Reviews — From the February 1997 issue

The Encyclopedia of Insanity

A psychiatric handbook lists a madness for everyone

Discussed in this essay: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association. 886 pages. $59.96 cloth; $45 paper.

Has there ever been a task more futile than the attempt to encompass, in the work of a single lifetime, let alone in a single work, the whole of human experience? For roughly five thousand years, poets, playwrights, philosophers, and cranks have incinerated untold quantities of olive oil, beeswax, and fossil fuel in pursuit of this maddeningly elusive goal; all have failed, sometimes heroically. Not even Shakespeare could manage it; closer to our own times, Dickens, a sentimental Englishman, the son of a clerk, perhaps came closest, though he believed in spontaneous human combustion and managed to miss the entirety of the twentieth century. Despite the best efforts of minds great, small, and sometimes insane, the riddle of the human condition has remained utterly impervious to solution. Until now. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (popularly known as the DSM-IV), human life is a form of mental illness.

Published by the American Psychiatric Association in 1994, the DSM-IV is some 886 pages long and weighs (in paperback) slightly less than three pounds; if worn over the heart in battle, it would probably stop a .50-caliber machine-gun bullet at 1,700 yards. Nearly a decade in the making, it is the product of work groups, task forces, advisers, and review committees (the acknowledgment of whom requires twenty-two pages) representing the flower of the profession and the distillation of its thought. The DSM-IV has no beginning, no middle, and no end; like a cookbook (which the preface is at pains to say it is not), the manual is organized by categories, not chapters. But it does have a plot (everyone is either nuts or going there), a central and unifying thesis (everyone is treatable), and it tells its stark tale with implacable simplicity. Here, on a staggering scale, are gathered together all the known mental disturbances of humankind, the illnesses of mind and spirit that cry out for the therapeutic touch of–are you ready for this?–the very people who wrote the book.

First, and primarily, the DSM-IV is a book of dogma, though as theology it is pretty pedestrian stuff, rather along the lines of the owner’s manual in an automobile glove compartment. Like all theories-of-everything, from the Protocols of the Elders of Zion to the collected lyrics of Mr. Snoop Doggy Dogg, the language is simultaneously precise and vague. The precision, which arrives in cool, clinical, and occasionally impenetrable language, provides the undertaking with an aura of scientific objectivity, and the vagueness is necessary because precision can be limiting in both a semantic and a financial sense. Secondly, the DSM-IV is a catalogue. The merchandise consists of the psychiatric disorders described therein, the customers are the therapists, and this may be the only catalogue in the world that actually makes its customers money: each disorder, no matter how trivial, is accompanied by a billing code, enabling the therapist to fill out the relevant insurance form and receive an agreed upon reward. The billing code for Encopresis (“repeated passage of feces into inappropriate places”), for instance, is 307.7. Last,the manual bears an astounding resemblance to a militia’s Web page, insofar as it constitutes an alternative reality under siege. The enemy, of course, is hard science and her white-coated thugs, who have long maintained that many psychiatric disorders do not exist and that others are physical diseases with mental consequences. Worse, things have been going hard science’s way in recent years, which threatens no small number of soft-science incomes. The DSM-IV, then, may be read as a counterattack along the lines of a fertilizer bomb.

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