Some Comments on Nomology, Diagnostic Process, and Narcissistic

Personality Disorders: Theory, Research, and Treatment 2011, Vol. 2, No. 1, 41–53

© 2011 American Psychological Association 1949-2715/11/$12.00 DOI: 10.1037/a0021191

Some Comments on Nomology, Diagnostic Process, and Narcissistic Personality Disorder in the DSM-5 Proposal for Personality and Personality Disorders
Aaron L. Pincus
Pennsylvania State University I comment on the DSM-5proposal for personality disorders (PDs), including discussion of the proposal’s nomological revisions and their implications, the development and prioritization of a set of general criteria for PD, the shift to prototype matching of narrative descriptions for assessment of personality impairments and prominent PD types, and the recommendation to delete five PD diagnoses. Although the general criteria forPD are promising, implementation of prototype ratings for both functional impairments and PD types remains psychometrically questionable. In addition, revising the format and content of the diagnostic criteria while simultaneously deleting five diagnoses confounds evaluation of the revisions for the purposes indicated in the proposal. Finally, the performance of prior DSM criteria sets should notbe the primary basis for considering the ontological status of prominent types because of construct definition problems with the criteria sets and criterion problems with DSM-based PD research. These concerns were highlighted in the case of Narcissistic PD—a diagnosis slated for deletion despite significant evidence for its clinical utility and validity when data beyond DSM criteria is considered.Changes of this magnitude are needed, but rigorous scientific evaluation is necessary before evolving from a proposal to the officially published DSM-5. Keywords: personality disorder, narcissistic personality disorder, diagnosis, DSM-5

The DSM-5 Proposal for Personality and Personality Disorders (PDs) (American Psychiatric Association [APA], 2010) initiated much handwringing, angst, and suspicionamong clinical scientists and practitioners, with many individual responses and “official positions” from scientific societies posted to the DSM-5 Website; and, many other commentaries and critiques being developed and disseminated across numerous scientific outlets. Thus, this commen-

To see further discussion of the Target Conceptual Articles, Commentaries, and Author Response, as well as tocontribute to the ongoing dialogue on this topic, please visit our Online Forum at http://pdtrtonline.apa.org/display/PER/Home Aaron L. Pincus, Department of Psychology, Pennsylvania State University. I thank Robert F. Bornstein for several helpful discussions regarding the DSM-5 Proposal for Personality and Personality Disorders. I also thank Aidan G.C. Wright for help assembling materials for thisarticle. Correspondence concerning this article should be addressed to Aaron L. Pincus, Department of Psychology, Pennsylvania State University, University Park, PA 16802. E-mail: alp6@psu.edu 41

tary does not attempt to cover every conceivable issue. It is one statement joining with many others to ensure critical issues are considered before proposals become decisions that later becomereifications that will impact the field for many years to come. This is serious business. As a scientist-practitioner, I agree with the DSM-5 PD workgroup that there is need for “a significant reformulation of the approach to the assessment and diagnosis of personality psychopathology” (APA, 2010, pp. 1). However, I have mixed reactions to committee’s recommendations, such that I like certain aspects of theDSM-5 PD proposal and I have significant concerns about other aspects of the proposal. These are discussed in the sections that follow. The Nomological Organization of Personality Disorders: New Genus and Species or Chimera? In the earliest efforts to document the process of natural selection and its implications for classification, Darwin (1859) noted, “. . . I was much struck how entirely...