Question about DSM billing codes

I know these codes are only used for billing purposes, but I always wondered why they are numbered/ordered the way they are. Can anyone shed some light on why the decimal digits skip so many places and why the PD’s are ordered this way? For example why aren’t the groups (Cluster A, B and C) grouped together–Avoidant PD (Cluster C) is between Narcissistic (Cluster B) and Borderline (Cluster B). That doesn’t make any sense to me. The same thing with Dependent (Cluster C) being between Antisocial and Histrionic (both Cluster B). Are these numbers just assigned randomly or is there a reason? Maybe a psychiatrist or medical billing expert here can answer this.
I know it doesn’t matter but I’ve always been curious about this.

301.20 Schizoid
Personality Disorder

301.22 Schizotypal
Personality Disorder

301.4 Obsessive-Compulsive
Personality Disorder

301.50 Histrionic
Personality Disorder

301.6 Dependent
Personality Disorder

301.7 Antisocial
Personality Disorder

301.81 Narcissistic
Personality Disorder

301.82 Avoidant
Personality Disorder

301.83 Borderline
Personality Disorder

301.9 Personality
Disorder NOS

Advertisements

6 Signs of Narcissism You May Not Know About (Psychology Today)

Interesting article about the lesser-known indicators of narcissism from Psychology Today. Contrary to popular opinion, narcissists do not love themselves, only their image.
I agree with Dr. Seltzer that these six traits should be added to the official diagnostic criteria for NPD.

6 Signs of Narcissism You May Not Know About: How can you recognize the fragility behind the narcissist’s grandiosity?
Post published by Leon F Seltzer Ph.D.

narc_lovers

The recently published 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists precisely the same nine criteria for narcissistic personality disorder (NPD) as did the previous version, published 19 years earlier. So these longstanding diagnostic yardsticks are by now quite familiar—not only to professionals but to interested laypeople as well. Because only the extreme, or “classic,” narcissist fits all of these criteria, DSM specifies that an individual need meet only five of them (barely more than half) to warrant this unflattering label.

As a starting point, I’ll reiterate these selected criteria—before, that is, adding six important ones of my own, which either complement or extend these “official” yardsticks. My particular measures for identifying pathological narcissists are based not only on my exposure to the voluminous writings on this character disorder, but also on 30+ years of clinical experience. This experience includes doing personal, couples, and family counseling with such troublesome individuals. But it also involves working independently with those involved with narcissists—whether their distressed children, spouses, parents, friends, or business associates—who repeatedly express enormous frustration in trying to cope with them.

To begin, however, here are DSM’s requirements (link is external) (slightly condensed, and with minor bracketed amendments) for “earning” the unenviable diagnosis of Narcissistic Personality Disorder:

1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration [regularly fishes for compliments, and is highly susceptible to flattery].
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy: is unwilling [or, I would add, unable] to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty [rude and abusive] behaviors or attitudes.

So what’s left out here? Actually, as regards identifying descriptors, quite a bit. And I’ve no doubt that other therapists could add further to the six additional characteristics I’ll provide here—features that, although regrettably minimized or omitted from DSM, I‘ve routinely seen displayed by the many dysfunctional narcissists I’ve worked with. So, to enumerate them, such individuals:

1. Are highly reactive to criticism.

grinch

Or anything they assume or interpret as negatively evaluating their personality or performance. This is why if they’re asked a question that might oblige them to admit some vulnerability, deficiency, or culpability, they’re apt to falsify the evidence (i.e., lie—yet without really acknowledging such prevarication to themselves), hastily change the subject, or respond as though they’d been asked something entirely different. Earlier for Psychology Today I wrote a post highlighting this supercharged sensitivity called “The Narcissist’s Dilemma: They Can Dish It Out, But . . . ”. And this aspect of their disturbance underscores that their ego—oversized, or rather artificially “inflated”—can hardly be viewed as strong or resilient. On the contrary, it’s very easily punctured. (And note here another related piece of mine, “Our Egos: Do They Need Strengthening—or Shrinking?”). What these characteristics suggest is that, at bottom and despite all their egotistic grandiosity, they…

2. Have low self-esteem.

narcissists_hate_themselves

This facet of their psyche is complicated, because superficially their self-regard would appear to be higher and more assured than just about anyone else’s. Additionally, given their customary “drivenness,” it’s not uncommon for them to rise to positions of power and influence, as well as amass a fortune (and see here my post “Narcissism: Why It’s So Rampant in Politics”). But if we examine what’s beneath the surface of such elevated social, political, or economic stature—or their accomplishments generally—what typically can be inferred is a degree of insecurity vastly beyond anything they might be willing to avow.

