The Book of Woe: The DSM and the Unmaking of Psychiatry Read Online Free PDF Page A

a diagnosis of Schizophrenia, in Remission
.
    Rosenhan’s recounting of his exploit, “On Being Sane in Insane Places,” appeared in the January 1973 edition of
Science
. Later that year, gay activists, including some psychiatrists, after years of increasingly public and contentious debate, finally persuaded the APA to remove homosexuality from the DSM—a good move, no doubt, but one that, especially after what had happened to the graduate students, couldn’t help but reveal that even when psychiatrists did agree on a diagnosis, they might have been diagnosing something that wasn’t an illness. Or, to put it another way, psychiatrists didn’t seem to know the difference between sickness and health.
    Forty years, two full rewrites, and two interim revisions of the DSM later, they still don’t. Psychiatrists have gotten better at agreeing on which scattered particulars they will gather under a single disease label, but they haven’t gotten any closer to determining whether those labels carve nature at its joints, or even how to answer that question. They have yet to figure out just exactly what a mental illness is, or how to decide if a particular kind of suffering qualifies.The DSM instructs users 34 to determine not only that a patient has the symptoms listed in the book (or, as psychiatrists like to put it, that they
meet the criteria
), but that the symptoms are “clinically significant.” But the book doesn’t define that term, and most psychiatrists have decided to stop fighting about it in favor of an I-know-it-when-I-see-it definition (or saying that the mere fact that someone makes an appointment is evidence of clinical significance). Instead, they argue over which mental illnesses should be admitted to the DSM and which symptoms define them, as if reconfiguring the map will somehow answer the question of whether the territory is theirs to carve up.
    This kind of argument leads to all sorts of interesting drama, much of which you will soon be reading about, but none of it can answer the question I posed about Sandy: Is
disease
really
the best way to understand his craziness? How much of our suffering should we turn over to our doctors—especially our psychiatrists?
    I don’t know the answer to that question. But neither do psychiatrists. Even in a case as florid as Sandy’s, they cannot say exactly how they know he has a mental illness, let alone what disorder he has or what treatment it warrants or why the treatment works (if it does), which means that they cannot say why his problem belongs to them. That’s no secret. Any psychiatrist worth his or her salt will freely acknowledge (and frequently bemoan) the absence of blood tests or brain scans or any other technology that can anchor diagnosis in a reality beyond the symptoms. What they are more circumspect about is the disquieting implication of this ignorance: that if a physician wants to claim that drapetomania and homosexuality and, as the DSM-5 has proposed, at one time or another, Hypersexuality
and Internet Use Disorder
and Binge Eating Disorder
are medical illnesses, there is nothing to stop him from doing so and if he is shrewd and lucky and smart enough to persuade his colleagues to follow him, the insurers, the drug companies, the regulators, the lawyers, the judges, and, eventually, the rest of us will have no choice but to go along.
    So while the psychiatrists who author the DSM and I share an ignorance about how much of our inner travail should be considered illness, only the psychiatrists have the power to decide, and only the American Psychiatric Association claims those decisions as intellectual property that is theirs to profit from. That’s why I think you should be more disturbed by their ignorance than mine. After all, if the people who write the DSM don’t know which forms of suffering belong in it, and can’t say why, then on what grounds can the next instance in which prejudice and oppression are cloaked in the doctor’s