Narcissism: The Malady of Me

No one has yet devised the perfect questionnaire to diagnose what’s commonly known as narcissism. But it hardly matters. Most people can smell it from across the company cafeteria, and in the most precious precincts of places like New York, Los Angeles and London, it’s a familiar scent.
This is why an escalating debate among psychiatrists about whether to drop narcissistic personality disorder from the field’s diagnostic manual is such a juicy one. For amateur psychiatrists (everyone over the age of 7), the argument strikingly illustrates the ways in which science informs language, and popular culture in turn broadens and enriches scientific ideas, sometimes altering the professional debate.
In recent months, experts working to update the American Psychiatric Association’sinfluential Diagnostic and Statistical Manual of Mental Disorders have been discussing whether to introduce a new approach to diagnosing the so-called personality disorders.
In psychiatry, this is a serious business. These disorders are severely disabling, and the new approach proposes to phase out five of the disorders — dependent, histrionic, schizoid and paranoid, in addition to narcissistic, the least common — in favor of choosing from a list of personality traits that best describe a particular patient.
All five disorders have taken on a life of their own among therapists as well as researchers. As with everything DSM, as the manual is known, the experts will be debating the new approach for years after the psychiatric association’s task force releases the final draft, expected in 2013.
Nonscientists have been appropriating technical terms going back at least to the ancient Greeks and their doctors’ notion of the humors. In more recent generations, people have borrowed freely from physics (black hole, light speed), geology (tectonic shift), cardiology (type A personality) and most of all psychology.
Freudian terminology spread like pollen in the first half of the 20th century, especially in postwar America, transforming precise concepts like ego, repression and projection into widely understood shorthand for behavior. Therapists in turn have reclaimed and reinterpreted these and other Freudian ideas as they refine their own work.
“This process goes on in all sciences, where terms with narrow, technical definitions move into general use and acquire much broader meanings,” said James G. Ennis, a sociologist at Tufts University. “But especially so in the social sciences, which hit people closer to where they live. Psychology, sociology, anthropology — all are essentially providing people with a way of understanding their identities.”
The modern DSM, more so than any other medical document, stirs this crossbreeding, because it tries to draw a line between normal and abnormal behavior. For years people used the term “schizophrenic” to mean split-minded, or scattered, despite the severity of the diagnosis. The DSM committee dropped so-called passive-aggressive personality from the manual years ago, but the phrase is such an evocative description of a familiar behavior that it has become a fixture of the shared language. Terms like O.C.D. andA.D.H.D. are quickly gaining a similar status.
Narcissism was always a natural. Its technical definition describes a devastatingly vulnerable person, compensating for a deeply imprinted inadequacy with a desperate need for admiration, and a grandiose self-image. “When you see extreme examples of this or other personality disorders, you sit back and say: ‘Wow. It’s just stunning,’ ” said Dr. Darrel Regier, research director at the psychiatric association and co-director of the team updating the DSM. “But all of these disorders are on a continuum with more normal behavior, and people will immediately pick up on some of more annoying traits in the definition and run with it.”
And why not? Virtually all of the narcissistic types most people see are the milder, more normal variety, and the idea that these pompous clowns are crying on the inside doesn’t excuse how they treat others. No blaming it on Mom or Dad or some nanny.
“There’s a lot of self-centeredness in the world, and narcissist has become an instantly recognizable type,” even if people don’t appreciate the complexity of the diagnosis, said Dr. Andrew E. Skodol II, chairman of the DSM personality disorders work group and research professor of psychiatry at the University of Arizona College of Medicine.
Stripped of most — but not quite all — of its pathology, “narcissist” becomes an easy way to flag the self-smitten (if not used as an all-purpose insult), and sounds so much more thoughtful than “egomaniac,” the older term, invoking Greek myth and modern psychiatry. “It’s a shorthand you can apply to all these powerful and famous people that allows you to feel superior and have this gloss of science,” said Dr. Michael First, a psychiatrist at Columbia and a former editor of the DSM.
A word like that is not going anywhere, regardless of what the experts working on the DSM decide. On the contrary: in recent months some of the researchers pushing to drop the diagnosis have softened their stance; the betting now is that the diagnosis is going to remain in the final revision.
The term, like so many people it describes in life and in treatment, cannot be so easily ignored.

Benedict Carey in The New York Times Dec 4 2010