The DSM, or Diagnostics and Statistics Manual, is published by the American Psychiatric Association and is widely known as the “bible of psychiatry”. This is the book that groups certain behaviors or thought patterns together, classifies them as symptoms, and labels that cluster of symptoms as a disorder.
It’s an imperfect science, to say the least.
Medicalizing Human thought and behavior is not so simple as say, peeing on a stick to confirm a pregnancy. In that case, the presence of a hormone produced by the body in early pregnancy causes pigmentation in the test window to activate, and a little line appears. False positives are rare. Neither is it as simple as viewing an x-ray of a femur and observing a line where there shouldn’t be one, confirming a fracture. In these instances, there is no room for ambiguity, or doubt.
The contents of the DSM have changed considerably over time, as well they should have. Homosexuality was included in the first edition of the DSM, published in 1952, as a “sociopathic personality disturbance”. Hysterical Neuroses, an affliction unique to women, was included in multiple incarnations of the DSM and only removed in 1980. So far as I can tell, hysterical neuroses was basically a catchall term for women who were wound up, pissed off, and not interested in tolerating their intolerable lives. (These women sound like my peeps. Can I meet these women??)
One of the terms I have the most difficulty with is “disorder”. Let’s take PTSD, or post Traumatic Stress disorder, as an example. When the Virginia Tech shooting happened in April of 2007, 32 people were killed and more than a dozen others were injured. I was a graduate student at the time, and I watched the coverage in horror. University campuses are teeming with life and possibilities, a place to take your overly large paper cups of hot beverages and your hungry brain and immerse yourself in the vast scope of human knowledge. I couldn’t imagine having all of that shattered, savagely and forever, by a mass shooting. It took Sanjay Gupta about five minutes to start talking about PTSD, and I was furious. How was a post traumatic stress response disordered? Were these students supposed to step around puddles of blood with their highlighters and textbooks and go on as if nothing had happened? How could they not be profoundly traumatized?
When I was in treatment, a man was there with a diagnosis of PTSD. He had been a soldier, stationed at various locations in Kandahar province. His job was to parachute out of planes into hostile territory and, in his words, “to seek and destroy the enemy”. I don’t know what he saw, and I don’t know what he did. I never asked, and I don’t think he would have wanted to tell me. But how could this man, a responsible and ethical human being, bright and soft-spoken, reconcile his personal values with what he had been ordered to do in battle? Whatever happened in Afghanistan, it broke him. Yes, his symptoms were painful and disruptive to his life, and without question, he needed help and healing. But were they disordered, inappropriate? Or were they simply a natural human response to horrific experiences that no one should have ever to have?
Another major question I have is where the line is between more extreme experiences and behaviors and actual pathology. When does a person who is wildly optimistic and positive about life, full of creativity, incredibly productive, exceedingly confident, prone to spending and possessed of a healthy sexual appetite become hypomanic? And what if, as in the case of a friend that I wrote about recently, a diagnosed hypomanic state serves someone so well that they have no interest in changing it?
The possibility of ADHD has recently been raised about a child I know very well. ADHD is hotly disputed, with many respected medical professionals feeling that it is grossly overdiagnosed. It is also, bizarrely, included in the DSM and considered a mental illness. Its three main features are impulsivity, inattention, and hyperactivity. How long is a five or six year old supposed to sit quietly, pay attention, and refrain from fidgeting? Is there an inherent bias here against gregarious, naturally exuberant children who prefer running and climbing and moving their bodies to more stationary activities like reading or drawing? What if the kid just has a temper?
I don’t know the answers to any of these questions, but they are, I think, important ones to consider. I once read the phrase in undergrad, written by a scholar whose name I can’t recall, that we are “catching ourselves in the complex act of being human”. This is what the DSM does…catch us the highly complex act of living and pathologize some of the ways we go about doing that, classifying some of those ways as healthy, and some as not.
Messy business, this task is. And many, many questions we need to keep asking.