That is, in various ways they’re constantly driven to prove themselves, both to others and to their not-so-confident “inner child” self. This is the self-doubting, recessive part of their being that, though well hidden from sight, is nonetheless afflicted with feelings and fears of inferiority. Inasmuch as their elaborate defense system effectively wards off their having to face what their bravado masks, they’re highly skilled at exhibiting, or “posturing,” exceptionally high self-esteem. But their deeper insecurities are yet discernible in their so often fishing for compliments and their penchant for bragging and boasting about their (frequently exaggerated) achievements. That is, they’re experts at complimenting themselves! And when—despite all their self-aggrandizement— others are critical of them, they…

3. Can be inordinately self-righteous and defensive.

right_wrong

Needing so much to protect their overblown but fragile ego, their ever-vigilant defense system can be extraordinarily easy to set off. I’ve already mentioned how reactive they typically are to criticism, but in fact anything said or done that they perceive as questioning their competence can activate their robust self-protective mechanisms. Which is why so many non-narcissists I’ve worked with have shared how difficult it is to get through to them in situations of conflict. For in challenging circumstances it’s almost as though their very survival depends on being right or justified, whereas flat out (or humbly) admitting a mistake—or, for that matter, uttering the words “I’m sorry” for some transgression—seem difficult to impossible for them.

Further, their “my way or the highway” attitude in decision-making—their stubborn.competitive insistence that their point of view prevail—betrays (even as it endeavors to conceal) their underlying doubts about not being good, strong, or smart enough. And the more their pretentious, privileged, exaggeratedly puffed-up self-image feels endangered by another’s position, the more likely they are to…

4. React to contrary viewpoints with anger or rage.

rage2

In fact, this characteristic is so common in narcissists that it’s always surprised me that DSM doesn’t specifically refer to it among its nine criteria. Repeatedly, writers have noted that angry outbursts are almost intrinsic to both narcissistic and borderline personality disorders. And although (unlike the borderline) it’s not particular fears of abandonment that bring out their so-called “narcissistic rage,” both personality disorders generally react with heated emotion when others bring their deepest insecurities too close to the surface.

The reason that feelings of anger and rage are so typically expressed by them is that in the moment they externalize the far more painful anxiety- or shame-related emotions hiding just beneath them. When they’re on the verge of feeling—or re-feeling—some hurt or humiliation from their past, their consequent rage conveniently “transfers” these unwanted feelings to another (and see here my PT post “Anger—How We Transfer Feelings of Guilt, Hurt, and Fear”).

The accompanying message that gets communicated through such antagonistic emotions is “I’m not bad (wrong, stupid, mean, etc.), you are!” Or, it could even be: “I’m not narcissistic, or borderline! You are!” (Or, in slightly milder version, “If I’m narcissistic, or borderline, then so are you!”) And if the mentally healthier individual has no clue as to what provoked their outburst in the first place, such a sudden explosion is likely to make them feel not only baffled but hurt, and maybe even frightened. But what cannot be overemphasized here is that narcissists…

5. Project onto others qualities, traits, and behaviors they can’t—or won’t—accept in themselves.

635223192958830312Projection2

Because they’re compelled from deep within to conceal deficits or weaknesses in their self-image, they habitually redirect any unfavorable appraisal of themselves outwards, unconsciously trusting that doing so will forever keep at bay their deepest suspicions about themselves. Getting anywhere close to being obliged to confront the darkness at their innermost core can be very scary, for in reality their emotional resources are woefully underdeveloped.

