You Could Look It Up (52 page)

The
Diagnostic and Statistical Manual
, better known as the
DSM
, is not much to look at—small, paperbound, nine inches high by six inches wide, and just 142 pages long. It does not even seem particularly controversial on first reading. It advances no theological heresies, no maxims for political revolutionaries, no threats to the established order. It simply tallies the recognized psychological disorders and assigns to each a number: childhood schizophrenic reaction is 000–x28, sleepwalking is 000–x74, and “psychophysiologic endocrine reaction” is 008–580. And yet how much power lies in that classification!

Classifying illnesses has a long history. François Boissier de Sauvages de Lacroix, a friend of Carl Linnaeus, compiled a
Nosologia methodica
in 1763, applying the Linnaean taxonomy of plants to diseases. Sauvages
identified ten classes, including insanity as number eight. The various classes were all divided into genera and species, for a total of twenty-four hundred diseases.
10
The
International List of Causes of Death
(1893), prepared by the International Statistical Institute, took recent medical thinking into account. As the nineteenth century turned into the twentieth, medicine became increasingly bureaucratic. Two forces pushed it toward statistics and classifications. The first was modern war, as more and more lethal weapons piled bodies higher and higher. Medical statistics in wartime translated into the ability to count, and perhaps thereby to reduce, various causes of mortality on the battlefield. The other was the insurance industry: the country doctor gave way to the bean counter, and the black bag was traded for red tape. Some of the world’s earliest health insurance statutes were introduced in Germany in 1883, the United Kingdom in 1911, and France in 1945; universal or
near-universal health care plans followed in the Soviet Union in 1937, New Zealand in 1939–41, Canada in 1946, and the United Kingdom in 1948. In the United States, Blue Cross and the Ross-Loos Medical Group were both founded in 1929—the beginning of the reign of the big health insurance companies. All demanded extensive paperwork.

Classifying mental disorders, though, proved more challenging than classifying physical disorders. It is comparatively easy to agree on what is ailing those suffering from the large majority of physical problems; though physicians are still unable to cure many conditions, they usually agree that this bone is broken, that sore is infected, or this organ is inflamed. Disorders of the mind are infinitely more complicated. Are there different kinds of mental, emotional, psychic, or spiritual unsoundness? If so, what are the categories, and how can we tell which sufferers have which diseases?

Classifying mental disorders is also exceedingly consequential. Expert witnesses in criminal trials often have to base their claims in the collective wisdom of the psychiatric profession, and that collective wisdom is contained in the reference books authorized by the professional societies. In most criminal prosecutions, our legal system demands a
mens rea
, an intention to do wrong. A psychiatric diagnosis that a defendant is incapable of distinguishing right from wrong may be enough to save him from imprisonment, even execution. The right diagnosis can keep a killer from the electric chair; the wrong one, conversely, can keep an otherwise qualified diplomat from government service, or an otherwise qualified soldier from serving in the military. A code in a reference book might be responsible for locking someone in an asylum.

What constitutes a mental disorder, and who gets to say? Are soldiers who refuse to rush into battle victims of shell shock?—of battle fatigue?—of PTSD?—or are they, as some have called them, merely cowards hiding behind a diagnosis? The boundaries of insanity are ill-defined, and they are easily influenced by the worldview of those drawing the lines. In 1851, Samuel Cartwright, a physician based in Louisiana who wrote
Diseases and Peculiarities of the Negro Race
, developed a pair of mental diagnoses that he said were characteristic of black slaves. The first, “dysaesthesia aethiopica,” accounted for their laziness; the second, called “drapetomania,” was an unaccountable desire on the
part of slaves to escape from servitude. With the right treatment, Cartwright maintained, “this troublesome practice that many Negroes have of running away can be almost entirely prevented.”
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He thus demonstrated that all manner of preconception or prejudice can be elevated to the level of quasiscientific diagnosis.

In the 1840s, the U.S. Census recognized just one variety of mental illness, identified as “idiocy” or “insanity.” The American Psychiatric Association devoted part of its founding year, 1844, to classifying patients in asylums, and began enumerating varieties of insanity.
12
By 1880, the list of maladies recognized by the census had grown from one to seven: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
13
The
Statistical Manual for the Use of Institutions for the Insane
(1918), the first attempt of the National Committee for Mental Hygiene to classify psychological disorders, included twenty-two diagnoses.

