While training in psychiatry, I frequently heard mental-health practitioners refer to the Diagnostic and Statistical Manual (DSM) as our profession’s “diagnostic bible.” The DSM, of course, is the text produced by a cabal of psychiatric experts that defines the parameters of mental illness and, by extension, mental health. It textually conveys the now commonplace assumption that psychiatry works through systems of classification and codification, a how-to manual through which clinicians observe their patients and then diagnose them as a premise for initiating treatment.
Bible, meanwhile, connotes the assumption that the DSM represents the first and final word about psychiatric conditions, passed from on high, to the diagnostic decisions of doctors, to the supplicant minds and bodies of parishioners.
To be sure, there are ways in which the DSM feels and acts like a bible. At a whopping 947 pages, the current version of the manual, the DSM-5, conveys a King Jamesean heft. And like any good religious text, the DSM demands a certain, structurally reinforced adherence. Mental health practitioners need to use DSM criteria to diagnose their patients, or they will not be reimbursed for their efforts. And patients need to be diagnosed with DSM-defined illnesses or they will not receive financial coverage for their office visits, medications, or hospitalizations. In this sense the DSM produces a congregate of doctors, patients, and insurers all of whom depend, in various ways, on spreading the good word.
There are tremendous benefits to this arrangement, none the least of which is the production of a common economy of suffering and treatment. At the same time, history suggests that blind devotion to DSM diagnostic categories as if by article of faith comes at a cost: diagnosing by-the-book can also mean reproducing a host of era-specific biases, prejudices, and stigmatizations.
For instance, as is well known, the first edition of the DSM—published in 1952 as Mental Disorders: Diagnostic and Statistical Manual—listed homosexuality as a sociopathic personality disturbance.[i] The text conveyed the common “scientific” notion that same-sex attraction represented a pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. The diagnosis of homosexuality also represented a deep conservatism that suffused the profession of psychiatry. Indeed, even in 1973, after the board of trustees of the American Psychiatric Association approved a resolution proclaiming that, “by itself, homosexuality does not meet criteria for being a psychiatric disorder,” the so-called Ad Hoc Committee Against the Deletion of Homosexuality from the DSM forced a vote of the entire APA membership. Only after a 58 percent to 37 percent victory for declassification did the nomenclature committee proceed with removal of homosexuality from the DSM.[ii]
The DSM also emerged at the center of discoveries that psychiatrists overdiagnosed schizophrenia in African American men in the 1960s and 1970s.[iii] Prior to the 1960s, psychiatry defined schizophrenia as a psychological “reaction” to a splitting of the basic functions of personality. The DSM-I described Schizophrenic Reaction as “emotional disharmony, unpredictable disturbances in stream of thought,” and “regressive behavior.”[iv] But in 1968, the second edition of the DSM recast paranoid schizophrenia as a condition of “hostility,” “aggression” and projected anger, and included text explaining that, “the patient’s attitude is frequently hostile and aggressive, and his behavior tends to be consistent with his delusions.”[v] 1968 was a year in U.S. history marked by political protest and racial tension, and the addition of terminology such as aggression and hostility had profound implications. In the aftermath of the DSM-II, clinician overdiagnosis of schizophrenia in African American men rose significantly. Published psychiatric research articles and case studies began to disproportionately describe “schizophrenic” African American men using terminology such as aggressive, hostile, or violent. And advertisements for antipsychotic medications published in leading U.S. journals made similar assumptions.[vi] An advertisement for the antipsychotic medication Haldol that appeared in the May 1974 Archives of General Psychiatry (732-33) shows the troubling, distorted image of an angry African American man below the text, “Assaultive and belligerent? Cooperation often begins with Haldol.”