Broadly recognized as narcissists by their fundamental lack of self-insight, very few of them (depending, of course, on how far out they are on the narcissistic continuum) can achieve such interior knowledge. For in a variety of ways their rigid, unyielding defenses can be seen as more or less defining their whole personality. And that’s why one of the most reliable ways for them to feel good about themselves—and “safe” in the world they’re essentially so alienated from—is to invalidate, devalue, or denigrate others. So they’ll focus on others’ flaws (whether or not they really exist) rather than acknowledge, and come to terms with, their own. And in many curious ways this habit causes them to…

6. Have poor interpersonal boundaries.

space_invasion
Space invasion!

It’s been said about narcissists that they can’t tell where they end and the other person begins. Unconsciously viewing others as “extensions” of themselves, they regard them as existing primarily to serve their own needs—just as they routinely put their needs before everyone else’s (frequently, even their own children). Since others are regarded (if they’re regarded at all!) as what in the literature is often called “narcissistic supplies”—that is, existing chiefly to cater to their personal desires—they generally don’t think about others independently of how they might “use” them to their own advantage. Whatever narcissists seek to give themselves, they generally expect to get from others, too (which is yet another dimension of their famous—or infamous—sense of entitlement).

Even beyond this, their porous boundaries and unevenly developed interpersonal skills may prompt them to inappropriately dominate conversations and share with others intimate details about their life (though some narcissists, it should be noted, can display an extraordinary, however Machiavellian, social savvy). Such private information would probably focus on disclosing facts others would be apt to withhold. But having (at least consciously) much less of a sense of shame, they’re likely to share things they’ve said or done that most of us would be too embarrassed or humiliated to admit. Still, with an at times gross insensitivity to how others might react to their words, they’re likely to blurt out things, or even boast about them, that others can’t help but view as tasteless, demeaning, insulting, or otherwise offensive.

They might, for instance, share—and with considerable pride!—how they “chewed” someone out, and expect the other person to be impressed by their courage or cleverness, when in fact the listener may be appalled by their lack of kindness, tact, or restraint. Additionally, they may ask others questions that are far too personal or intimate—again unwittingly irritating or upsetting them. And such a situation can be particularly difficult for the other person if the narcissist is in a position of authority over them so that not responding could, practically, put them in some jeopardy.

To conclude, I can only hope that these additional characterizations of the pathological narcissist (vs. those with less pronounced narcissistic qualities) may be helpful in enabling you to identify them before their “malignancy” does a number on you. And if you’ve already been duped by their machinations or manipulations, perhaps this piece will be a “heads up” for you to prevent them from wreaking any further havoc in your life.

NOTE 1: I’d be remiss if I didn’t point out that the narcissism addressed here centers on its most maladaptive, or “toxic,” forms. Unlike DSM (the standard diagnostic reference tool for mental health professionals), the Psychodynamic Diagnostic Manual (link is external)(PDM, 2006)—respected, but much less well known than this official volume—explicitly notes that the disorder exists “along a continuum of severity, from the border with neurotic personality disorders to the more severely disturbed levels.” And additionally, that “toward the neurotic end [these] narcissistic individuals may be socially appropriate, personally successful, charming and, although somewhat deficient in the capacity for intimacy, reasonably well adapted to their family circumstances, work, and interests.”

My daughter is officially BPD, not NPD!

BPD

So, my daughter finally agreed to see a psychiatrist and took a battery of tests and interviews in his office.

She got her her official diagnosis. She has a number of mental issues but I am so thankful NPD isn’t one of them. She’s Borderline, as I suspected, not that that’s any bowl of blackberry/cherry compote either.

She is agreeing to see a therapist, probably because the psychiatrist recommended it to her instead of me (and she also told me he was “hot”!) 😀 I bet probably has something to do why she agreed to it.

I asked the psychiatrist who did the evaluation to write out his findings IN ENGLISH instead of Doctorese. He had his receptionist write out the results for me; here they are.

