Diagnosis: Totally Sane
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 The
Selling 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.
