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Transcript

Are you crazy? Yeah, we all say that, usually in exasperation or disbelief. The word “crazy” entered English in the 16th century and originally meant cracked or flawed, like the craze on the surface of pottery; it could also mean sickly or frail. It was another few years before it took on the connotation of “unsound mind” or “insane” or, of course, “nuts” (which originally meant “infatuated” in Britain; Americans made it mean “deranged.” Typical.).

No matter how that question is put, it’s not seeking a diagnosis. It’s a bit too colloquial for most professionals, I’m guessing, and anyway they have a far more sophisticated and extensive vocabulary and terminology to describe all our syndromes and such. It all started with a thin little spiral bound volume, very technical and very dry, which has changed and grown several times, and which completely changed the way we think about, and talk about, our minds and selves.

A document that changed the world
The Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM published by the American Psychiatric Association
1952

I’m Joe Janes of the University of Washington Information School. 1952 was a remarkable year: Elizabeth II takes the throne, the Today show premieres, the polio vaccine is introduced, Ralph Ellison publishes Invisible Man. You could make an argument that the publication of the DSM, and what came after it, is in that same league. Its roots go back over a century earlier, to the 1840 US Census, which was the first to try to determine the number of people who were “insane” or “idiotic”. Controversy ensued when substantially larger proportions of blacks in free states were categorized that way, leading to claims that slavery was beneficial, and that the numbers were flawed.  

From there, the process got more sophisticated, leading first to a manual for standardizing statistics for insane asylums in 1918 which reads as though it could just as easily be discussing hospital patients, prisoners, students, even cars in a garage, down to suggestions for color coding cards for various record keeping purposes and using black ink for men and red for women. Some of the 22 categories here sound familiar, like paranoia or psychosis, some don’t like presbyophrenia, and many are things we now think of quite differently; the manual lists multiple sclerosis, epilepsy and syphilis as “mental diseases,” and includes some very peculiar language about racial categories. There’s also the obligatory catch-all “undiagnosed psychoses” and #22, “Not insane”.

During and following World War II, the War Department got into the act with the somewhat sinister-sounding “Medical 203”, a technical bulletin which really first attempted to seriously tackle diagnostic nomenclature, and in the process, help to build up psychiatry as a profession to be taken more seriously. In its few pages, it lays out a number of “psychiatric disorders and reactions,” an important addition, as this is also among the earliest portrayals of mental disorders as the results of external stimuli rather than being just inherent.

Then the fun begins; other attempts, including international ones, are being undertaken, and in the early 1950’s several are merged, with Medical 203 at the center, by the American Psychiatric Association in the publication of the Diagnostic and Statistical Manual of Mental Disorders in 1952. In its 130 pages or so, we find just over 100 diagnoses with explanatory material, code numbers, standard forms, all very official and impressive. (Though the copy I’ve got is printed badly in places with pages obviously not from clean rolls of paper.)

It’s since been revised several times, at first quietly to what’s known as DSM II which apparently nobody liked, and then increasingly publicly and loudly for subsequent versions, each of which largely repudiate the bases of the previous one, all emerging from a complex stew of forces— scientific, economic, social and cultural, political—that act on it.

Some documents are very simple—Lincoln writes the Gettysburg Address and reads it. Others are tortuously complex; the DSM V took 14 years to work through and there’s still great unhappiness about it. Lots of controversies, about distinctions made too fine and not fine enough, reliance on symptoms rather than causes, cultural bias, financial conflicts of interest with the pharmaceutical industry, and of course the big one, what is a mental disorder?

Many stories are told about the controversies around revisions. In DSM V, approved in 2012, Asperger’s Syndrome was dropped as a separate category and PTSD has substantially changed, both of which have inflamed lots of people. The classic story, though, is homosexuality, which somehow slipped into DSM II (code 302.0) as one of several otherwise undefined “sexual deviations” along with pedophilia, transvestism, and voyeurism, nestled snugly between “inadequate personality” and “alcoholism” in the nonpsychotic mental disorders. Many years of struggle, activism, and debate led it to be dropped in the third edition, which meant, in effect, that homosexuality was a mental disorder for a few years and then it wasn’t, because the book said so.

The DSM, like many systems, creates its own reality. I’m not saying that mental illness isn’t real, far from it, but this manual prescribes, literally, a way of thinking about, classifying, and discussing it, with all the ramifications and consequences that follow, intended and otherwise. Its definitions effectively create the disorders: no definition, no disorder, no diagnosis, no treatment, no insurance. And it makes a few million dollars a year for the APA in the process, not to mention the whole secondary structure of training programs, guidebooks, software, and so on, to help people use the thing.

It’s telling that the DSM’s roots go back to the census and record-keeping. Those early efforts were more about how many than what...but then you eventually get to what because once you start counting, you want to make the counting better and more precise. Statistics beget analysis, which begets more statistics, and so on; witness for example the recent proliferation of ever more exotic baseball statistics in an era of Sabermetrics. The diagnostic component here is not so much an afterthought as a largely inevitable consequence.

A diagnosis, especially in this realm, can be comforting, even empowering, as well as leading to treatment and therapeutic regimes. Having a name for something, knowing that you’re not just...crazy...can be a huge relief. Of course, the opposite is true, as well, the potential for stigmatization, the way you’re perceived by others or yourself, or even treatment for the “wrong” thing.

So, names have power, at least the power we give them. If it feels like everybody’s got a syndrome these days, there might be a reason for that. From those 22 categories in 1918, the DSM V has 20 chapters, the rate of mental disorder diagnoses continues to rise, and many of these have entered the popular lexicon: how often do you hear bipolar, OCD, and ADHD thrown around casually? More names, more sophisticated names, more use of those names, more power, and on and on.

As I was researching the DSM, I remembered a quote from one of the 20th century’s great philosophers, Douglas Adams, who said in the Hitchhiker’s Guide to the Galaxy that the best way not to be unhappy is not to have a word for it. Food for thought in an ever-more-diagnosed and diagnosing world.

References:

American Psychiatric Association, Committee on Nomenclature and Statistics, American Psychiatric Association, & Committee on Statistics. (1952). Diagnostic and statistical manual: mental disorders. Washington: American Psychiatric Assn., Mental Hospital Service.
American Psychiatric Association, National Committee for Mental Hygiene, & Bureau of statistics. (1918). Statistical manual for the use of institutions for the insane,. New York: [National committee for mental hygiene].
Clegg JW. (2012). Teaching about mental health and illness through the history of the DSM. History of psychology, 15(4), 364–70.
Grob, G. N. (1991). Origins of DSM-I: a study in appearance and reality. American journal of psychiatry, 148(4), 421–431.
Houts AC. (2000). Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203. Journal of clinical psychology, 56(7), 935–67.
Kupfer, D. J., First, & Regier. (2002). A research agenda for DSM-V. Washington, D.C.: American Psychiatric Association.
Kutchins, H., & Kirk, S. A. (1999). Making us crazy: DSM ; the psychiatric bible and the creation of mental disorders. London: Constable.
Litwack, L. F. (1958). The Federal Government and the Free Negro, 1790-1860. The Journal of Negro History, 43(4), 261–278. doi:10.2307/2716144
Nomenclature of psychiatric disorders and reactions. Office of the Surgeon General, Army Service Forces. War Department Technical Bulletin, Medical 203. 1946. (2000). Journal of clinical psychology, 56(7), 925–34.
Timeline | APA DSM-5. (n.d.). Retrieved August 7, 2013