AXIS I: 296.89 Bipolar Disorder II, 300.02 Generalized Anxiety Disorder
AXIS II: 301.83 Borderline Personality Disorder
AXIS III: 292.2 Cannabis Related Disorder, 291.9 Alcohol Related Disorder NOS, 305.10 Nicotine Dependence, ICD-9 493.3 Asthma, Unspecified
AXIS IV: 309.81 Post-traumatic Stress Disorder, v62.2 Occupational Problem,v62.81 Relational Problem NOS

Not great dx’s, but I’m glad because of all these disorders, even BPD, have a better prognosis and are more amenable to therapy than any form of Narcissistic Personality Disorder. That doesn’t diminish the seriousness of a few of the disorders she does have, though. Hopefully she sticks with her therapist this time.

It’s creepy how close the code for BPD (301.83) is to NPD (301.81). But they’re just billing codes so it probably doesn’t mean much.

Sociopath vs. psychopath: is there a difference?

psychopathy

I’ve been using the terms psychopath and sociopath interchangeably on this blog, even though I’m aware there are differences between the two. I was curious enough to Google what the difference is, and came across an article in Psychology Today that explains how they are alike–and how they differ.

How to Tell a Sociopath from a Psychopath
By Dr. Scott Bonn

Many forensic psychologists, psychiatrists and criminologists use the terms sociopathy and psychopathy interchangeably. Leading experts disagree on whether there are meaningful differences between the two conditions. I contend that there are clear and significant distinctions between them.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), released by the American Psychiatric Association in 2013, lists both sociopathy and psychopathy under the heading of Antisocial Personality Disorders (ASPD). These disorders share many common behavioral traits which lead to the confusion between them. Key traits that sociopaths and psychopaths share include:

A disregard for laws and social mores
A disregard for the rights of others
A failure to feel remorse or guilt
A tendency to display violent behavior
In addition to their commonalities, sociopaths and psychopaths also have their own unique behavioral characteristics, as well.

Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional outbursts, including fits of rage. They are likely to be uneducated and live on the fringes of society, unable to hold down a steady job or stay in one place for very long. It is difficult but not impossible for sociopaths to form attachments with others. Many sociopaths are able to form an attachment to a particular individual or group, although they have no regard for society in general or its rules. In the eyes of others, sociopaths will appear to be very disturbed. Any crimes committed by a sociopath, including murder, will tend to be haphazard, disorganized and spontaneous rather than planned.

Psychopaths, on the other hand, are unable to form emotional attachments or feel real empathy with others, although they often have disarming or even charming personalities. Psychopaths are very manipulative and can easily gain people’s trust. They learn to mimic emotions, despite their inability to actually feel them, and will appear normal to unsuspecting people. Psychopaths are often well educated and hold steady jobs. Some are so good at manipulation and mimicry that they have families and other long-term relationships without those around them ever suspecting their true nature.

When committing crimes, psychopaths carefully plan out every detail in advance and often have contingency plans in place. Unlike their sociopathic counterparts, psychopathic criminals are cool, calm, and meticulous. Their crimes, whether violent or non-violent, will be highly organized and generally offer few clues for authorities to pursue. Intelligent psychopaths make excellent white-collar criminals and “con artists” due to their calm and charismatic natures.

The cause of psychopathy is different than the cause of sociopathy (1). It is believed that psychopathy is the result of “nature” (genetics) while sociopathy is the result of “nurture” (environment). Psychopathy is related to a physiological defect that results in the underdevelopment of the part of the brain responsible for impulse control and emotions. Sociopathy, on the other hand, is more likely the product of childhood trauma and physical/emotional abuse. Because sociopathy appears to be learned rather than innate, sociopaths are capable of empathy in certain limited circumstances but not in others, and with a few individuals but not others.

Psychopathy is the most dangerous of all antisocial personality disorders because of the way psychopaths dissociate emotionally from their actions, regardless of how terible they may be. Many prolific and notorious serial killers, including the late Ted Bundy and John Wayne Gacy, and Dennis Rader (“Bind, Torture, Kill” or BTK) are unremorseful psychopaths. Psychopathic killers view their innocent victims as inhuman objects to be tormented and violated for their amusement.

