Issue 8 Pharmacopia Fall 2002
Why You're Crazy: The DSM Story
Mark S. Roberts and David B. Allison
The Diagnostic and Statistical Manual of Disorders, known informally as the DSM, is a sleek, presumably authoritative, assuredly comprehensive, and putatively objective manual of mental disorders distributed to millions of readers world wide. Nearly one thousand pages long and boasting over one thousand contributors, the latest version of the manual has an editorial staff that reads like the Who’s Who of clinical psychiatry. In fact, in its current rendition, the DSM is so impressive that it is often referred to as “the Bible” of mental disorders. Yet modern editions of the DSM manuals have grown into virtual monsters of social control, attempting to set the transgressive limits of virtually every human action and capacity. Behaviors such as caring, bereavement, anger, love, hatred, sexual desire, reading, nose-picking, writing, shitting, pimple-picking, nightmares, delusions (both “bizarre” and “non-bizarre” versions), hair twirling, and body odors all have their reasonable limits, which are set strictly by the DSM and its clinical interpreters. Twirl your hair to the extent that the damage is undetectable, and you may not be subject to a diagnosis of Trichotillomania (312.39)—that is, unless you express significant distress about hair twirling. Have a delusion that lasts for only twenty-nine days, rather than thirty, and you may escape being diagnosed with the dreaded Delusional Disorder (297.1). Fail to overcome your fear of mathematics, and you may be tagged with the equally onerous Mathematics Disorder (315.1)—unless, of course, it is medication-induced. But don’t despair. According to the DSM-IV-TR, the fourth and most current edition, you may have the dreaded Mathematics Disorder (315.1) and at the same time sexually abuse a child, but only have that recorded in the manual as a problem (see V61.21, Sexual Abuse of Child) rather than a full-blown disorder.
Before the DSM, mental diseases in the US were largely subsumed under neurological categories. Throughout the 19th century, neurasthenia, which was non-existent as a self-standing disorder, was a perfect example of this tendency. Almost every malady and complaint having to do with the brain or central nervous system was diagnosed as neurasthenia. In fact, mental disorders as such were so little acknowledged that the 19th-century diagnostic nomenclature was generally limited to only four disorders: hysteria, dipsomania, paranoia, and dementia praecox. Fatigue, eating disorders, sexual dysfunction, brain seizures, hysterical symptoms, stress, and so on were all considered the result of a weakened nervous system; and, as such, were treated almost exclusively by neurologists. In 1913, the American Medico-Psychological Association (the forerunner of the American Psychiatric Association), created a committee on psychological statistics at the suggestion of the census bureau. The resulting publication, the Statistical Manual for the Use of Institutions for the Insane (1918), offered the first standard psychiatric classification. The manual, however, was immediately criticized, primarily because it almost exclusively reflected the biases of institutionally oriented psychiatrists and physicians and was thus of little practical interest to outpatient psychiatrists. The project persisted, and the manual went through ten editions. The widespread experience of psychiatrists treating the psychologically traumatized soldiers during and after World War II led to further development of a statistical manual and, finally, the creation of the DSM-I in 1952.
To all appearances, the DSM-I was better organized and more popularly relevant than the previous standard manuals. It reflected marked social and political shifts in American psychiatry, particularly the movement away from the troublesome somatic tradition that stressed a physiological basis for mental disease. This shift could be explained, at least in part, as a response to the kinds of mental disorders that had afflicted soldiers returning from the war. Many patients did not respond to either standard medications or hospitalization, but, rather, were much more successfully treated on an outpatient basis. DSM-II, published in 1968, continued the first edition’s emphasis on less severe behavioral disorders but greatly expanded the number of disease categories. But the expansion of these categories, and the lack of critical reflection on the part of their inventors, also created the grounds for the acceptance—and, in some cases, the construction—of extremely questionable disorders. It is precisely this awesome propensity of the DSM to try to control and direct the social parameters of normalcy that has negatively affected the lives of thousands, perhaps hundreds of thousands, of individuals.
