The Problem With Psychiatry,

the DSM, and the Way We

Study Mental Illness
Psychiatry is under attack for not being scientific enough, but the real problem is its blindness
to culture. When it comes to mental illness, we wear the disorders that come off the rack.

In the 1880s, women by the tens of thousands displayed the distinctive signs of hysteria:
convulsive fits, facial tics, spinal irritation, sensitivity to touch, leg paralysis. (ILL!"#$"I%&:
'I()*LL* ")%'+!%&,
Imagine for a moment that the $merican +sychiatric $ssociation was about to
compile a new edition of its Diagnostic and Statistical Manual of Mental Disorders.
-ut instead of .01/, imagine, 0ust for fun, that the year is 1880.
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"ransported to the world of the late 11th century, the psychiatric body would have
virtually no choice but to include hysteria in the pages of its new volume. 2omen by
the tens of thousands, after all, displayed the distinctive signs: convulsive fits, facial
tics, spinal irritation, sensitivity to touch, and leg paralysis. &ot a doctor in the
2estern world at the time would have failed to recogni3e the presentation. 4"he
illness of our age is hysteria,5 a 6rench 0ournalist wrote. 4*verywhere one rubs
elbows with it.5
)ysteria would have had to be included in our hypothetical 1880 DSM for the e7act
same reasons that attention deficit hyperactivity disorder is included in the 0ust8
releasedDSM-5. "he disorder clearly e7isted in a population and could be reliably
distinguished, by e7perts and clinicians, from other constellations of symptoms.
"here were no reliable medical tests to distinguish hysteria from other illnesses then9
the same is true of the disorders listed in the DSM-5 today. +ractically spea:ing, the
criteria by which something is declared a mental illness are virtually the same now as
they were over a hundred years ago.
"he DSM determines which mental disorders are worthy of insurance
reimbursement, legal standing, and serious discussion in $merican life. "hat its
diagnoses are not more scientific is, according to several prominent critics, a
scandal. In a ma0or blow to the $+$;s dominance over mental8health diagnoses,
"homas #. Insel, director of the&ational Institute of 'ental )ealth, recently declared
that his organi3ation would no longer rely on the DSM as a guide to funding
research. 4"he wea:ness is its lac: of validity,5 he wrote. 4nli:e our definitions of
ischemic heart disease, lymphoma, or $I<!, the DSM diagnoses are based on a
consensus about clusters of clinical symptoms, not any ob0ective laboratory
measure. In the rest of medicine, this would be e=uivalent to creating diagnostic
systems based on the nature of chest pain or the =uality of fever.5 $s an alternative,
Insel called for the creation of a new, rival classification system based on genetics,
brain imaging, and cognitive science.
"his idea>that we might be able to strip away all sub0ectivity from the diagnosis of
mental illness and render psychiatry truly scientific>is intuitively appealing. -ut there
are a couple of problems with it. "he first is that the science simply isn;t there yet. $
functional neuroscientific understanding of mental suffering is years, perhaps
generations, away from our grasp. 2hat are clinicians and patients to do until then?
-ut the second, more telling problem with Insel;s approach lies in its assumption that
it is even possible to strip culture from the study of mental illness. Indeed, from
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where I sit, the trouble with the DSM> both this one and previous editions>is not so
much that it is insufficiently grounded in biology, but that it ignores the inescapable
relationship between social cues and the shifting manifestations of mental illness.
It is true that the DSM has a great deal of
influence in modern America, but it may be
more of a scapegoat than a illain!
PS"#$IAT%" T&'DS '(T T( learn from its past. 2ith each new generation,
psychiatric healers dismiss the enthusiasms of their predecessors by pointing out the
unscientific biases and cultural trends on which their theories were based. Loo:ing
bac: at hysteria, we can see now that 11th8century doctors were operating amidst
fanciful beliefs about female anatomy, an assumption of feminine wea:ness, and the
@ictorian8era weirdness surrounding female se7uality. $nd good riddance to bad old
ideas. -ut the more important point to ta:e away is this: "here is little doubt that the
symptoms e7pressed by those thousands of women were real.
"he resounding lesson of the history of mental illness is that psychiatric theories and
diagnostic categories shape the symptoms of patients. 4$s doctors; own ideas about
what constitutes Areal; dis8ease change from time to time,5 writes the medical
historian *dward !horter, 4the symptoms that patients present will change as well.5
"his is not to say that psychiatry wantonly creates sic: people where there are none,
as many critics fear the new DSM-5 will do. $llen 6rances>a psychiatrist who, as it
happens, was in charge of compiling the previous DSM, the DSM-IV>predicts in his
new boo:, Saving Normal, that the DSM-5 will 4mislabel normal people, promote
diagnostic inflation, and encourage inappropriate medication use.5 -ig +harma, he
says, is intent on ironing out all psychological diversity to create a 4human
monoculture,5 and theDSM-5 will facilitate that mission. In 6rances; dystopian post8
DSM-5 future, there will be a psychoactive pill for every occasion, a diagnosis for
every inconvenient feeling: 4<isruptive mood dysregulation disorder5 will turn temper
tantrums into a mental illness and encourage a broadened use of antipsychotic
drugs9 new language describing attention deficit disorder that e7pands the diagnostic
focus to adults will prompt a dramatic rise in the prescription of stimulants li:e