Contrary to popular mythology, most serial killers are not mentally ill or “evil” geniuses. See my related article: http://www.psychologytoday.com/blog/wicked-deeds/201406/serial-killer-myth-1-theyre-mentally-ill-or-evil-geniuses

tedbundy ed_gein
Although both were deadly serial killers, Ted Bundy was a psychopath who gave a good impression and knew how not to get caught; Ed Gein was most likely a sociopath who acted more impulsively, was more disorganized and didn’t give a very good first impression. Though both men’s crimes were equally heinous, Bundy’s eyes seem “colder” than Gein’s.

Although the traits of a psychopath more closely resemble those of a person with Narcissistic Personality Disorder (NPD) than those of the more impulsive, disorganized sociopath, both are actually described here as variations of ASPD, not NPD. Once again, if ASPD is really “NPD on crack” then it follows that NPD and ASPD are both on the same spectrum, with ASPD (and psychopathy/sociopathy) at the top of the spectrum. If this is in fact the case, people with NPD, even malignant narcissists, may border on psychopathy, but would not actually qualify as true psychopaths.

Here’s a little graph I devised to illustrate where all the Cluster B disorders may fall on a spectrum. These are just my guesses and are not based on psychological research, just my instinct and gut feelings.

psychopathy_graph
Click image to enlarge.

Is antisocial personality disorder really NPD on crack?

I have to admit I’ve been confused by the distinctions between the Cluster B personality disorders, especially those of NPD and ASPD. There seems to be little distinction in most literature between NPD and ASPD (antisocial personality disorder) with most experts saying the difference is just a matter of degree, with ASPD (psychopathy or sociopathy) being higher on the spectrum than NPD.

Let’s turn to the Bible of mental disorders for some clarification. These are from the DSM IV-TR, but have apparently been updated, because these descriptions are all labeled obsolete. But for our purposes, I’ll stick with these criteria.

Diagnostic criteria for 301.81 Narcissistic Personality Disorder

Handsome narcissistic young man looking in a mirror

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Diagnostic criteria for 301.7 Antisocial Personality Disorder

antisocial_personality

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course ofSchizophrenia or a Manic Episode.

Just for comparison’s sake, let’s include the (obsolete) criteria for the other two Cluster B disorders: BPD (Borderline Personality Disorder) and HPD (Histrionic Personality Disorder):

Diagnostic criteria for 301.83 Borderline Personality Disorder

borderline

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostic criteria for 301.50 Histrionic Personality Disorder

histrionic_personality

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are

It does seem that ASPD is more linked to criminality than NPD, most likely due to poor impulse control, which isn’t a problem in people with NPD. People with ASPD are more willing to break the law and are more likely to be in prison. They are less likely to be concerned with image or consequences of their actions (most people with NPD want to maintain their sqeaky clean image which means staying out of prison). Antisocials also seem more prone to violent behavior.

The DSM criteria for ASPD seem to describe psychopathy/sociopathy. Most narcissists are probably not psychopaths, but are on the same spectrum. Does this mean that ASPD and NPD should really be considered the same disorder, with ASPD higher on the psychopathy spectrum?

BPD is more clearly distinguishable from ASPD and NPD because a person suffering from this disorder does have a conscience and can feel empathy and remorse, but like someone with ASPD they have problems with impulse control. Also, their motives for doing what they do are different: they fear abandonment, while people with ASPD and NPD fear their true self being exposed.

HPD seems very similar to the somatic form of narcissism and includes many narcissistic traits. However, it seems that someone with HPD would be more prone to drama, neediness and tantrum throwing (although these traits aren’t unknown in narcissists). Like BPD, the motives for the sufferer’s behavior seem based on insecurity and fear of abandonment rather than the need to maintain a false front.

NPD and ASPD are more common in males than females, and HPD and BPD are more common in females than males. Does gender determine what disorder a child is more likely to develop later in life? Are BPD and HPD really the “female” forms of the other two disorders?

ASPD almost seems like an exaggeration of typically male traits–aggressiveness, lack of emotion (except rage), and risk taking; whilst HPD seems like an exaggeration of typically female traits — excessive emotionality, preoccupation with beauty/sexiness, and excessive neediness. BPD and NPD are somewhere in between these two and can include elements of both: ASPD –> NPD –> BPD –> HPD

The fact that the American Psychiatric Association keeps changing their criteria just makes things even more confusing.