In 1971, gay activist Frank Kameny stormed the American Psychiatric Association’s annual conference, held that year in a Washington ballroom.
Pushing his way past shocked elderly psychiatrists, he seized the microphone and shouted:
“Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”
What inspired Kameny’s activism? At the time, it was the psychiatric establishment’s diagnostic hostility toward people of alternative sexualities. But it targeted something much larger, too; namely, the entire enterprise of psychiatric diagnosis through the APA’s rigidly judgmental classification system, the so-called “Diagnostic and Statistical Manual of Mental Disorders (DSM).”
Like Kameny, we too declare war on American psychiatry for its reliance on the DSM. Although the DSM may no longer specifically deride gay people as “pathological personality types” as it did in years past, it continues its intolerant tradition against many other people in many other ways. Today, the DSM deigns to impose a standard of “normalcy” upon us all, labeling as “abnormal” all who exist within its superficial, categorical caricatures. Like a criminal code, it defines and demonizes deviations from “appropriate lifestyles,” medicalizing all those who fall under its gaze, without regard to specific circumstances, causes, or backgrounds.
But unlike a criminal code, the DSM does not prescribe punishments. It prescribes “treatments” through expensive pharmaceutical products. This, in turn, has led to a medicalized–and medicated–population. It has led to an analyzed, branded, categorized, demonized, drugged population, even when drugs may do nothing to relieve their pain. Worse, the DSM inflicts permanent psychological damage through the “life sentences” it imposes on its subjects, labeling them as “abnormal,” “deviant,” “mentally ill,” or “sick.”
Unquestionably, the DSM wields enormous power. It is accepted as scientific authority by clinicians, researchers, drug regulation agencies, health insurance companies, the court system, legislatures, and policy makers. Its categorical definitions of “mental illness” sway official opinion and authorize involuntary medical treatment. It purports to speak for our society, telling its readers who does not belong, whose behavior is dangerous, and who needs “help.” In the process, it assumes a guardian-like role, enshrining itself as the enforcer of normal living, normal behavior, normal thought. In every sense, the DSM is a moral work as much as an allegedly “scientific” one: It vindicates the “normal” against all else, as if such a thing as normal ever existed at all.
How did the DSM assume its powerful position? And how exactly does it function?
As the DSM’s title suggests, statistics played a primary role in compiling an authoritative handbook on mental disorders. Western society–and especially American society–has long had an interest in knowing which of its citizens are “crazy.” American society has not only wanted to know how they are crazy, it has also wanted to know how many of them live in the community. In the United States, the first official drive to answer these two questions came in 1840, when the Census Bureau created a category called “Insanity/Idiocy” to count how many “insane people and idiots” lived in a particular community. A crude method, to be sure. But it began the whole American program of locating, counting, and categorizing those who somehow “did not fit” in “normal” society.
In these early times, medicine did not really play a role. From the statistician’s perspective, it did not matter how a person was an “idiot.” It was up to the census counter to decide whether the person was or was not an idiot. If he was, he got a check mark. If he was not, he did not get a check mark. Deciding whether a person was crazy was a layman’s decision. There was no professional obfuscation; it was essentially just a common sense judgment, such as deciding whether or not someone is drunk.
Still, deciding whether a person is “crazy” is undeniably a judgment. It involves observation, value assessment, and conclusion based on the observer’s values. This process requires language, and as the history reveals, language took a leading role in the DSM’s development.
By the early 20th Century, the medical community had taken a “scientific” interest in people formerly dismissed as “idiots” or the “insane.” For these early doctors, “idiot” and “insane” did not sufficiently describe these people; they needed more specific names. So they set about formulating a whole new language to categorize them. For the first time, statistics and medicine mixed. Now, it was not just a census question whether a person was an idiot or insane; it was also a technical, medical one.
In 1917, the American Psychiatric Association’s committee on statistics compiled a document called the “Statistical Manual for the Use of Institutions for the Insane.” For the first time, it listed diagnoses — 22 of them. Around the same time, the New York Academy of Medicine created an “official” psychiatric nomenclature, just as other medical communities had created “official” nomenclatures for body pathology and anatomy. It called its work the “Standard Classified Nomenclature of Disease.”