More recently, the release of the DSM-5 in 2013 led to concerns that the text catered to the pharmaceutical industry by expanding the boundaries of illness beyond psychiatric expertise into ever-more-broad realms of everyday life.[vii]
These and other tensions provide fodder for growing communities of DSM agnostics. For instance, a subcommittee of the Society for Humanistic Psychology recently established a Global Summit on Diagnostic Alternatives intent on producing “alternatives to the current diagnostic paradigm” in mental health.[viii]
Such critiques are well founded, in my opinion. While production of the DSM-5 involved a great deal of thought and effort, current controversies suggest that we psychiatrists still have much to learn from our past mistakes.
At the same time, whatever manual emerged in the aftermath of a total diagnostic cataclysm would still need to address the central lessons that we, as a profession, have learned from progressive versions of the DSM. These are lessons of the need for diagnostic flexibility even in the face of demands for diagnostic orthodoxy. Make no mistake, we psychiatrists want to know what causes mental disease, and science offers promising clues about nosology. But we are not there yet. We do not diagnose schizophrenia, depression, or a host of other illnesses through x-rays, brain scans, or specific laboratory tests. Instead, we query, listen, observe, categorize, and expertly surmise.
Thus, even in an era dominated by an ever-expanding manual, diagnosis remains a projective act, one that combines scientific understanding with a complex set of ideological and political, assumptions. Seemingly straightforward attempts to help people, by naming their anguish and then addressing it, always and already become intertwined with a host of complex cultural, commercial, or political agendas.
In this sense, much like the actual bible[ix], psychiatry’s DSM is to my mind best understood, not as a reflection of timeless truth, but as an ever-changing reflection of the ways we make sense of an ever-changing world and its aberrations.
Jonathan Metzl is the Frederick B. Rentschler II Professor of Sociology and Psychiatry, and the Director of the Center for Medicine, Health, and Society, at Vanderbilt University in Nashville, Tennessee. He received his MD from the University of Missouri, MA in humanities/poetics and Psychiatric internship/residency from Stanford University, and PhD in American Culture from University of Michigan. A 2008 Guggenheim fellow, Professor Metzl has written extensively for medical, psychiatric, and popular publications. His books include The Protest Psychosis, Prozac on the Couch, and Against Health.
[i] Mental Disorders: Diagnostic And Statistical Manual. Washington: APA Press, 1952.
[ii] Even then, although homosexuality per se was expunged from the third edition of the DSM (1980), the manual still contained the diagnosis of “ego-dystonic homosexuality,” an ill-defined condition in which a person’s same-sex desire caused psychic distress.
[iii] Jonathan M. Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease (Boston: Beacon Press, 2010).
[iv] Mental Disorders: Diagnostic and Statistical Manual. Washington: APA Press, 1952, pp. 26-27.
[v] Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (Washington: APA Press, 1968), vii, viii.
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I read Dr. Metzl’s book The Protest Psychosis. Wonderful in its unique organization and detail. The man in the Haldol ad from ’74 looks a lot like characters from the ’72 blaxsploitation film “Superfly.”
I had to teach on changes from DSM IV-TR to V last year and a psychiatric nurse friend recently retired from the VA tipped me to look very carefully at what had been done with PTSD. Divorcing it from the anxiety disorders, creating a separate trauma related category, creating some lesser versions of PTSD when so many combatants are coming home from Afghanistan and Iraq with serious health problems–all this seemed to my friend to be economically motivated as a way to limit benefits to veterans. I have learned to ponder economic effects of DSM decisions. So, when I see that V has also collapsed Asperger’s and other autism spectrum disorders into a single category but then created a lesser category for problems with social communication that seems it would fit many young Aspergians, I have to ask myself, “why?”. What are parents doing with this? What are the insurance implications? What are the implications for educational services? Does it change thresholds for qualifying for therapy services in the school system?
I teach my students that human misery and suffering take myriad forms, prompt myriad behavioral reactions and that psychiatry carves these up into mutable changing categories and that the boundaries between and among those categories are patrolled by drugs. I enjoyed this essay and think I am a diagnostic agnostic.
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