In their rush to create the most comprehensive listing of mental disorders possible, diagnosticians regularly conflated mental illness with a range of social and political concerns, professional consensus, and cultural, racial, and gender biases to arrive at a dizzying array of hybrid disorders. Homosexuality, for example, had been a largely controversial category since it was included in the first edition of the manual.1 The Freudian interpretation of homosexuality as a deviation in sexual development, and therefore a “disease state,” was largely accepted in this early edition. Effectively, a practicing homosexual in the late 1950s onward could be “officially” labeled as having a psychiatric disorder and thus burdened with all the opprobrium and, often, the punitive constraints associated with these types of disorders. Throughout the 1960s, however, gay men and lesbians, support groups, and enlightened analysts and clinicians fought the DSM’s designation, but they were unable to have the disorder removed from subsequent manuals. In later editions, the language changed but the disordered character of homosexual activity remained. Retaining the disorder was a direct result of the strictly unscientific institutional power plays that had become common to the formation of the newly issued editions of the DSM. The Nomenclature Committee, the most powerful arm of the APA’s so-called Task Force, had skillfully maneuvered the other small committees to create a new designation, Ego-Dystonic Homosexuality (302.00). In this rearranged substitute illness, the homosexual was still sick, but now he was sick because of the immense guilt he felt at being a homosexual, and the overwhelming need to change his tormented ways. In a homophobic society, this resulted in little more than blaming the victim.
Women do not fare much better in the history of the DSM. Early editions of the DSM tended to translate common biases against women into full-fledged disorders, and later editions maintain the subtle nomenclature of sexism, developed by the all-male committees first convened by the APA, that are still widely used within psychiatry and medicine. A good example of this is the designation and subsequent re-designation of Masochistic Personality Disorder. In earlier editions of the DSM, women’s supposed passivity and dependence on men fit nicely with the psycho-sexual dynamics of Freudian construed masochism. In short, mistreated women got what they begged for, psychologically speaking. This designation, however, ran into some trouble in subsequent editions, particularly when it became linked with a DSM-III-R invention: Paraphilic Rapism, a disorder in which certain males cannot help themselves from raping females. If a female Masochistic personality type comes in contact with a male victim of Paraphilic Rapism, she might give him exactly the kind of signals that would turn him on. Then, if apprehended, the poor devil could make either an insanity plea or to elicit extreme sympathy on the part of judge or jury. Feminists who fought hard to exclude this unfortunate confluence from the DSM-IV were able to have the Paraphilic Rapism category completely altered and retro-fitted, but Masochistic Personality Disorder remained.2 It appears in the form of the cleansed emendation, Self-Defeating Personality Disorder. Rapism is dispensable; sexism is not.
After so many editions and emendations, one would expect that the editors of the DSM-IV-TR would have finally straightened out the kinks in the series. They haven’t. The editors have made only “protective” nominal or surreptitious changes in many of the ossified, adamantine, “old boy” designations that have characterized previous manuals. In fact, the most recent edition has generated ever-more ridiculous new categories of disorder, making the current volume about twice the bulk of the DSM-III. Take, for example, the alteration of the dreaded math disease. In DSM-III, it was merely an Arithmetic Disorder (315.10); now it has been expanded into a full-blown Mathematics Disorder (315.1) to cover, we assume, Riemann’s mapping theorem, diophantine equations, and chaotic dynamical systems. More controversial entries, like Ego-Dystonic Homosexuality and Self-Defeating Personality Disorder, have been either quietly removed or reduced to “one liners” buried deep in the text. The full “diagnostic” description devoted to Ego-Dystonic Homosexuality in earlier editions now remains in the form of a single example under the general category Sexual Disorder Not Otherwise Specified: “persistent and marked distress about one’s sexual orientation.”3 But even these superficial changes serve as further proof of the repressive and unscientific nature of the series. Controversial entries, like Masochistic Personality Disorder and Ego-Dystonic Homosexuality, eventually disappear from or are modified in the diagnostic “Bible” but only because resistance by gay and feminist activists to these “labels” eventually force the various APA committees to retract or seriously alter them. The “irrefutable” scientific reliability of these “thoroughly researched” entries in earlier editions was thus not in any way adjusted on scientific grounds but, rather, as a result of constant and ever-increasing external pressures.
