The Diagnostic and Statistical Manual of Mental Disorders is the reference source clinicians use for diagnosing, labeling, and treating psychological illnesses. Preparation of the latest, the fifth, edition has stirred years of strong controversies. A lot is at stake, from properly caring for the distressed to billing for their treatment.
Underlying the controversies over what constitutes a specific disorder and its symptoms is the fact that mental “illnesses” are not self-evident. Unlike, say, a broken leg, conditions like depression, schizophrenia, and ADHD get “socially constructed”: detected, defined, and diagnosed in negotiations among experts and the wider public. How Americans recognize and understand others’ and their own unusual experiences and behavior have changed greatly over the centuries. Obviously, many fewer Americans today than in the 18th century consider possession by an evil spirit or being bewitched as a reasonable account, say, for hearing voices or for suicide attempts (although these remain popular diagnoses elsewhere). Most intriguing is the possibility that changes in how we define mental disorders shape not just the labeling, but also people’s actual experiences and behavior.
Trends in diagnoses often follow changes in conditions, clientele, and culture. In the 1810s, Philadelphia doctors replaced many diagnoses of “insane” with “delirium tremens” since being thought an alcoholic seemed less damning for middle-class men than being thought crazy. In the nineteenth century, doctors commonly diagnosed troubled, fatigued, fretful middle-class women with “neurasthenia” and recommended rest cures; in the twentieth century, middle-class women with similar complaints were instead said to suffer from “nervous breakdowns” and given more medicalized treatments. Similarly, antebellum doctors recognized a “melancholic” personality syndrome that apparently was no longer around a few decades later. In an earlier post, I discussed the nineteenth-century diagnosis of “nostalgia” or homesickness. An occasionally fatal condition then, homesickness became a passing childhood worry by the mid-twentieth century. Earlier understandings of “senility” as just an inevitable stage in life gave way to specific neurological diagnoses. What we understand to be “drug addiction” shifted historically as who was addicted shifted from doctors, Civil War veterans, and middle-class housewives in the nineteenth century to lower-class men in the twentieth.
More recently, the American Psychiatric Association removed homosexuality as a disorder from the second version of the DSM, perhaps as much a result of political mobilization as of new research. Much of the autism “epidemic,” sociologist Peter Bearman has shown, followed the spread of parents’ awareness of the syndrome, treatment options, and access to diagnosticians, so that more children with borderline symptoms have become officially “autistic.” And a live debate now is how long can people be sad about a personal loss – be it a death, failed romance, or other setback – before they are clinically depressed.
Perhaps those shifting diagnoses have actually shaped Americans’ experiences and behaviors. Did the news about neurasthenia lead more American women, in some unconscious way, to feel fatigued? Did twentieth-century Americans who felt stressed decide that they were suffering “nervous breakdowns” and search themselves for other symptoms? (One might think about this as a deeper version of “medical students’ disease” — they start to feel symptoms of the diseases they are studying.)
Contemporary Americans have learned a great deal about psychological disorders. Millions take psychology classes in college, read about psychology in self-help books and blogs, and watch instant diagnoses on programs such as “Dr. Phil.” (A Woody Allen character complains to his girlfriend, “Why do you always reduce my animal urges to psychoanalytic categories?”) In the last several decades, Americans have broadened their understanding of what constitutes “mental illness” to cover an increasingly wider range of conditions.
As the DSM-V debate resolves, we should be sensitive not only to its implications for treatment and health expenses, but the messages it conveys about what is normal and abnormal behavior. In some ways, the naming of a syndrome helps create it.