The business of observing and judging “deviance” now fell to doctors, and they expressed their conclusions in arcane, inaccessible language. Society still had an interest in knowing who was crazy and how many crazy people there were. The difference now was that it entrusted doctors to make the call.
Language gave rise to the DSM. As the 20th Century progressed, doctors further refined the language they applied to “mental disorders,” streamlining their criteria and shaping their elements. They invented a whole new vocabulary to talk about what their forerunners simply called “insanity.”
Like botanists, they observed their subjects and noted their particularities. They standardized, classified, subclassified, defined. They invented Greek and Latin neologisms to encompass every form of so-called “deviant behavior.” They treated “mental disorders” like any other bodily ailment: They listed elements, dressed them in fancy language and set about applying them as “professionals in practice.”
Despite these developments, there was still no standardized, authoritative manual for mental disorders. Enterprising doctors had formulated their own definitions and diagnoses, but there was no lingua franca among fledgling “mental health professionals.” There was still no centralized authority that empowered one language over another.
All that changed during World War II. The army had a substantial interest in assessing the psychological well-being of soldiers. In order to select, process, assess and treat both recruits and active duty personnel, the army wanted a standardized handbook listing mental disorders. Like the census bureau a hundred years before, the army wanted to know who was crazy, and how many of them infiltrated the ranks. The questions hadn’t changed, only the language.
To draft such a handbook, the army turned to a well-known psychiatrist, William C. Menninger. Menninger’s claim to fame before the war had been to open a clinic called The Menninger Foundation in Kansas, specializing in the “treatment of behavioral disorders.”
In 1943, Menninger compiled the closest direct ancestor of the DSM: War Department Technical Bulletin, Medical 203 (“Medical 203”). This document streamlined all previous efforts to classify mental disorders, setting forth clear diagnostic categories with concise, medically-based language. In short, Medical 203 established an authoritative language for defining, labeling, assessing, and diagnosing mental disorders as “psychopathology.” It became a universal dictionary for military psychiatrists, ending all debate as to which “disorders” actually “existed,” setting forth standardized criteria for identifying them.
Medical 203 proceeded on the assumption that mental disorders were “diseases” with symptoms. It assumed such things as “normal,” “moral” personalities and drew distinctions between disorders that affected “normal people” as opposed to “abnormal people.” Additionally, Medical 203 assumed a class of “permanently flawed personalities,” including an entire section on “Pathological Personality Types.” These “types” could not be helped; they were simply abnormal. At best, they could be identified and avoided. Medical 203 also refused to analyze causes; it merely listed symptoms and assumed that these symptoms stemmed from underlying pathology.
In essence, Medical 203 took no account of the individual. It simply observed behavior from a detached, medical perspective and described how it deviated from normal expectations. It assumed things such as “normal stress,” “unconventional behavior,” “reality,” and “effective work habits.” It also demonized “eccentricity,” “queerness,” “immaturity,” “people who are always in trouble” and “people who do not adequately relate in social situations.”
Medical 203 also took a decidedly moral tone, despite its claims to neutral “medicine.” Not surprisingly, it considered homosexuality “sexual deviance,” in the same category as “transvestitism,” “pedophilia,” “fetishism,” “rape,” “sexual assault” and “mutilation.” It bears noting that “sexual deviance” appears in a category right next to “Asociability,” referring to habitual criminals, “gangsters, vagabonds, racketeers and prostitutes.”
After the war ended, the American Psychiatric Association was so impressed with Medical 203 that it substantially accepted the text as the first incarnation of the DSM. Having seen the advantages of authoritative, standardized diagnostic language in military application, the APA eagerly sought to apply the same language to civilian life.
DSM-I appeared in 1952, containing 106 diagnoses for so-called “mental disorders.” Its language largely tracked Medical 203, which was notably a military document intended to “select, process, assess and treat soldiers.”
