The Diagnostic and Statistical Manual of Mental Disorders (DSM), which was used to identify mental disorder in the South Australian survey, was devised and published by the American Psychiatric Association (APA). The APA is the main professional organisation of psychiatrists in the United States, and the APA’s diagnostic manual has become one of two international standards for psychiatric diagnosis. (The other is the World Health Organisation’s ICD-10, which will be discussed in Chapter 2). The DSM system is deeply entrenched in the medical practice of English-speaking countries such as the United States and Australia, and codes from the manual are used for making medical claims for psychiatric expenses.
Early versions of the DSM had little pretence of being scientific and were largely heuristic guide-books that incorporated much of the psychiatric lore derived from Freudian psychoanalytical techniques.[5] But with the third revision in 1980, a ‘fateful point in the history of the American psychiatric profession was reached . . . The decision of the APA first to develop DSM-III and then to promulgate its use represents a significant reaffirmation on the part of American psychiatry to its medical identity and its commitment to scientific medicine’.[6] Subsequent revisions of the manual have also claimed scientific status.
The recent editions of DSM attempt to classify all deviant personality types so as to provide a universal reference for aspects of human expression and identity that require psychiatric modification. The preparation of the most recent edition of the manual, DSM-IV, was a ‘team effort’ involving more than a thousand people. Codes and descriptions are supplied for nearly four hundred separate mental disorders. They range in scope from ‘Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence’ such as the learning disorders (315.00 Reading Disorder and 315.1 Mathematics Disorder) and the disruptive behaviour disorder (313.81 Oppositional Defiant Disorder) through to a whole range of adult forms of deviancy including substance abuse of various kinds, sexual dysfunctions, personality disorders and psychoses. A recent reviewer, prompted by the breadth of its scope, facetiously observed that, ‘According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (popularly known as DSM-IV), human life is a form of mental illness’.[7]
There are obvious dangers to civil liberties arising from the empowerment of medical practitioners to use the DSM system as a template for dividing the general population into a normal 75 per cent and an unfit 25 per cent. But even if the alienation of a quarter of the population were acceptable in terms of civil liberties, why should a conservative American professional organisation be allowed to specify the types of people that are socially unacceptable in other countries such as Australia? Consider some of the features of 301.7 Antisocial Personality Disorder, for instance:
"Irresponsible work behaviour may be indicated by significant periods of unemployment … or by the abandonment of several jobs without a realistic plan for getting another job. There may be a pattern of repeated absences from work … They may have an inflated and arrogant self-appraisal (for example feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured or cocky."[8]
This type of person may be unattractive to employers in the United States, and indeed to employers in other parts of the world as well, but do most people really believe that these character traits are manifestations of mental disease? Some Australian psychiatrists have argued against the respect given to the DSM system in Australia, particularly by courts of law, complaining that ‘the DSM is no more than a distillate of the prejudices and power plays of a group of aging American academics, of no interest to most Europeans and only passing relevance to some Australasians.’[9]
Apart from the doubtful classification system, which purports to match aspects of personality and self-expression with specific underlying mental diseases, there is also uncertainty about whether diagnosticians can be consistent in their identification of the forms of deviance the manual describes. The classification system largely deals with manifestations of mind and personality, and diagnosing the mental disorders that the system specifies requires subjective value judgements that have to be made without the assistance of definitive methods of measurement or laboratory tests. Someone who is ‘excessively opinionated, self-assured and cocky’ to one diagnostician could easily be ‘well-informed, confident and amusing’ to another. Where two psychiatrists are required to interview the same patient on admission to a psychiatric hospital, it has been found that the level of agreement between them is often little better than chance. In regard to schizophrenia, for instance, after assessing six studies conducted in the US and the UK, researchers concluded that diagnostic agreement between psychiatrists was ‘no better than fair’.[10]
Next: Growth of the Mental Health Industry
[5] Stuart A. Kirk and Herb Kutchins, The Selling of DSM: The Rhetoric of Science in Psychiatry, pp. 4–5.
[6] G. L. Klerman, ‘The Advantages of DSM III’, p. 539.
[7] L. J. Davis, ‘Diagnostic and Statistical Manual of Mental Disorders, 4th ed.’, Harper's Magazine, p. 61.
[8] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, fourth edition, (DSM IV), pp. 646–7.
[9] Michele T. Pathe and Paul E. Mullen, ‘The Dangerousness of the DSM-III-R’, p. 48.
[10] Kirk and Kutchins, op. cit., p. 60.