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
There was a time, back in the '60s, when psychiatry appeared to loom over vulnerable minds with a kind of menacing grandeur. White coats seemed scarcely less ominous than white hoods, and fervid anti-psychiatrists like Szasz and Foucault inflamed lovers of freedom against the depredations of nosology. Nowadays, though, news of a freshly minted mental disorder--or, better yet, a new edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders containing many such novelties--tends to be an occasion for merriment. The DSM, now in its fourth edition, is the reference book which details all the mental disorders currently acknowledged by the APA. As such, it provides comic material for a certain contemporary genre of psychiatry criticism that finds it laughable (rather than sinister) that psychiatry appears to be expanding its territory from real craziness to everyday life--coining diseases like "premenstrual dysphoric disorder" (PMS), and "caffeine-induced sleep disorder." Countless articles in this vein have been published in the past few years--the recent controversial New York Times piece on the absurdity of the diagnosis "road rage," for instance ("You're Not Bad. You're Sick. It's in the Book."), or L.J. Davis' sweeping, stumbling caricature in last February's Harper's ("The Encyclopedia of Insanity--A Psychiatric Handbook Lists a Madness for Everyone.").
Herb Kutchins and Stuart Kirk, professors of social work and social welfare respectively, have, in their second joint effort, Making Us Crazy (their first was called TheSelling of DSM), combined the paranoid and the snooty modes of critique to produce a book about the DSM that's more reproving than suspicious, and more earnest than parodic. Its criticisms are typical of any number of articles attacking the DSM, and can be summed up in four of the most common contra-psychiatric fallacies bandied about today. To wit:
1 If you ever do something that's listed in the DSM as a symptom, it means psychiatrists think you're cuckoo.
This is the most common criticism of the DSM. Once upon a time, the argument goes, crazy people were crazy people: They were the ones barking like dogs and thinking they were Napoleon. The rest of us, meanwhile, suffered only from ordinary problems of living. "There is a growing tendency in our society to medicalize problems that are not medical, to find psychopathology where there is only pathos," complain Kutchins and Kirk. "The psychiatric bible has been making us crazy--when we are just human."
The problem with this reasoning is that the concept "crazy" is entirely foreign to the DSM. Insanity is a legal and literary notion now, not a psychiatric one. Mental disorders in the DSM tend to differ from ordinary problems less in quality than in quantity and context. Checking to see if your oven is off is not a sign of mental disorder; feeling compelled to check it 50 times every time you leave your apartment probably is. Which is not to say that someone who checks their oven 50 times is crazy, whatever that means--but rather that if he should apply to a psychiatrist for help, he would find that the psychiatrist would produce a name for his behavior, would assure him that other people engage in it also, and might offer him drugs to help him stop.
2 The DSM changes its mind about what it's going to call mental disorders every few years, so obviously we can't trust it as a guide to what mental disorders really are.
It is certainly the ambition of the biologically oriented majority of psychiatrists to produce a manual of mental disorders which, as the saying goes, "carves nature at its joints"--one which lists diseases that are each traceable to a unique, identifiable malfunction in the brain. The DSM as it now stands, however, has no pretensions to being such a manual. The DSM is neutral as regards etiology, which is to say that its disorders are grouped according to observable symptoms rather than presumed cause. If you look up a disorder in the DSM, you will find that it's defined by a list of problems (such as impaired motor activity, or feeling numb and empty), a certain number of which qualify a person as having the disease.
To maintain, then, as do Kutchins and Kirk, that "having an operational procedure for determining whether a phenomenon belongs in a class, such as the checklist of symptoms in DSM, does not substantiate what that construct or class is," is to completely misunderstand how the DSM works. Arguing that "Antisocial Personality Disorder" is not really what the DSM says it is, is like arguing that Madame Bovary didn't really do all those things Flaubert said she did. Antisocial Personality Disorder is its DSM description. Kutchins and Kirk like to refer to the DSM as "psychiatry's bible," implying that it inspires reverence and is in need of suspicious interpretation, but the DSM is better described as psychiatry's dictionary. It is periodically revised in response to arguments about usage and usefulness, but new disorders do not represent claims to fresh biological knowledge. Which is to say that yes, a particular mental disorder is whatever the DSM says it is.
3 Unbeknownst to the credulous public, the DSM is not truly a scientific document but the product of crude politicking and cynical compromises.
In 1974, after a series of heated and embarrassingly public quarrels on the topic, the APA decided to resolve the question of whether or not homosexuality should be called a mental disorder by means of a ballot mailed out to its members. The majority of those responding felt that homosexuality was not a mental disorder, and the APA accordingly removed it from the DSM's next published edition. This incident was unusual, and yet not so very different from the APA's standard modus operandi. Each edition of the DSM is the product of arguments, negotiations, and compromises. Kutchins and Kirk cite a particularly amusing example of such disputes: Robert Spitzer, the man in charge of DSM-III, was sitting down with a committee that included his wife, in the process of composing a criteria-set for Masochistic Personality Disorder--a disease that was suggested for, but never made it into, the DSM-III-R (a revised edition). In response to one of the proposed symptoms, Spitzer's wife protested, "I do that sometimes," and Spitzer responded, "OK, take it out."
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.
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 New York magazine and Lingua Franca and an advisory editor at the Paris Review.