Home > health/safety > They Aren’t Crazy, They’re Eccentric

They Aren’t Crazy, They’re Eccentric

Wednesday, December 1, 2010, 17:58 EDT Leave a comment Go to comments

Mental healthOnce upon a time, I spent several years managing psychiatric disability claims. What we called them changed from time to time. When I first started in this business, the term at our company was “psychiatric,” then came “mental/nervous,” followed by “MNAD” (for mental/nervous/addiction disorders, I think), and finally “behavioral health.” We just kept calling it the psych unit. Its mission didn’t change: if the primary cause of the insured’s disability was a condition included in the DSM on Axis I of the Multiaxial system, the claim was handled in the psych unit. Axis I diagnoses include conditions as serious as Schizophrenia to addictions of all kinds all the way down to Adjustment Disorder, the diagnosis applied to most people in therapy who are having a tough time dealing with life’s problems. (If that applies to you, don’t complain. That diagnosis is what allows your therapist to get paid by your insurance company.) Axis II diagnoses were stickier and generally considered non-disabling, since they are characteristics rather than illnesses. Mental retardation is an Axis II diagnosis, not really an illness but rather a condition to be managed. The rest of the Axis II diagnoses are personality disorders. So for our purposes, if someone had obsessive-compulsive disorder all by itself, the claim might not have been compensable. A lot depended on the language in the insured’s particular policy and jurisdictional statutes and precedents. Often, someone with a personality disorder also had an Axis I diagnosis, allowing us to breathe a sigh of relief over not having to deal with the Axis II compensability question.

That was a really long digression before I even got to my point. Which was…

The DSM is sort of the Bible of mental health diagnosis. Its full name is The Diagnostic and Statistical Manual of Mental Disorders, and it is compiled and revised periodically by the American Psychiatric Association. New editions might add or remove conditions, as when the APA famously removed homosexuality from its list of psychiatric disorders prior to publication of the DSM-III. Additions have probably been more common, as the field of mental health progresses to recognize previously unnamed disorders.

The new version is the fifth edition; thus it will be known as DSM-5 or DSM-V, depending on whether you feel the need to use Roman numerals. The APA, in its apparent wisdom, has decided to remove half of the previously listed Axis II personality disorders from the new edition. According to the New York Times, the decision has caused quite a reaction in the mental health care community.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition.

Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.

[ . . . ]

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.

Wow. Fighting words.

I am not a mental health clinician, but I always wondered about personality disorders and their classification as psychiatric conditions. Diagnosis is in many cases a matter of degree; just because I arrange my paper money in my wallet by denomination with the obverses facing forward and all corners unfolded, that doesn’t mean I have OCD, Obsessive-Compulsive Disorder. (Actually, my son likes to say I have CDO, which is like OCD except the letters are in alphabetical order, the way they should be.) I consider my behavior a mere quirk, but I suppose if I were so obsessed that it interfered with my occupational or social functioning, then it would be a pathology. My point is that lots of people have quirks of behavior or thought, characteristics that aren’t considered normal. Where is the line drawn?

As I believe I’ve mentioned here before, I wouldn’t be at all surprised if President Barack Obama were to meet the clincal definition of Narcissistic Personality Disorder. Yet he obviously functions well enough to have achieved a high position in his career, formed a family, and presumably made friends over the years. Why, then, call it a disorder? Please, you mental health practitioners who might be reading this, don’t bother telling me my diagnosis is wrong. I fully realize I’m not qualified to make a diagnosis. I’m not making the case that the President has NPD. I’m merely making the case that based on the definition of the condition, it’s quite possible for someone to have it and still be fully functioning. Why is functional impairment not included in the definition?

Time will tell if the APA’s removal of NPD and four other personality disorders from its magic list will withstand internal scrutiny. If it does, I hope it will promote further debate about the nature of human personality and a rethinking of how differences are treated by the mental health establishment.

(By the way, in the entire Times article, the other four personality disorders that have been removed are never identified. If anyone knows what they are, please post them in the comments.)

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