Diagnosis: Totally Sane

Better ideas.
Nov. 13 1997 3:30 AM

Diagnosis: Totally Sane

The DSM isn't crazy in the slightest.

Making Us Crazy: DSM--The Psychiatric Bible and the Creation of Mental Disorders
By Herb Kutchins and Stuart A. Kirk
The Free Press; 304 pages; $27.50

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To Kutchins and Kirk, this kind of ad hoc list-making is not science but politics. But it's not clear that any science is so pure that it's exempt from committee decisions about what's to be considered valid research. Kutchins and Kirk claim that the DSM isn't a true account of mental illness because it's informed by particular social values. But of course the DSM is informed by social values. Medicine is informed by social values. To declare something a disease (rather than simply a part of life) is to declare it unacceptable and in need of treatment by doctors. When is a person too unhappy? When does eccentricity become psychosis, or political suspicion paranoia? How much pain is pathological? Under what circumstances should a person's death be described as "natural" and attributed to old age, rather than described as "premature" and the result of a disease? Social questions, all.

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4 The DSM insults the victims of traumas and societal injustice by calling their problems "mental disorders," thus implying that the victims are wacko and have brought their problems on themselves.

It's always entertaining to go back and read about the racist inanities of psychiatrists past. Take Samuel Cartwright, for instance, who in 1851 coined two ingenious new diagnoses to be applied to slaves: drapetomania, or running away (recommended treatment: whipping), and dysaesthesia aethiopis, whose symptoms were sloth and a tendency to break things (recommended treatment: whipping). Yes, there can be no doubt that psychiatry has been--and continues to be--used for very dubious purposes, and that diagnosis is always inflected by the politics of its creators.

To assume, though, as do Kutchins, Kirk, and many other left-oriented critics, that psychiatry is an inherently sinister enterprise, and that diagnosis--labeling people--is mean, is to ignore many of the ways psychiatry is used. Take Posttraumatic Stress Disorder, for instance. This diagnosis, which describes the delayed aftereffects of extremely unpleasant experiences, made it into the DSM-III as a result of lobbying by Vietnam veterans who wanted their continued suffering symbolically and financially recognized. PTSD has since been applied to all sorts of people, from the victims of domestic violence to the consumers of excessive numbers of Twinkies. It has become one of the DSM's most popular disorders, in part because it is so very useful to its diagnosees: It makes them eligible for insurance-reimbursed therapy, for instance, and it can bolster an insanity defense.

Paradoxically, though, while it's often used as part of insanity pleas, PTSD implies not that its victims are crazy, but rather that they aren't. Before PTSD became a recognized disorder, after all, a Vietnam veteran suffering from hallucinatory flashbacks and wild mood swings looked, to the benighted layperson at least, nuts. But now his behavior seems ordinary, even to be expected. Kutchins and Kirk appear to believe that attaching diagnoses to victims must necessarily be in the service of evil conservatism, but pathologizing misfortune is a technique more often employed by the left than the right--by those, that is to say, who want to mitigate responsibility by drawing attention to its causes, rather than those who want to assign blame.

As long as psychiatry is in the business of forced institutionalization (and it still is, though less so than in the '60s), it seems clear that the diagnoses that license dragging people off the street can hardly be subject to enough old-fashioned suspicious scrutiny. But with regard to the vast majority of psychiatric encounters, which involve adults showing up in offices and asking for help, railing against the men in white coats is mostly beside the point. Labels can be reassuring. Drugs can be our friends. Subtler tools are necessary.

Larissa MacFarquhar is a contributing editor at Lingua Franca and an advisory editor at the Paris Review.