Rethinking Abnormal Behavior
What is "normal" when it comes to brains, behavior, and emotional life? Some things, like hallucinations or debilitating melancholy, are clearly diagnosable. But what about "caffeine intoxication" --characterized by insomnia, muscle twitching, nervousness, perhaps even rambling thoughts after more than two to three cups of joe? Or how about premenstrual irritability?
Since 1952, the American Psychiatric Association has published what over time became the complicated, much-criticized, often satirized, but endlessly utilized diagnostic arbiter of "normal" in the world of mental health. While the first two editions of the Diagnostic and Statistical Manual of Mental Disorders did not make much of an impression, when DSM-III was published in 1980, it transformed the landscape of mental health--for good and ill. The slender paperback manual of 1952 ballooned to 943 pages in 2000 with the revised version of DSM-IV, cataloging more than 350 mental disorders.
Practitioners celebrated the standardization of emotional disorders. Critics, however, were appalled at the oversimplification, lack of nuance, and arbitrariness being imposed on the infinite varieties of human behavior gone awry. Not to mention the way that the DSM seemed to pathologize what in many cases could reasonably be seen as simple quirks of normal human behavior, like getting jittery after too much coffee.
Multipurpose. The DSM became, in the words of Harvard psychologist Richard McNally, a DSM consultant, an "instrument that serves different masters." It helps clinicians identify patients' disorders and points to the best treatments. It also helps researchers better organize the study of mental illnesses. It has become the only tool that insurance companies use to decide if they are going to pay for medicine, hospitalization, or therapy, and it figures in legal and employment contexts as well. The problem, McNally continues, is that "all these masters are not necessarily always congruent." In addition, says critic Paul Genova, a psychiatrist and author of The Thaw: Reclaiming the Person for Psychiatry, "You start out billing this way, and a year or two later you are thinking this way." Doing great disservice to patients in the process.
In fact, the descriptive nature of the document is one of its greatest problems and one that those who are planning for DSM-V, due in 2011, are trying to correct by including more biology and hard science. Despite the enormous progress in understanding the brain through genetic research and imaging technologies, these diagnoses are still determined by a cluster of behaviors that becomes a cluster of symptoms that becomes a discrete diagnosis. "The problem is that when you have a category, there is an implication that a boundary exists between who fits in and who doesn't," says psychiatrist Michael First, editor of DSM-IV. "We have a model that appears to have hard boundaries that don't actually fit what we see in the real world."
This story appears in the May 2, 2005 print edition of U.S. News & World Report.
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