A Metaphysics of Psychopathology

11. Is Narcissistic Personality Disorder Real?

11 Is Narcissistic Personality Disorder Real? 11.1 Two Problems with Personality Disorders There is No Decline in Functioning Personality disorders are problematic members of the psychiatric domain, with many important questions about their validity outstanding—including questions about the nature of personality itself. Although we readily perceive consistency between the childhood and adult versions of those we know well, there is also inconsistency. Many people have the experience of growing up with a sibling who comes to have the same personality as an adult that he or she had as a child. Such stability is not imaginary, but when people talk about a sibling as having “the same personality,” they are emphasizing what is the same and minimizing what is different. Children and adolescents are typically emotionally labile, self-centered, impulsive, and dependent but change as they grow older. If young people were to be evaluated using the standards of adulthood, many of them would appear personality disordered, but that will not be the case by the time they are adults (Cohen, Crawford, Johnson, & Kasen, 2005). For example, most of the children who can be diagnosed with conduct disorder at age twelve will not be diagnosable with antisocial-psychopathic personality disorder at age thirty. Distinguishing between the temporary immaturity of childhood and the early signs of personality problems is no easy task. Some children who have conduct problems and a predisposition to personality disorder can still have a good outcome as adults, but others will enter adulthood with a personality disorder. By definition a personality disorder appears early in development. It is believed to be already present when stable traits, interests, and motivations normally emerge in adolescence and young adulthood. Unlike the kinds of 182 Chapter 11 deficits seen in Alzheimer disease and the psychoses, a personality disorder is not an intrusive decline in functioning. The category of personality disorder is, therefore, one of those additions to the domain of psychiatric disorders that make the domain an imperfect community. “Personality Disorder” May Be a Label for Unlikable People diagnosed with personality disorders are difficult to get along with. Many of them come to the attention of mental health professionals because their family members, whose lives they have disrupted, are seeking help. They may also be sent by court mandate to mental health professionals as a consequence of legal problems. In neuropsychological settings people with personality disorders are encountered after they decide that they no longer want to cope with working and are seeking disability benefits. Therapists are attuned to the kinds of emotional reactions that they will experience when working with people who have a personality disorder (Beck, Freeman, & Davis, 2004; PDM Task Force, 2006). Consider a patient seeking treatment for depression who so fears rejection that she regularly tests others to make sure they will not reject her, often by engaging in the very behaviors that lead to rejection. In treatment this may manifest as complaining about the therapy, demanding more time, haggling over the bill, and continually asking to reschedule meetings. An experienced therapist who, uncharacteristically, starts to feel that she wants this patient to go away may infer that her own emotional reaction is providing information about the patient’s need to test others. She would also know that such interpersonal dynamics are indicative of a personality disorder. Strong feelings of being manipulated are also construed along similar diagnostic lines. One problem with using the feeling of being manipulated as a diagnostic indicator is that rather than a personality disorder causing someone to be difficult, it may be that “personality disorder” is a label given post hoc to those who are difficult. Critics of psychiatry can claim that unlikabilty is being inappropriately medicalized. They might also argue that the concepts of “pathological,” “sick,” and “broken” were originally used metaphorically to describe certain unlikable personalities but have subsequently become dead metaphors. As a result, particular kinds of unlikable personalities are considered to be literally pathological. The suspicion that unlikable personalities have been medicalized has some scientific support. The two personality traits most consistently found Is Narcissistic Personality Disorder Real? 183 in those with personality disorders are high neuroticism and low agreeableness (Saulsman & Page, 2004, 2005). Low agreeableness (or antagonism) includes being manipulative, uncooperative, argumentative, and deceptive. In other words “personality disorder” is a label given to people who experience a lot of negative emotions and are also unlikable. Patients who are moderately agreeable are less likely to receive...