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.
Perhaps some examples are in order. According to the DSM-IV, something called frotteurism (302.89) is the irresistible desire to sexually touch and rub against one’s fellow passengers on mass transit. Something called fugue (300.13) consists of travel in foreign lands, often under an assumed identity. In reality, it may very well be that the frotteurist is a helpless victim in the clutches of his obsession, but it’s equally possible that he’s simply a bored creep looking for a cheap thrill. Perhaps the fuguist is in psychological flight from a memory that cannot be borne and will utterly fail to welcome the news that he is not the Regent of Pomerania traveling incognito in Provence, but maybe he’s just having his spot of fun. The DSM-IV is a stranger to such ambiguities. The DSM-IV says that the frotteurist and the fuguist, despite all conceivable arguments to the contrary, have lost their marbles, period and end of discussion.
Not content with the merely weird, the DSM-IV also attempts to claim dominion over the mundane. Current among the many symptoms of the deranged mind are bad writing (315.2. and its associated symptom,poor handwriting); coffee drinking, including coffee nerves (305.90), bad coffee nerves (292.89), inability to sleep after drinking too much coffee (292.89), and something that probably has something to do with coffee, though the therapist can’t put his finger on it (292.9); shyness (299.80, also known as Asperger’s Disorder); sleepwalking (307.46); jet lag (307.45); snobbery (301. 7, a subset of Antisocial Personality Disorder); and insomnia (307.42); to say nothing of tobacco smoking, which includes both getting hooked (305.10) and going cold turkey (292.0). You were out of your mind the last time you had a nightmare (307.4 7). Clumsiness is now a mental illness (315.4). So is playing video games (Malingering, V65.2). So is doing just about anything “vigorously.” So, under certain circumstances, is falling asleep at night.
The foregoing list is neither random nor trivial, nor does it represent the sort of editorial oversight that occurs when, say, an otherwise reputable zoology text contains the claim that goats breathe through their ears. We are here confronted with a worldview where everything is a symptom and the predominant color is a shade of therapeutic gray. This has the advantage of making the therapist’s job bot remarkably simple and remarkably lucrative. Once the universe is populated with enough coffee-guzzling, cigarette-puffing, vigorous human beings who are crazy precisely because they smoke, drink coffee, and move about in an active and purposeful manner, the psychoanalyst is placed in the position of the lucky fellow taken to the mountaintop and shown powers and dominions. Here, hard science cannot attack with its niggling discoveries about bad brain chemicals and their effects on people who believe that gunplay is a perfectly reasonable response to disapproval, humor, or minor traffic accidents. Instead, the pages of the DSM-IV are replete with mental illnesses that have been hitherto regarded as perfectly normal behavior. The therapist is invited not merely to play God but to play lawyer–to some minds, a superior calling–and to indulge in a favorite diversion of the American legal profession known as “recruiting a fee.”
By confining themselves to a single interpretation of the human dilemma–madness–the DSM-IV‘s authors have joined the monkeys-and-type-writers school of foul-weather marksmanship: give a hunter an infinite amount of ammunition, an infinite amount of time, a distant target shrouded in fog, and the hunter will sometimes hit the target and sometimes will hit something else:
The essential feature of Shared Psychotic Disorder (Folie à Deux) is a delusion that develops in an individual who is involved in a close relationship with another person (sometimes termed the “inducer” or “the primary case”) who already has a Psychotic Disorder with prominent delusions (Criterion A). The individual comes to share the delusional beliefs of the primary case in whole or in part (Criterion B). The delusion is not better accounted for by another Psychotic Disorder (e.g., Schizophrenia) or a Mood Disorder With Psychotic Features and is not due to the direct physiological effects of a substance (e.g., amphetamine) or a general medical condition (e.g., brain tumor) (Criterion C)…. The content of the shared delusional beliefs … can include relatively bizarre delusions (e.g., that radiation is being transmitted into an apartment from a hostile foreign power, causing indigestion and diarrhea), mood-congruent delusions (e.g., that the primary case will soon receive a film contract for $2 million … ), or the nonbizarre delusions that are characteristic of Delusional Disorder (e.g., the FBI is tapping the family telephone and trailing family members when they go out). Usually the primary case in Shared Psychotic Disorder is dominant….
