The DSM now permeates American society. You see it in the widespread, casual use of such terms as “bipolar disorder” and “autism spectrum.” One key player in the DSM’s rise to influence was the insurance industry. As insurance companies became involved in paying for mental-health care, they needed a standard by which to parse which disorders’ treatment merited reimbursement and which did not. They turned to the DSM. Clinicians were at first skeptical about how well the DSM’s classifications reflected their patients’ needs and conditions. But over time clinicians, too, became wedded to it for fear that any major modification might jeopardize their ability to get paid.
A formal diagnosis facilitates access to services, so parents came to rely on the DSM’s multiplying diagnoses and resisted any changes that might diminish that access. Drug companies haven’t directly influenced the DSM’s contents, Mr. Horwitz observes, but they have contributed to its popularization. In the early 1970s, the Food and Drug Administration started requiring pharmaceutical companies to stipulate, in ad campaigns, which specific diagnoses their products treated. Drug ads made household names out of DSM diagnoses that, often enough, patients now give to themselves before setting foot in a clinician’s office.
Mr. Horwitz persuasively critiques the underlying vagueness of the DSM’s approach to classifying disorders, but he is himself at times vague about how far he wants to press that critique. Where to draw the line between challenging the scientific basis of the DSM and the scientific basis of psychiatry itself? At times he seems to doubt whether the anti-psychiatry movement has ever been adequately refuted. But in the past undermining psychiatry has tended to make worse off those Americans who, without question, suffer from incapacitating psychiatric disorders. Somewhere around 500,000 severely mentally ill people are either institutionalized, incarcerated or homeless. Unless we’re going to tell such vulnerable people to snap out of it and get a job, psychiatry has a place in American society.
That’s not to say that psychiatry bears no responsibility for persistent doubts about its validity and effectiveness. In Mr. Horwitz’s history of the DSM’s evolution, psychiatrists sometimes come off as referees mediating disputes over the nature of mental disorder that are, at root, about financial incentives or changing social norms.
In the early 1970s, gay activists lobbied to remove homosexuality from the DSM. Some psychiatrists resisted this change because they believed that framing homosexuality as a medical condition was preferable to framing it as a crime, its status for centuries prior, and because they saw outside-pressure groups as a threat to psychiatry’s legitimacy. This dispute took place at a time when mental illness was commonly said to be a myth; the renegade psychiatrist Thomas Szasz, among others, argued that modern psychiatry had become a form of social control. Gay activists won that dispute, paving the way for more outside intrusions into the DSM, though these have usually taken shape as calls for extending the reach of psychiatric diagnosis. Veterans lobbied for the inclusion of PTSD, then feminists demanded its expansion to “repressed” traumas. More recently, transgender activists have defended the inclusion of “gender dysphoria” so as to protect access to insurance reimbursement for sex-change operations. It’s tempting to say that psychiatric diagnosis is more an art than a science, except that art-making may well be less fraught with financial conflicts of interest.
The DSM defines mental disorders as patterns of observable symptoms, which is how psychiatrists 200 years ago defined them. It is neutral as to the etiology of mental disorders. That neutrality reflects political and cultural pressures, but those pressures wouldn’t be so compelling were the underlying science stronger. An unhealthy mental or behavioral pattern, to qualify as a psychiatric disorder—this according to the DSM itself—can’t be, for example, an expected reaction to adversity (heartbrokenness over being dumped), a culturally expected practice (hearing voices in a religious ceremony) or a form of social deviance (criminality). Mr. Horwitz believes many of the DSM’s classifications do fall under these categories and therefore aren’t legitimate mental disorders. “Diagnostic criteria, which must appear to portray evidence-based empirical research,” he writes, “in fact emerge from uncertainty, factionalism, intense political conflicts, economic considerations, and other interests.”
Mr. Horwitz’s account is especially trenchant on the subject of what I would call scientism, the often suspect ways in which medical professionals assert and defend their authority. He writes with an even tone and strives, as much as possible, to avoid taking sides. The book is historical rather than polemical. His conclusions are startling, even so, and disturbingly persuasive. The DSM, it appears, is with us for good.
______________________ Stephen Eide is a senior fellow at the Manhattan Institute and contributing editor of City Journal. This piece originally appeared in The Wall Street Journal