to acknowledge the damage they do. Even when they end up in therapy — usually because of a family or work crisis — they don’t last long, he said. Most quickly decide that they can fix their troubles better than their therapist can.
And that’s the other problem with narcissism: It’s hard to study because almost no one admits to having it. Estimates on the number of narcissists range from well under 1 percent of the general public to 20 percent of people in the Air Force, according to a 1992 study.
The committee that’s supposed to decide the fate of narcissism and other personality disorders sat down a few years ago to review available research. For some of the 10 disorders, they found paper after paper. For narcissism, there were plenty of stories describing patients, but relatively few studies that took a hard scientific look at the disorder. And many of the people diagnosed with narcissism seemed to have other personality disorders, too.
So the group — the American Psychiatric Association’s Personality Disorders Work Group — decided to view narcissism as a trait, rather than a disorder. Someone might have narcissistic tendencies, for instance, just like they might have a positive outlook on life or a shy personality. The committee would also do away with a few other less well-known problems, such as histrionic personality disorder, and add in a scale to rate the severity of such traits.
The decision to reclassify narcissism was met with horror by doctors who treat the condition, and the committee is still split on whether to finalize the change. Oldham, who supports maintaining narcissism as its own disorder, is in the minority. Dr. Renato D. Alarcon, professor of psychiatry at the Mayo Clinic College of Medicine, and Dr. Carl C. Bell, clinical professor of psychiatry and public health at the University of Illinois, both said they favor folding it in.
Bell and Alarcon said they like the idea of calling narcissism a trait rather than a disorder, because many people can be narcissists and still function in society. And, Bell added, some people might have narcissistic tendencies, but life has taught them that they simply need to stop acting like a jerk.
“I think people are sort of sick and tired — at least I am — of psychiatrists diagnosing the hell out of everything and not paying any attention at all to issues of spirit, to issues of community, to issues of social fabric that encourage people to do better,’’ said Bell, also president and CEO of Community Mental Health Council, a treatment center in Chicago. “There’s been a sort of shift, so now, people are beginning to recognize that you can have these disorders and you can actually get better.
Elsa Ronningstam, an associate clinical professor of psychology at the Harvard-affiliated McLean Hospital, who is not on the committee, agrees that narcissists can recover, but said that calling narcissism a trait belittles the pain that it causes. Narcissists may seem cocky and self-centered, but on the inside they feel worthless and ashamed.
Narcissism deserves its own category, she said, because like most mental ailments, narcissistic personality disorder is partially genetic and partially created by one’s environment. People whose parents are narcissists are more susceptible, as are people with certain early experiences. Children who grow up in homes where a parent’s needs are primary, for example, can be left feeling needy, but also powerful — knowing their parent is dependent on them, Ronningstam said. Having a truly loving, supportive relationship in the child’s life can counteract this, she said.
The committee’s work is part of a reassessment of all mental illness in preparation for a fifth edition of the book that defines all major psychiatric disorders, known as the Diagnostic Statistical Manual, in 2013.
The new categories will be tested in the field starting as soon as this month. “Maybe clinicians will say we can’t get along without these [disorders], in which case we may bring them back,’’ said Dr. Andrew E. Skodol, the committee’s chairman and a research professor at the University of Arizona College of Medicine.
“One way or the other, folks will be recognized by their clinicians,’’ Skodol said. “It’s just how they’ll be recognized — as a type or through these dimensional traits.’’
Karen Weintraub can be reached at firstname.lastname@example.org