Viewed broadly, the DSM arose from a tradition that views human beings as specimens to be labeled, counted, demonized, and judged against an assumed standard of “normalcy.”
Criticism has dogged the DSM from its first appearance. In the 1960s, opponents chiefly challenged the entire notion of “mental illness.” After all, the DSM’s classification system only applies to “mental disorders.” Before the DSM even applies, one must accept the concept of “mental disorder” (as a metaphysical matter) in the first place. Critics like Erving Goffman contended that “mental illness” was a canard, a heavy-handed social weapon intended to suppress non-conformists. Thomas Szasz argued that “mental illness” had nothing to do with health; it referred simply to individual moral conflict. At the same time, behavioral psychologists claimed that the DSM’s methodology was fatally flawed because it relied on unobservable phenomena like “normalcy,” as well as unverifiable cultural bias.
In response to these attacks, the APA revised the DSM, publishing DSM-II in 1968. This incarnation attempted to clarify its diagnostic language while expanding its reach. It contained 182 “disorders” this time, retaining the DSM-I’s original classification against homosexuality as a “deviate sexuality.” The DSM-II’s stance against homosexuality further inflamed critics, leading to an “anti-psychiatry movement.” These critics blamed the DSM-II for providing medical justification for bigotry and intolerance, not just against homosexuals, but against anyone whose behavior did not match an assumed “norm.” This movement led Frank Kameny to crash the APA’s annual meeting in 1971, impugning all psychiatric diagnosis as biased and illegitimate.
At the same time, a new generation of data-oriented psychiatrists criticized the DSM-II’s nonscientific language. Columbia University’s Robert L. Spitzer called DSM-II an “unreliable diagnostic tool” because no two practitioners could similarly diagnose a patient presenting the same symptoms. Spitzer argued that the DSM-II needed tighter language, more objective data and greater uniformity. Critics like Spitzer were not “anti-psychiatry;” they merely wanted to make psychiatry “more scientific.”
Once again, the APA reacted to the attacks. In 1974, its Executive Board rewrote the DSM-II’s section on homosexuality. For the first time, it removed homosexuality from the classification “mental disorder” and placed it in a new category: “Sexual orientation disturbance.” And during the late 1970s, Robert Spitzer served as chairman for developing the new DSM-III, bringing mainstream expression to the new “data-oriented” trend in psychiatry.
In 1980, Spitzer’s committee published DSM-III, containing 265 diagnoses. Using “reliability” as a guiding principle, DSM-III substantially overhauled DSM-II’s categories in an effort to promote greater uniformity in diagnosis. To achieve this result, Spitzer insisted on greater research and data to support particular classifications. He also aimed to change the DSM’s language, making it even more medical and inaccessible.
In Spitzer’s words, “mental disorders are a subset of medical disorders,” and medical disorders required their own, inscrutable language. Now, homosexuality was no longer called “Sexual orientation disturbance.” DSM-III completely covered it over in jargon, labeling it “ego-dystonic sexuality.” This trend toward inscrutable medical language permeated the entire text, making the business of psychiatric diagnosis more inaccessible to laymen than it had ever been.
And there was another reason DSM-III changed its language. Beyond the customary professional impulse to keep language confusing so as to retain power over laymen, DSM-III had to adjust its words to accommodate a new player in the psychiatric landscape: Pharmaceutical companies.
The Tyranny of the DSM: Pharmaceutical Pressure
By 1980, psychiatrists increasingly prescribed more and more complicated medications to those they deemed “mentally ill.” To respond to the demand, pharmaceutical companies had an incentive to formulate newer drugs for various conditions. In order to get Federal regulatory approval for new drugs, however, pharmaceutical companies needed specific language to appease the Food and Drug Administration. The FDA did not like DSM-II’s imprecise language; it wanted regulatory language supported by at least some scientific research. This requirement played a significant role in the DSM-III’s linguistic transformation. Now, the DSM not only had to express itself in less understandable terms. It also had to support its categories with some research, spawning a whole new industry in self-serving “data collection” intended to appease FDA regulators.