This cowardly “consensual science” becomes even more evident in the case of “disorders” that lack significant power bases or support. Disorders involving children and adolescents, for example, which were included originally in the manual due to authoritarian moral preferences and not scientific nosology, remain pretty much intact in the most recent edition. Adolescents, according to the earlier DSM-III, would clearly suffer from the dreaded aggressive variety of Conduct Disorder (312.23) if they (1) demonstrate physical violence against persons or property (2) have one or more peer friendships that lasted over six months, and (3) show concern for the welfare of friends and companions. One would think that such clearly absurd signs of an adjustment disorder as showing concern for friends, making long-term friendships, and avoiding “blaming or informing on companions” would have come under considerable scrutiny and eventually would have been changed in subsequent editions of the manual. Simply asking the question of how one distinguishes such behavior from more ordinary adolescent social interactions would seem daunting, at the very least. But Conduct Disorder remains largely unchanged in the DSM-IV-TR. The absurd and patently non-specific language of the earlier editions is simply ameliorated by what appears to be more acceptable contemporary terms. What was previously expressed, in clumsy and vague terms, as “chronic violations of a variety of important rules”4 is now artfully redone as “actively defies or refuses to comply with adults’ requests or rules.”5 One might add, though, that children have not been completely abandoned to these cranky designations. In the DSM-III-R, Oppositional Defiant Disorder, an axial sub-category related to Conduct Disorder, has been softened by the removal of “uses of obscene language.” Kids can now curse away, confident of not being hauled off to the psychiatric ward. Obviously, as children and adolescents were and remain a powerless minority, these more police-inspired forms of social control will continue largely intact. All this, one might add, remains the same despite ever-increasing forms of physical, emotional, psychological and sexual abuse directed against children and adolescents.
What are psychiatrists doing to us? What are the social and historical origins of psychiatry’s attempt to exercise power and authority over the individual? The full answer to the question is, of course, extraordinarily complex, involving an immense array of socio-economic, medico-scientific, historical, and political factors.6 The rudimentary design of this sort of medico-psychiatric power and control, however, can be traced to two decisive historical phenomena: what Michel Foucault had described as “The Great Confinement,” and the relation of psychiatric practice to the medical model. Briefly stated, the “The Great Confinement” was a response to a broad range of presumably abnormal and depraved behavior. The destitute, degenerate, diseased, disabled, unemployed, and the mad were set apart from the general population by some form of incarceration. Many were sent on a lifelong sea voyage on the so-called “ships of fools.” Others were just imprisoned. The confinement had become so widespread that, by the beginning of the mid-17th century, one of every hundred Parisians was imprisoned in some sort of institution.
Foucault argues that this was not merely an administrative reorganization: “In its functioning, or in its purpose, the Hôpital Général had nothing to do with any medical concept. It was an instance of order, of the monarchical and bourgeois order being organized in France during this period.”7 As such, this sort of administrative system became a locus for the development of what Foucault calls “power/knowledge.” The administration of this complex consolidation of services was overseen by directors who were assigned to their position for life. They exercised their power within this massive skein of confining institutions, which eventually became a quasi-juridical entity that could decide, judge, and execute outside the court system.8 The scene of confinement thus became a source of power, and a locus for the generation of discourses about those confined. With the further addition of doctors and, eventually, psychiatrists to this broad institutional consolidation, the power of the physician and his relation to the patient changed drastically. The psychiatrist was now entrusted with the full remediation of all mental patients, and this remediation included both the social and moral dimensions of their lives. Every remedy, every therapy, was now considered morally obligatory, not so much in terms of medical treatment, but in terms of the patient’s compliance with a resolute set of institutional imperatives. The eventual construction of a taxonomy of mental disorders and a system of mental institutions was thus begun not so much in the context of medical science, empirical observation, and medico-psychiatric theory, but, rather, in one of absolute moral authority and constraint.
Once the mental patient had been confined, established as a subject of the institution and its various discourses, the second factor contributing to the rise of psychiatric power, the medical model, came into play. The term “medical model” has a long and diverse history within the annals of medicine itself. It can be traced back to early Greek medical practice, particularly the Hippocratic and Galenic ideas of the physico-organic basis of all diseases. But the type of medical model central to the development of psychiatric authority and power does not fully evolve until the 19th century.
