A friend who works in social care speaks to me earnestly about a troubled young colleague: ‘Of course, she’s got a borderline personality disorder…’ I check her there: ‘What do you mean by that?’ She thinks for a moment and continues: ‘Well, she’s very emotional, she can’t maintain relationships, and she’s very defiant…’ I wait for a moment to see if there’s anything else before I say my bit: ‘Perhaps she just has a bad character — because fundamentally that’s all a personality disorder is: epithetic psychiatry. There’s no defined organic basis for these so-called disorders, no psycho-dynamic aetiology either, no progression — and, of course, no cure.’
My friend doesn’t really absorb this information. Indeed, it’s as if she can’t hear it at all; she continues talking about the young woman in the same vein, before casually affixing another label to her troubled psyche: ‘She’s bipolar as well.’ There’s no point in repeating what I’ve already said. My friend — a compassionate, intelligent woman — needs these diagnoses, as so many people do, to make sense of a world that has become increasingly defined by an entire ideology of mental illness (and health) that bears as much relation to the psychic reality of human beings as the Harry Potter novels. Arguably less.
If I could’ve prevailed upon my friend to read Allan Horwitz’s exemplary account of the Diagnostic and Statistical Manual of Mental Disorders (DSM) which since 1952 has been published in five distinct iterations (with two substantive revisions) by the American Psychiatric Association, then perhaps her delusional view of the delusional could have been dispelled. Horwitz subtitles his study ‘A History of Psychiatry’s Bible’; but while this captures the significance of the DSM, it does a grave disservice to the Bible, which has far more in the way of succour for the mentally ill and advice for those who would help them than it does.
The DSM is American, but while NHS psychiatrists are meant to use the World Health Organisation’s own ICD (International Classification of Diseases), it so closely mirrors the DSM that in practice they default to it when it comes to making diagnoses. This is perverse, given that our health care is meant to be universal and free on demand; for the system the DSM has come to exemplify and perpetuate is one based on an unholy alliance between psy-professionals, insurance companies and Big Pharma. That disturbed patients in Britain should be ‘diagnosed’ with pseudo-pathologies that are in fact retroactively defined on the basis that their supposed symptoms are alleviated by one or other psychotropic drug, the profits from which are used to fund the very researchers who compile the DSM, is just another aspect of how especially unpleasant our relationship is with the increasingly senile hegemon.
A decline in power is evidenced as much by the Americans’ psychopathological preoccupations as their incompetence in foreign affairs. In fact, the DSM allows for all relevant parties — including the mentally ill and their families — to benefit in this crass financial way. Without a diagnosis of a ‘pathology’ it recognises, clinicians and their patients are unable to claim insurance payments and drug companies (and the researchers they fund) are unable to push their dubious nostrums without establishing that they can be used, specifically, to treat one of these ‘disease entities’. Since the second world war, which was the proximate reason for the creation of the DSM, the supposed incidences of all mental pathologies in the USA, from autism to schizophrenia, have increased exponentially. The question is: is this a function of iatrogenesis — doctor-created diseases — or have Americans (and their little British cousins) become substantially more mentally ill?
Have the Americans and British really become substantially more mentally ill since the second world war?
It was the many soldiers who suffered from battlefield trauma during the war that led to the rise in the number of psychiatrists and the need for a diagnostic manual that would enable these physicians to treat them in a standardised manner. Simultaneously, the arrival of Freudian psychoanalysis in the New World led to a shift in the conception of mental health therapy, away from warehousing incurable patients in long-stay mental institutions and towards the couch-born treatment of neurotic outpatients.
Horwitz presents a dialectical movement in the development of the DSM: a conflict between psychodynamic, theory-driven approaches towards mental distress, exemplified by Freudianism, on the one hand; and on the other, theory-neutral empirical approaches that aim to exhaustively classify it. In the first instance, the focus is subjective: psychosis as much as neurosis is conceived of as a function of a unique gestalt of individual proclivities and experiences. In the second it’s objective: mental illnesses are diseases that people ‘get’, as they might ‘get’ a cold — or Covid, for that matter.
The first iterations of the DSM attempted to accommodate these two radically divergent philosophies with a complete fudge. After all, the psychoanalysts, since they didn’t believe in monolithic mental pathologies, didn’t really need such a manual. Then the empiricists gained the upper hand, and cast the DSM in their own image. The trouble is that despite exhaustively cataloguing symptoms and shoehorning them into a sort of nosology, none of the ‘diseases’ so identified really qualified for the ascription. Indeed, the theoretical/empirical dialectic that played out through the first four editions of the DSM in a tragic manner — pathologising millions, vastly enriching a few thousand — was then farcically recapitulated in the formulation of the latest edition: DSM-V.
Along the way, controversy dogged the entire enterprise. First, homosexuality was a mental illness, then it wasn’t; later, in the 1980s, feminists took aim at the DSM for pathologising perfectly reasonable psychic responses to the subordinated social position of women. Finally, with DSM-V, we come full circle: the trans community campaigns to have the diagnosis of ‘gender dysphoria’ retained in the manual, because without it they will be unable to access insurance funding for gender reassignment surgery.
‘Diseases’ such as MDD (Major Depressive Disorder) came into being in lockstep with drug companies’ remarketing compounds supposedly developed to treat anxiety (the SSRIs, or Selective Serotonin Reuptake Inhibitors), to treat it instead. And there were yet more egregious examples of this tailoring of malady to cure. The worst is probably the creation of the ADHD (Attention Deficit Hyperactivity Disorder) diagnosis, to take advantage of the paradoxically calming effects of stimulant drugs on children with what Horwitz terms ‘distressing and disruptive behaviour’. From 2002-13 sales of these drugs in the US quintupled, until American parents were spending $9 billion on speed for their troublesome kids.
The problem all along has been — as Horwitz pitilessly exposes again and again — that there’s no real consensus on what mental illness is, and no irrefutable scientific evidence either. Instead, psy-professionals were assembled under the auspices of the American Psychiatric Association (which publishes the DSM, and has been massively enriched by it), to enact professional closure by committee.
DSM-V was expressly meant to change this. The rise of genomics and then neuroscience — off the back of new techniques of brain-imaging — was to finally locate these fiendishly elusive disease-entities. But, to the bewilderment of all who’d placed their faith in a biological basis to mental illness, research uncovered a picture pretty much congruent with the long-discredited Freudian view of mental illness: maladies difficult to define separately, that blur into one another, and which seem to be related to the same relatively small number of gene sequences.
Thus, if you’re liable to autism, you may also be liable to schizophrenia. And this puts us all — given the now irrefutable fact that mental illness exists not discretely, but on a continuum with mental health — back in the stygian darkness from which psychiatry has always struggled to emerge. Horwitz retains a scrupulous objectivity; but nonetheless, the tale he tells is of one of the most resounding and damaging follies of modern scientism. Of course, that won’t help my friend’s colleague. Only once we stop depending on bogus labels for our manias and melancholias, and the therapists and clinicians who mark them on our brows, will we get to grips with what truly ails us.
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