$dderall and #italin9 the removal of the bereavement e7clusion from the diagnosis of
ma0or depressive disorder will stigmati3e the human process of grieving. "he list
goes on.
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In .00B, a large study suggested that CD percent of $mericans will receive a mental8
health diagnosis at some point in their lifetimes. (ritics li:e 6rances suggest that,
with the new categories and loosened criteria in the DSM-5, the percentage of
$mericans thin:ing of themselves as mentally ill will rise far above that mar:.
-ut recent history doesn;t support these fears. In 111C the DSM-IV>the edition
6rances oversaw>launched several new diagnostic categories that became hugely
popular among clinicians and the public (bipolar II, attention deficit hyperactivity
disorder, and social phobia, to name a few,, but the number of people receiving a
mental8health diagnosis did not go up between 111C and .00B. In fact, as
psychologist Eary Ereenberg, author of The Book of Woe, recently pointed out to
me, the prevalence of mental health diagnoses actually went down slightly. "his
suggests that the declarations of the $+$ don;t have the power to create legions of
mentally ill people by fiat, but rather that the number of people who struggle with
their own minds stays somewhat constant.
2hat changes, it seems, is that they get categorized differently depending on the
cultural landscape of the moment. "hose wal:ing worried who would have accepted
the ubi=uitous label of 4an7iety5 in the 11F0s would accept the label of depression
that rose to prominence in the late 1180s and the 1110s, and many in the same
group might today thin: of themselves as having social an7iety disorder or $<)<.
@iewed over history, mental health symptoms begin to loo: less li:e immutable
biological facts and more li:e a :ind of language. !omeone in need of
communicating his or her inchoate psychological pain has a limited vocabulary of
symptoms to choose from. 6rom a distance, we can see how the flawed certainties
of @ictorian8era healers created a sense of inevitability around the symptoms of
hysteria. "here is no reason to believe that the same isn;t happening today. )ealers
have theories about how the mind functions and then discover the symptoms that
conform to those theories. -ecause patients usually see: help when they are in need
of guidance about the wor:ings of their minds, they are uni=uely susceptible to being
influenced by the psychiatric certainties of the moment. "here is really no getting
around this dynamic. *ven Insel;s supposedly ob0ective laboratory scientists would,
no doubt, inadvertently define which symptoms our troubled minds gravitate toward.
"he human unconscious is adept at spea:ing the language of distress that will be
understood.
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W$" D( PS"#$IAT%I# DIA)'(S&S fade away only to be replaced by something
new? "he demise of hysteria may hold a clue. In the early part of the .0th century,
the distinctive presentation of the disorder began to blur and then disappear. "he
symptoms began to lose their punch. In 6rance this was called la etite h!sterie.
%ne doctor described patients who would 4content themselves with a few
gesticulatory movements, with a few spasms.5 )ysteria had begun to suffer from a
:ind of diagnostic overload. -y 11/0s or so, the dramatic and unmista:able
symptoms of hysteria were vanishing from the cultural landscape because they were
no longer recogni3ed as a clear communication of psychological suffering by a new
generation of women and their healers.
It is true that the DSM has a great deal of influence in modern $merica, but it may be
more of a scapegoat than a villain. It is certainly not the only force at play in
determining which symptoms become culturally salient. $s 6rances suggests, the
mar:eting efforts of -ig +harma on "@ and elsewhere have a huge influence over
which diagnoses become fashionable. !ome commentators have noted that shifts in
diagnostic trends seem uncannily timed to coincide with the term lengths of the
patents that pharmaceutical companies hold on drugs. Is it a coincidence that the
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diagnosis of an7iety diminished as the patents on tran=uili3ers ran out? %r that the
diagnosis of depression rose as drug companies landed new e7clusive rights to sell
various antidepressants? (onsider for a moment that the diagnosis of depression
didn;t become popular in Gapan until Ela7o8!mithHlein got approval to mar:et +a7il
in the country.
Gournalists play a role as well: 2e love to broadcast new mental8health epidemics.
"he dramatic rise of bulimia in the nited Hingdom neatly coincided with the media
fren3y surrounding the rumors and subse=uent revelation that +rincess <i suffered
from the condition. !imilarly, an $merican form of anore7ia hit )ong Hong in the mid8
1110s 0ust after a wave of local media coverage brought attention to the disorder.
"he tric: is not to scrub culture from the study of mental illness but to understand
how the unconscious ta:es cues from its social settings. "his :nowledge won;t ma:e
mental illnesses vanish ($mericans, for some reason, find it particularly difficult to
grasp that mental illnesses are absolutely real and culturally shaped at the same
time,. -ut it might discourage healers from leaping from one trendy diagnosis to the
ne7t. $s things stand, we have little defense against such enthusiasms. 42e are
always 0ust one bloc:buster movie and some wee:end therapist;s wor:shops away
from a new fad,5 6rances writes. 4Loo: for another epidemic beginning in a decade
or two as a new generation of therapists forgets the lessons of the past.5 Eiven all
the players stirring these cultural currents, I;d ma:e a si3able bet that we won;t have
to wait nearly that long.
http://www.psmag.com/health/real-problem-with-dsm-study-mental-illness-
58843/
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