Jargon, redundancy, and turgidity aside, what we have here is a fairly accurate description of Newt Gingrich’s House of Representatives. The billing code is 297.3.
This same uncanny, if accidental, ability to describe the nation’s movers and shakers crops up again and again in the DSM-IV. Between them, Bill and Hillary Clinton meet all the diagnostic criteria for Narcissistic Personality Disorder.”1) has a grandiose sense of self-importance…; 2) is preoccupied with fantasies of unlimited success…; 3) believes that he or she is ‘special’…; 4) requires excessive admiration; 5) has a sense of entitlement… ; 6) is interpersonally exploitative…; 7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others; 8) is often envious of others or believes that others are envious of him…;9) shows arrogant, haughty behaviors or attitudes.” And it is also clear that Bipolar Disorders I (296.01, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.40) and II (296.89)–which include Manic Episode (296.00), Mixed Episode (296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.60), and Hypomanic Episode (296.40)–may be combined with Antisocial Personality Disorder (301.7) to account for an inflated sense of personal brilliance, a willingness to play fast and loose with other people’s money, an urge to instruct the nation, and an inability to foresee the consequences of one’s actions. Closely associated maladies are, apparently, plagiarism and the wearing of inappropriate garb. By this definition, most of Wall Street is completely crackers.
Welcome to the broad pathological world of the ingenious, versatile Bipolars and their catchall allies, the Antisocial Personalities. In the vernacular, the Bipolars et al. come under the heading of gotcha!–the ever-popular rhetorical device of the ideologue or the man in the checkered suit with a briefcase full of shares in a phlogiston mine. For example, a telltale symptom of Antisocial Personality Disorder is the tendency of the victim to steal things. The layman, the hard scientist, and the policeman might take issue with the diagnosis, but vigorous dissent (and what, pray tell, is the definition of “vigorous”) is a sure sign that the dissenter suffers from a Bipolar disorder and is therefore nuts. In other words, not only is anyone who pursues a goal with dedication, verve, and discipline a prime candidate for the therapist’s couch but so is the psychiatrist who rises at a hospital staff meeting to protest the fact that her colleagues are ripping off everybody in sight with bogus diagnoses. One begins to understand what exceedingly handy tools these definitions be.
The Bipolars wear many hats and perform many useful functions, but, as the DSM-IV admits in a rare moment of candor, these disorders may not even exist. The numeral 6 at the end of the Bipolar billing codes (themselves such a source of rich cross-diagnostic possibilities that an entire subsection is devoted to them) indicates that the symptoms are in full remission, which means that the patient does not have them, may never have had them, and may never develop them. No matter–the therapist still gets paid.
It was not ever thus. As recently as 1840, the U.S. census recognized precisely one form of madness, idiocy/insanity, omitting a definition because, presumably, everyone knew what it was. (In the 1840s, however, southern alienists anticipated the DSM-IV by discovering a malady called Drapetomania–the inexplicable, mad longing of a slave for freedom.) The 1880 census obligingly followed the march of science by listing no fewer than seven categories of dementia: mania, melancholia, monomania, paresis, dementia (again), dipsomania, and epilepsy. (This would not be the last time that a bald-facedly physical affliction crept into the psychological canon; among the maladies described in the DSM-IV is snoring, 780.59.) Even so, it cannot be said that the profession’s urge to colonize the human mind proceeded at a blinding pace. The term “mental illness” did not enter the vocabulary for another forty years. Many decades would pass, and much caution would be thrown to the winds, before things began to get really out of hand.