The number continued to rise over the first half of the twentieth century, culminating in 1952 in the American Psychiatric Association’s
Diagnostic and Statistical Manual, Mental Disorders
, universally known as the
DSM
. It laid out a taxonomy of 106 mental disorders as understood in the early 1950s—that is, an essentially Freudian understanding of the world—backed up with epidemiological data. The word
reaction
appeared often in its pages, reflecting the understanding that most mental disorders were responses to stresses in the outside world—repressed trauma, unresolved tensions with family members, inadequately absolved guilt. When conditions in the
International Statistical Classification of Diseases
, concerned with somatic illnesses, had a connection to psychiatry, the
DSM
shared the appropriate code: nail biting is 324.3, cancerophobia is 313, weight loss is 788.4, and moral deficiency is 320.5. Much of the book is tabular:

PERSONALITY DISORDERS

–X  DISORDERS OF PSYCHOGENIC ORIGIN OR WITHOUT CLEARLY DEFINED TANGIBLE CAUSE OR STRUCTURAL CHANGE

The first edition of the
DSM
reveals much about the state of psychiatry at midcentury, but the interesting story appeared in its subsequent revisions. Fourteen years after the
DSM
came
DSM-II
. It was a little shorter than its predecessor—136 pages rather than 145—but included more conditions. Children’s behavioral disorders were recognized for the first time, including “hyperkinetic reaction,” akin to what would later be called attention deficit hyperactivity disorder. More telling, the word
reaction
got much less use in
DSM-II
, and an essay appended to the manual justified the exclusion: the editors did not want the book to reflect any particular school of thought, and “reaction” was too tightly bound to Freudian psychoanalysis.

DSM-II
was a critical dud, and within a few years of publication, the discontent translated into plans for a third edition. In the meantime, several developments had prompted a change in thinking about mental pathologies. In 1972 a large comparative study of diagnosed cases of schizophrenia in both London and New York City revealed the incidence was twice as high in New York as in London—forcing psychiatrists to think hard about the need for precise diagnostic criteria. More important, medications were showing promise in controlling what had been conceived of as strictly mental disorders: mania and depression seemed to be responding to pharmaceuticals.

The result was a walloping increase in the number of conditions identified—and in the size of the
DSM
. The original edition had identified 106 conditions, the second 182. By 1980,
DSM-III
was 494 pages long and included 265 diagnoses, arranged in a new classification system. In the first two versions, psychopathologies were regarded as manifestations of underlying subconscious states. This makes diagnosis difficult, since one behavior might be an expression of dozens of underlying conditions. Starting in the 1980s, the editors strove for a classification system that would be agnostic on questions of etiology. Instead they proposed a taxonomy based strictly on symptoms—on objective expressions in the real world. The buzzwords were now “objectivity” and “truth,” and the
manual was billed as a victory for science. Not everyone, though, regards
DSM-III
as a step forward. For some it was a victory not for science but for the pharmaceutical industry: the supposedly objective system of classification, dependent on no particular theory, paved the way for the medicalization, and therefore monetization, of many behaviors that had never before counted as pathologies.

Subsequent versions continued moving in the same direction. No sooner had
DSM-III
appeared than there were plans for
DSM-IIIR
(“revised”) in 1987. Seven years after that came a
DSM-IV
, and six years later a
DSM-IV TR
(“text revision”). By the time of the fourth edition, the book had grown to 886 pages, backed up by four volumes of sources, and the number of diagnoses now stood at 279. The ever-finer distinctions among diagnoses partly reflected the best scientific thinking, but they also represented the influence of insurance companies that demanded billing codes.

With each change, the sorts of behavior considered “normal” or “pathological” were readjusted, often with real-world consequences. Michael First, a Columbia University professor of psychiatry who worked on
DSM-IV
, described the stakes: “Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled.” There were dangers: “the more disorders you put in,” First continued, “the more people get labels, and the higher the risk that some get inappropriate treatment.”
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Many think psychiatry has gone overboard with “disorders” such as binge eating and gambling, while excluding Internet addiction and sex addiction.
15
And as some putative mental illnesses are added, other long-familiar conditions simply disappear through fiat. Hysteria, a common diagnosis for millennia, was defined out of existence in the revision of 1980.

Probably the most controversial change in the history of the
DSM
was the editors’ decision that one condition was no longer to be considered a disorder. The original
DSM
included, as number 000–x63, “Sexual deviation,” with the instruction to “specify the type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation).”
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This
classification reflected the general, if not universal, consensus of the profession in the 1950s: psychoanalysis saw homosexuality as a pathological “inversion.” But times change, as do moral judgments about behavior. After Alfred Kinsey’s groundbreaking
Sexual Behavior in the Human Male
(1948) reported that 37 percent of otherwise “normal” men had at some time engaged in this “pathology,” though, it became more difficult to consider the behavior—increasingly thought of as an identity —as a “disorder.” The meeting of the American Psychiatric Association (APA) in 1970, just months after the so-called Stonewall riots, was marked by controversy: protesters were out in numbers; they blocked the entrance to the conference and destroyed a booth that sold equipment for “aversion therapy” to “cure” homosexuality. The APA responded, as bureaucracies are wont to do, by forming a committee, this one headed by Robert Spitzer. The committee’s report came to four conclusions: