Who Decides What is Normal and What is Not?

dsmThe Big Book: Following up on this week’s earlier postings on labeling, today we thought we’d take a look at the DSM, the hefty 943-page widely used Diagnostic and Statistics Manual of Mental Disorders, published by the American Psychiatric Association. The DSM is used by mental health professionals as a diagnostic tool. Every mental disorder, from autism to depression to ADHD to schizophrenia to paranoid personality disorder, is defined according to how long and how intense a specific list of symptoms has been present. Take a look at this definition of Intermittent Explosive Disorder to get an idea of a diagnosis that has become a popular way of labeling people with road rage.

The Politics Behind the DSM: A little bit of background on the DSM. The first edition was published in 1952; the latest version came out in 2000. The first edition had only 50 diagnoses. Today’s DSM lists 374 diagnoses, more than seven times the original book. Does this mean cases of mental illness have grown in leaps and bounds over the past half century? Not exactly. The increase in the number of diagnoses is more reflective of insurance companies’ demands for very detailed and specific diagnoses. It is also related to the increasing availability of medications that can only be prescribed for certain clusters of symptoms, thus making it necessary to invent names for these symptoms.

Diagnoses end up in the DSM as a result of votes by a panel of psychiatrists. Of course, the panel reviews research, listens to recommendations from mental health experts, and spends lots of time discussing each diagnosis. In the end, though, a diagnosis gets into the DSM if it is the panel’s opinion, or value judgment, that it is actually a mental disorder. Consider the diagnosis of Homosexuality. For years, the DSM counted it as a mental disorder, in spite of the fact that there was no research to support this. Thanks to the efforts of gay and lesbian mental health professionals to educate the public about this, the Homosexuality diagnosis was finally voted out of DSM in 1973.

i was #87More and more people who work in the mental health field have been writing about how unfair and harmful DSM diagnoses can be. Women, for example, have been labeled with psychiatric disorders just for having normal mood swings because of changes in hormones related to childbirth or their periods. African Americans and other minorities, including Deaf people, have often been labeled as paranoid even though their fears and anger make a lot of sense due to the oppression they experience.

One Deaf Woman’s Misdiagnosis: If you are looking for a book for your summer reading list, here is one worth checking out. I Was #87, by Anne Bolander and Adair Renning is a story that makes us glad that more and more Deaf professionals work in the mental health field today, making it less likely that Deaf people will be misdiagnosed.

  1. Jenn June 22, 2006

    It is ironic to see ASC support an anti-psych diagnosis attitude, but understandable. The problem is that people don’t understand illness and that mental illness almost never lasts forever if properly treated.

    In China, they don’t really believe in psychariatric illness as a separate diagnosis, they will diagnose the symptoms and treat the symptoms, they also have very practical lifestyle advice/ prescription such as exercise, dietary restrictions, not just medicine.

    As a result “depression” is not a term in China. Also, there is a belief that man-power (will, hard work, education, planning) and environment (feng shui and other stuff) can go a long way to combat problems from early childhood and genetics.

    I once read a book about Korean elders who admitted to having depression, but they were FUNCTIONAL– they went out, they did everything they were supposed to do even when depressed. Part of this is because Korean has a strong taboo against depression. So for those elder people to admit they had depression was very dramatic.
    A korean-american friend said when I told her about the book– “wow, they actually admitted it?” The book also outlined their lifestyles and how they got support to function normally, and what the sources of depression were.

    For many, it was the clash between American and Korean cultures, for others it was the loss of independence– stuck in an car-dependent area and not having a car or a driving license, or being stuck in a land where they couldn’t speak the language.

    There were also analyses about how strongly the people felt about not giving into to their depression (cultural norms) and, as a result, they did not develop behaviors that would have worsened their depression, such as irregular sleep hours, eating habits, and forcing themselves to be active and stay connected as best as they could, even when they didn’t “feel like it.”

    I think the book, despite its strong cultural focus on Koreans, had findings relevant to anybody thinking about how to improve the mental health of the disabled community.

  2. ASC June 22, 2006

    Jenn, thanks for your comment. ASC is mostly concerned about the over-emphasis on diagnosis. Even if the problems go away, labels tend to stick around for a long time and they can be very stigmatizing. When children are diagnosed with oppositional defiant disorder, for example, their parents and teachers sometimes begin to interpret every behavior as a symptom of the disorder. This can make it difficult for the child to break out of the cycle of behaviors, especially when everyone is expecting the child to act rebelliously.

    What’s the name of the book you mentioned about the Korean elders who admitted to having depression? The fact that these people continued to function in the community shows how much cultural expectations influence how people cope with different symptoms. It makes us think of the Pygmalion Effect.


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