Following World War II, the U.S. Army and the Veterans Administration revisited the timeless discovery that the experience of battle did unpleasant things to the minds of its luckless participants. As a result, the number of known mental disturbances grew to a still-reasonable twenty-six. The DSM-I appeared in 1952; it was the first professional manual that attempted to describe, in a single concise volume, the disorders a clinician might encounter in the course of daily practice. The DSM-I also described the disorders as actual, discernible reactions to something–an event, a situation, a biological condition. But when the DSM-II was published in 1968, the word “reaction” had vanished, never to reappear. Unobserved by the larger world, a revolution had taken place. By severing cause from effect, the psychiatric profession had privatized the entire field of mental illness, removed it from the marketplace of ideas, abandoned the rigorous proofs of the scientific method, and adopted circular thinking as its central discipline. Henceforward, in the absence of cause and effect, a mental illness would be anything the psychiatric profession chose to call a mental illness. Increasingly, and with gathering speed, American psychiatry came to resemble a man with a hammer.
A defining moment, both for the profession and for the country, arrived with the publication in 1974 of the revised edition of the DSM-II, which abolished homosexuality as a mental illness. This was heartening news for a great many people, but they weren’t quite off the hook. When the DSM-III was published in 1980, the world was informed that believing one’s homosexuality to be a mental illness was now a mental illness (Ego-dystonic Homosexuality, 302), regardless, apparently, of where that belief might have originated.
For years, countless numbers of other people continued to be told that they suffered from a crippling disorder called dementia praecox, that women experienced penis envy, and that schizophrenia was caused by bad parents. By the time the DSM-IV rolled around, all these former truths were inoperative, bad luck indeed to the thousands who had been convinced, in defiance of their senses, that they were either hopelessly off their chumps, rotten human beings, or both. The fact that so many people had been treated, punished, or stigmatized for conditions and circumstances that did not exist failed to suggest to the public at large that modern psychotherapy had no idea what mental illness was. Nor did the tumbrels roll when the psychiatric profession went on to discover (and make a bundle from) two entirely new nation-threatening epidemics for which no empirical proof exists: chronic depression (based on the readily observable fact that a whole lot of people, including people with serious or potentially fatal diseases, don’t feel so hot about their lives) and suppressed memory. The profession had discovered a truth as old as the Republic: no one ever went broke by turning a mote into a beam.
It’s one thing for the psychological profession to defend itself against the onslaught of physical medicine and quite another for it to go on the attack. In a widespread and disturbing tit for tat, the DSM-IV displays a tendency to claim dominion over afflictions that are clearly best handled by the harder scientists. Leaving aside such suspect entries as psychotic disorder caused by a physical illness (293.82) and Vaginismus (306.51), a look at the section entitled “Pain Disorder” is instructive. Pain Disorder comes in two billable forms: Pain Disorder Associated with Psychological Factors (307.80) and Pain Disorder with Both Psychological Factors and a General Medical Condition (307.89). Its variant form–Pain Disorder Associated with a General Medical Condition–seems to cede ground to the physicians, but subsequent text plainly reveals this to be a snare and an illusion:
Pain may lead to inactivity and social isolation, which in turn can lead to additional psychological problems (e.g., depression) and a reduction in physical endurance that results in fatigue and additional pain.
On the small chance that this bit of legerdemain does not suffice, the text goes on to hint less subtly:
The associated mental disorders may precede the Pain Disorder (and possibly predispose the individual to it), co-occur with it, or result from it.
If your knee hurts, in other words, you have bats in your belfry.
Even when a problem has admittedly physical origins, the DSM-IV manages to argue that it, too, is treatable by the adepts of the psychological craft. With an audacity that would be shameless in another context, the book devotes an entire section to the psychological maladies caused by drugs prescribed to alleviate other, perhaps imaginary, psychological maladies. This is a little bit like receiving a bill from a virus. Elsewhere, the manual’s logic shows a similar taste for the absurd, devoting almost a hundred pages to the discovery that chronic intoxication (a matter of keen interest to the DSM-IV) results from the ingestion of intoxicating substances (a matter of no visible interest to the DSM-IV) and often results in (but is not caused by) both crime and poverty. The poor, by the way,frequently suffer from impoverished vocabularies (Expressive Language Disorder, 315.31).
Nowhere is this strange conflation of cause and effect on more prominent display than in the passage entitled Reactive Attachment Disorder in Infancy or Early Childhood (313.89). “The child,” we are informed,
shows a pattern of excessively inhibited, hypervigilant, or highly ambivalent responses (e.g., frozen watchfulness,resistance to comfort, or a mixture of approach and avoidance)…. By definition, the condition is associated with grossly pathological care that may take the form of persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection….
