Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. - book review

If life becomes difficult or confused, a visit to a psychiatrist or psychologist may seem in order, largely because we assume these professionals operate like other doctors. By listening to a description of symptoms, asking astute questions, and sometimes performing various tests, a medical specialist arrives at a diagnosis. More often than not, this diagnosis reflects an understanding of why things have gone wrong, not just what is amiss, because it is based on a chain of sound scientific research into the etiology of the disorder. For that reason, modern physicians can tailor a treatment that is specific to the illness, or, at worst, can inform the patient that there is nothing to be done. But Herb Kutchins and Stuart A. Kirk, authors of Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders,(*) suggest that in the case of the mental-health professions, the situation may be quite different from what we expect.

Making Us Crazy is the latest in a long series of attempts by these two authors to shine the light of day into the murky places where psychiatric diagnosticians ply their trade. The DSM to which their title refers is the Diagnostic and Statistical Manual of Mental Disorders, a weighty tome currently in its fourth incarnation and therefore known as DSM-IV for short. Produced and published by the American Psychiatric Association, it is supposed to bring some order to the bewildering variety of ways in which the human mind can cease to function normally. It catalogues dozens of major categories of mental disorder, most with many subtypes and variants, that range from dysfunctional personality to full blown psychosis. Most people, including many clinicians themselves, believe that it will guide them to the same kind of useful diagnosis available to other medical specialties. Kutchins and Kirk are of the opinion that any such belief is ill-founded at best.

Their argument in this book is built around a careful analysis of several telling episodes in the history of the construction of DSM since its first appearance in 1952. For example, they recount the story of how homosexuality was transformed from its pre-DSM status of moral blight to a medical condition classified as a "Personality Disorder." In later versions of the manual, it was reclassified as a "Sexual Orientation Disorder." Still later, diagnostic labels were restricted to homosexuals who were unhappy about their homosexuality ("Ego Dystonic Homosexuality"). Finally, in 1987, homosexuality was expunged from the manual altogether. Far from being a story of careful and cumulative scientific research, Kutchins and Kirk expose, in fascinating detail, the fundamentally political nature of these decisions. The public rhetoric may have appealed to science as justification for the changes, but, behind the scene, it was all power politics.

This theme - that politics often outweighs science in the construction of DSM - is one of the book's most disturbing revelations. An entire chapter is devoted to the fascinating tale of how feminists derailed the attempt to introduce "Masochistic Personality Disorder" to the list of ills in DSM-III. They did so by arguing that the pattern of behavior supposed to characterize this mental illness - a tendency to avoid or undermine pleasurable experiences and personal achievement, a tendency to seek out situations and relationships that cause suffering, a tendency to reject assistance from others - was a role into which women had been traditionally socialized. It was argued that to consider this pattern pathological would have been to add insult to injury by labeling as sick a personality profile encouraged by the same culture that proposed the label. It helped that the so-called science supposed to support the masochistic diagnosis was weak, but, according to the authors, the real battle was political.

Indeed, Kutchins and Kirk are convinced that DSM often functions as a tool for political and cultural defense of the established order at the expense of the weak and powerless. Revisions to DSM tend to increase the probability that such people will be diagnosed as mentally ill, while protecting those in power, especially those who happen to be in the psychiatric professions. This is possible, they argue, because the use of poorly researched and inconsistent criteria for diagnosis leaves the door open for abuse by unscrupulous or merely incompetent clinicians.

Examples of such abuse are to be found in two chapters at the end of the book, one on racism in psychiatric diagnosis and the other on the troublesome diagnosis of "Borderline Personality Disorder" (BPD). Tales of the role of race in psychiatric diagnosis have been often told, but the story of BPD is an insider's story. Like most diagnostic categories in DSMIV, BPD is identified by checking off items in a Chinese menu of symptoms; it doesn't actually matter which subset of symptoms is present, so long as there are enough of them. The list includes self-damaging impulsivity, intolerance of being alone, chronic feelings of boredom, a pattern of unstable relationships, emotional instability, recurrent accidents, and physical fights. The fuzzy, but clearly negative, nature of the BPD classification makes it a useful wastebasket category for troublesome or obnoxious patients.