The 19th century, perhaps more than any other period, witnessed an efflorescence of disturbing and mysterious disorders. Emerging from centuries of witchcraft, alchemy, folk remedies, bleeding, leeching, trepanning and the like, medical practitioners during this period were particularly concerned with distinguishing themselves from the earlier, unscientific, superstitious tradition that had come to be associated with medicine. The criteria of diagnosis, anatomy, symptomatology, course of treatment, specification of etiology, and prognosis of disorders were now all subject to experimental hypothesis and empirical verification. This rational method marked a considerable advance over previous ideas of diagnosis and treatment—the century saw progress in virtually every branch and discipline—and it created an articulated system involving methods, terminologies, and approaches that, when carefully followed, appeared to be objective and determinant. In other words, practically any disorder that could be accommodated by the diagnostic, procedural, and terminological discourse of the “new science” of medicine would perforce enjoy scientific validation.
This method, of course, had a number of serious drawbacks. Most obvious among these drawbacks was the fact that the “universal” validity of a scientific system of medicine masked a number of faults, particularly the practice of importing a broad variety of already existing social and cultural biases into the system. What should have been free from these biases had, in many instances, served to perpetuate and intensify them by adapting or incorporating the substances of these biases into the effective practice of the scientific operations themselves. Thus, while the medical model can be extremely useful in identifying and treating diseases like typhoid or syphilis, it can also be applied to other aspects of the human condition that are not truly disorders at all. That is to say, the medical model can be applied, quite inappropriately, to any number of social conditions and to a wide range of human behaviors.
A dramatic example of this unfortunate tendency can be found in the medical theories of the American physician Samuel A. Cartwright. Appointed by the Louisiana Medical Association in 1850 to examine “the diseases and physical peculiarities of the Negro race,” Dr. Cartwright focused his research on a disturbing “behavioral abnormality,” one common to runaway slaves. Using “scientific” biological, clinical, and even etymological methods, Cartwright was able to determine that the “insane desire” to wander away from home was caused by a dreaded disorder, “drapetomania” (from the Greek drapetes, meaning “the fact of absconding”). Not only was he able to diagnose this new disorder, but he also established in etiology, prognosis, and, even more remarkably, a cure for it:If any one or more of them, at any time, are inclined to raise their heads to a level with their master or overseer, humanity and their own good requires that they should be punished until they fall into that submissive state which was intended for them to occupy. They have only to be kept in that state, and treated like children to prevent and cure them from running away.9
Even given these precautions, certain slaves were still subject to unruly behavior, precisely because they were suffering from yet another abnormality, namely, an insensitivity to pain while being whipped. Unfazed, Cartwright was able to medically link this disorder with drapetomania, and create a common etiology for the two “disorders”: partial insensibility of the skin and “great hebitude of the intellectual faculties,” which led to imperfect atmospherization or vitalization of the blood. He called this parallel disorder “dysethesia.”10
The effect of the medical model on the “whole cloth” creation of disorders is, we expect, quite clear in this instance. Dr. Cartwright was able to find what appeared to be a relatively sound basis for the otherwise completely absurd medical claim—a claim that was nothing more than a poorly disguised justification for slavery itself. He accomplished this, in part, by drawing upon the systematic model of a developing medical science. Once their status as disorders was established on seemingly “scientific” grounds, drapetomania and dysethesia could assume their place in the nomenclature of medical science. Their specifications, names, anatomical locations, prognoses, etiologies, symptomatologies, and treatments having been established, they could be compared, studied, discussed, debated, read about, all within the framework of medical “science.” No one, in truth, could deny the existence of such disorders, only debate their specifics. Hence, even though the disorders were the completely absurd, self-serving inventions of a deeply biased individual and his regional culture, they enjoyed the status of being “real,” of being completely scientifically plausible—so much so that a hundred years later the 1957 edition of Dorland’s Medical Dictionary still defined drapetomania as “the insane desire to wander away from home.”11
Clearly, the reputed legitimacy and authority of the medical model has had a profound effect on the DSM’s “Biblical” status. Churning in a sea of technical language, statistics, physician reports and consensuses, clinical and experimental studies, and the like, any disorder listed in the DSM assumes a certain aura of the authoritative and real. To question whether a mental condition is in fact a disorder or whether a certain disorder exists at all is to question the very authority of medicine as a scientific discipline. Indeed, questioning the reliability and authority of the DSM is much like questioning that of the Bible itself. The only difference is that, while the Bible ends at Revelation 22 with the word “Amen,” the DSM has no end, awaiting the future addition of yet another category, disorder, or disease to its never-ending compendium.
David B. Allison is co-author of Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome (1998). His most recent work is Reading the New Nietzsche (2001).
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© 2002 Cabinet Magazine