Thirty-five thousand years of human history says that the kid is reacting logically to an intolerable situation. The DSM-IV says that the kid, like the drunk and the poor person, is not playing with a full deck. Neither is any other kid who hits the hormonal wall in the mid-teens, a condition well known to generations of parents whose darkest suspicions are confirmed by the DSM-IV‘s version of the scientific method. Under the heading of “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” the DSM-IV lists Attention-Deficit/Hyperactivity Disorder (314.00, 314.01, and 314.9), Conduct Disorder (312.8), Oppositional Defiant Disorder (313.81), and Disruptive Behavior Disorder Not Otherwise Specified (312.9). A close reading of the text reveals that the illnesses in question consist of failure to listen when spoken to, talking back, annoying other people, claiming that somebody else did it, and (among a lot of other stuff familiar to parents) failure to clean up one’s room. According to the DSM-IV, adolescence is a mental disorder.
At this point in the proceedings it is time for the standard author’s disclaimer. First, a number, perhaps even a large number, of practicing therapists are sensible, upstanding citizens who never cheat on their expense accounts and who know perfectly well that poor people aren’t crazy. The problem is finding out who these therapists are. The DSM-IV lists as contributors many of the most stellar names in the profession, and the daunting task of weeding out misguided, deluded, corrupt, or stupid therapists doesn’t even begin to address the legions of social workers, lawyers, nurses, administrators, and jumped-up file clerks who use the DSM-IV as a kind of Cliffs Notes while filling out paperwork and blackening countless reputations with descriptions of illnesses that do not exist.
Next, and obviously, there actually is such a thing as mental illness. Any form of normal human thought or behavior carried to a grotesque extreme and persisting despite all appeals to reason is, by definition, a mental illness. The DSM-IV, however, appears to be unaware of this. The manual’s lengthy discussion of schizophrenia (295.30, 295.10, 295.20, 295.90, and 295.60), surely one of the most studied pathologies ever to afflict the mind of man, boils down to this: a schizophrenic is a person who thinks very odd thoughts,behaves weirdly, and suffers from bizarre delusions, which suggests that the authors of the DSM-IV either don’t know what schizophrenia is or suffer from poor writing skills (315.2). Hard science has developed compelling evidence that schizophrenia, like appendicitis, is not something that its victims can be talked out of, but one begins to suspect that the entire strangely imprecise section has been composed with the wisdom of the serpent: if the DSM-IV were to admit that schizophrenia is in all probability a physical illness with profound mental consequences, then the game would no longer be worth the candle.
Nowhere in the DSM-IV is a state of sanity defined or described, and a therapist is therefore given no guidance concerning therapy’s goal. In the DSM-IV‘s own terms, sanity appears to be the absence of everything in its pages. And for all their effort to sweep every known disturbance of mankind under psychology’s jurisdictional rug, the book’s authors seem to have overlooked a few real moneymakers. A number of people believe, for example, that they have been abducted by intergalactic superbeings and subjected to fiendish experiments, but because the DSM-IV never describes this condition, there is nothing at all wrong with such people. A person who snores or travels incognito is ready for the booby hatch, but a person who claims to have been kidnapped by a flying saucer is perfectly sane.
Well, almost. Perhaps he is “agitated,” in which case it would be reasonable to treat him for “agitation” (and bill his insurance company accordingly). Is he depressed about the incident? If so, perhaps he has gone Bipolar. And the saucer story could, of course, be read as a schizophrenic delusion. The possibilities are various.
This, in the end, is the beauty of the DSM-IV. Hangnails seem to have avoided the amoeba’s kiss, and the common cold is momentarily safe (unless it is accompanied by pain), but precious little else is. As psychiatry refines its definitions with an eye toward profit, piling Pelion on Ossa like a playwright dressing a set, the human mind becomes increasingly less comprehensible, not more. If every aspect of human life (excepting, of course, the practice of psychiatry) can be read as pathology, then everything human beings thought they knew,believed, or had deduced about their world is consigned to the dustbin of history or a line on an insurance form.