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Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders Paperback – September 18, 2003
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Used by doctors and therapists all around the country, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is the closest thing America has to a bible of mental illness. Currently in its fourth edition, the DSM (as it's commonly called) classifies more than 200 disorders and their symptoms, from Post-Traumatic Stress Disorder to Generalized Anxiety Disorder and everything in between. In so doing, say Herb Kutchins and Stuart Kirk, the DSM applies the language of mental illness to everyday behavior, transforming ordinary reactions to life's vicissitudes into billable pathology.
In Making Us Crazy, Kutchins and Kirk have used 15 years of studying the DSM to produce a lengthy diatribe against its ever-growing list of psychiatric disorders and their overly inclusive symptoms, including bad handwriting, impulsive shopping sprees, and reckless driving. The DSM, they contend, is most influenced by the needs of the insurance industry; every illness comes with its own diagnostic code, widely used for insurance claim forms. Moreover, its choices of which disorders to include and exclude are widely influenced by social prejudices as well as special interests. Given the DSM's list of diagnostic criteria, it is possible to classify almost anyone with objectionable views or behavior that deviates from social norms as "crazy." But in doing so, any mental-health professional would be acting irresponsibly by ignoring the behavior's context--the one factor a reference such as the DSM cannot quantify. --This text refers to an out of print or unavailable edition of this title.
From Library Journal
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952 but has become increasingly important?and controversial?in the past few decades, as managed health care plans have pressured psychiatrists for more "scientific" diagnoses. Kutchins (social work, California State Univ., Sacramento) and Kirk (social welfare, UCLA) counter arguments that DSM is a nonpolitical compendium by examining the processes of advocacy and protest that led to the exclusion of homosexuality, the inclusion of posttraumatic stress disorder, controversies over the use of the Borderline Personality diagnosis, and the history of racial discrimination in the assignment of diagnostic categories. Their admirable book belongs in academic libraries. Smaller public libraries are better served by less specialized titles that make many of the same points, such as E. Fuller Torrey's Out of the Shadows: Confronting America's Mental Illness Crisis (LJ 2/1/97).?Mary Ann Hughes, Neill P.L., Pullman, Wash.
Copyright 1997 Reed Business Information, Inc. --This text refers to an out of print or unavailable edition of this title.
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This is a very detailed social/political history of the DSM, in and out of committee meetings and individual correspondence, providing the evidence of the point made so well by others such as Kaplan: that the DSM is in fact a political document, evolving to suit conflicting political and financial interests. More than a story of good guys and bad guys, much of this history includes the sad moral of unintended consequences, as in the fight to get PTSD into the DSM.
I teach undergraduate psychology, and I applaud the authors' coherent explanations of technical issues such as reliablity and validity of assessment. My teaching experience informs me that this is a tedious exercise for most students, and, I assume, for the educated lay readership to whom Kutchins and Kirk appeal. But it is critical to the central theme of the story: the misuse of the aura of science to mask a fundamentally political process.
Are there victims and villains of this process? Of course, and they are the usual villains: a system of managed care, and a variety of bureaucracies and agencies pursuing government funding, grants and influence based on ultimately manipulated numbers. And the usual victims: the over-labelled, over-prescribed and stigmatized recipients of "care".
The story wanders through so many mazes that a reader may lose the thread: PTSD, homosexuality, female masochism, borderline personality disorder. Each story differs in who started the process of getting a diagnosis in or out of the DSM, the motivation for doing so, the outcome of the fight, and the specific consequences. Fortunately, the authors provide an excellent summary in the last chapter, and weave those threads back together.
More than once in reading this book, I found myself thinking that every political or social issue fight needs its policy wonks. Kutchins and Kirk may be our wonks.
They wrote in the Preface to this 1997 book, "It is precisely because issues of psychiatric diagnosis, commentary by psychiatrists on all manner of social issues, and the use of medical authority are so ubiquitous in our lives and because we are so vulnerable to the misuse of psychiatric diagnosis and authority that we wrote this book. There is a growing tendency in our society to medicalize problems that are not medical, to find psychopathology where there is only pathos, and to pretend to understand phenomena by merely giving them a label and a code number... in this book we question the legitimacy of this tendency and describe its risks. To pursue this goal, we take the reader into the world of the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM)... As the authoritative manual of the American Psychiatric Association (APA), DSM defines, classifies, and describes what the association says are mental illnesses." (Pg. x) They add, "In this book we examine critically how the APA creates categories of mental disorders.... we trace how the psychiatric profession struggles with various political constituencies to create categories of mental disorder and to garner support for their official acceptance." (Pg. 15-16)
They note, "The psychiatrists had to fight with the psychologists' association over professional turf. The dispute arose when Robert Spitzer... attempted to develop a general definition of mental disorder... When he presented his ideas ... he made the assertion that 'mental disorders are a subset of medical disorders.' This statement... attempted to establish that mental disorders are fully within the province of medicine, a notion that caused a storm of protest from the American Psychological Association... when DSM-III was released in 1980, the disputed passage had been dropped. What was learned, however, was that defining mental disorders is not only conceptually difficult but also politically controversial." (Pg. 30)
They say, "Most of these changes passed without controversy, until feminist psychotherapists confronted the APA about the proposed inclusion of three new psychiatric disorders, which they viewed as having serious negative consequences for women---Paraphilic Rapism, Premenstrual Dysphoric Disorder, and Masochistic Personality Disorder." (Pg. 47)
They record, "Spitzer ... was dissatisfied with the definition of mental disorder he had used to justify replacing the psychiatric diagnosis of homosexuality with Sexual Orientation Disorder in DSM-II... it finally appeared... as Ego-dystonic Homosexuality (EDH)... The adoption of EDH proves that not every change in DSM was the result of outside political pressure or new scientific evidence... There was some opposition to EDH... Gay activists decided against another public battle, one they feared they might lose... The wisdom of the gay activists' decision was confirmed in 1987, when Ego-dystonic Homosexuality was quietly eliminated from ... DSM-III-R." (Pg. 78) They observe, "Throughout the entire struggle over the inclusion or exclusion of homosexuality from DSM, the minor role played by scientific research has been striking... it was a political debate, not a scientific one." (Pg. 99)
This is an excellent, very informative book, that will be of great interest to a wide variety of readers interested in issues relating to psychiatry and psychology.