DSM-III set the pattern for modern psychiatric practice in the United States. For the first time, the DSM allied itself closely with the pharmaceutical industry, adjusting its language to guarantee regulatory approval for new drugs, while at the same time providing an authoritative, quasi-scientific manual by which practitioners could medicate more and more people.
As the 1980s progressed, even Dr. Spitzer lamented this trend, noting that DSM-III led to the “medicalization of 20-30% of the population who may not have had any serious mental problems.”
By the 1990s, the trend toward medicalization had accelerated. As it did, the DSM adjusted itself accordingly, introducing more and more “science” to support its diagnostic categories. To keep pace with ever-increasing FDA applications from the pharmaceutical industry for new psychiatric medications, the APA commissioned DSM-IV. It appeared in 1994 under the supervision of Allen Frances.
Like its predecessor, DSM-IV cloaked itself in inscrutable scientific language. This time, however, it took active steps to reveal its processes, ostensibly to allay criticisms against hidden bias. To formulate new diagnoses and to overhaul old ones, it created a so-called “Steering Committee” composed of 27 members divided into 13 work groups of 5-6 members each. These “work groups” then conducted a three-step process to hash out new diagnoses: First, they carried out an “extensive literature review” on the matter; second, they solicited “new data” from practitioners and researchers to buttress their conclusions; and third, they conducted “field trials” to test the revised language. Following this apparently “transparent” process, DSM-IV promulgated 297 diagnoses in 884 pages.
Despite its efforts at transparency, however, DSM-IV never cited its sources. Instead, it merely released four “sourcebooks” relating to its “guideline development process.” These “sourcebooks” shed some light on the evidence each work group used to make its conclusions, without expressly stating sources.
DSM-IV’s authoritative language provided the ideal vehicle for the FDA to approve new drugs. Its language, coding system and classification methods tracked exactly what the FDA needed to hear from an applicant, as well as what insurance companies wanted to hear in requests for reimbursement from patients seeking medications and psychiatric treatment. DSM-IV created a symbiotic relationship between the psychiatric community (which received payments from the health insurance industry), the pharmaceutical industry (which received regulatory validation from the DSM-IV’s carefully crafted language and “research”) and the health insurance industry (which received more and more premiums from people seeking “mental health treatment”).
This is the background against which the APA approved the DSM’s latest incarnation, DSM-V. Now, the alliance between the APA, the pharmaceutical industry and the health insurance industry is set in stone. And just as the DSM-IV did before it, the DSM-V provides the linguistic grease that keeps the economic wheels turning.
But all this begs essential questions: Is the DSM-V any more valid today than DSM-I was valid in 1952? Is there anything about the DSM’s methodology that invites criticism? And perhaps most importantly, does the DSM actually cause more psychological harm than good?
As we have seen from reviewing the history, there is nothing intrinsically “correct” about the DSM. We have seen that it is merely an experimental, judgmental dictionary that enshrines dubious “normalcy” as a standard for evaluating–and now medicalizing–all kinds of human behavior. It is merely an arbitrary nomenclature that has grown organically over time with no real authority beyond what it has awarded itself.
We must expose the DSM for what it is: A culturally biased, judgmental handbook that springs from an intolerant tradition; a presumed medical lexicon with no intrinsic authority; a text co-opted by the empowered to enforce a version of “normalcy” that serves the existing economic order. What more proof do we need than the DSM’s own checkered history, its lack of acceptance abroad, the constant debates surrounding its legitimacy and its deepening commercial ties to drug companies?
In short, human beings are far too complicated to be categorized. The DSM’s categorical methodology proceeds on the wrong assumptions about people. Its ascendancy has less to do with intrinsic worth than with power’s relentless urge to maintain stable–and unequal–economic hegemony within society. Power enthroned the DSM, and power keeps it there. Power married psychology with science, science with medicine, and medicine with medication.
We are so much more than the superficial specimens outlined in the DSM. We deserve better. We deserve to be free from the tyranny of “normal.”
That is why we must agitate against the DSM. Our very individuality–and humanity–depends on it.