Hysterical woman screaming. Albert Londe, c. 1890. / Courtesy of Wellcome Library, London.
Photo Credit: Wikimedia
Imagine for a moment that the American Psychiatric Association was about to compile a new edition of its Diagnostic and Statistical Manual of Mental Disorders. But instead of 2013, imagine, just for fun, that the year is 1880.
Transported to the world of the late 19th century, the psychiatric body would have virtually no choice but to include hysteria in the pages of its new volume. Women by the tens of thousands, after all, displayed the distinctive signs: convulsive fits, facial tics, spinal irritation, sensitivity to touch, and leg paralysis. Not a doctor in the Western world at the time would have failed to recognize the presentation. “The illness of our age is hysteria,” a French journalist wrote. “Everywhere one rubs elbows with it.”
Hysteria would have had to be included in our hypothetical 1880 DSM for the exact same reasons that attention deficit hyperactivity disorder is included in the just-released DSM-5. The disorder clearly existed in a population and could be reliably distinguished, by experts and clinicians, from other constellations of symptoms. There were no reliable medical tests to distinguish hysteria from other illnesses then; the same is true of the disorders listed in the DSM-5 today. Practically speaking, the criteria by which something is declared a mental illness are virtually the same now as they were over a hundred years ago.
The DSM determines which mental disorders are worthy of insurance reimbursement, legal standing, and serious discussion in American life. That its diagnoses are not more scientific is, according to several prominent critics, a scandal. In a major blow to the APA’s dominance over mental-health diagnoses, Thomas R. Insel, director of the National Institute of Mental Health, recently declared that his organization would no longer rely on the DSM as a guide to funding research. “The weakness is its lack of validity,” he wrote. “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” As an alternative, Insel called for the creation of a new, rival classification system based on genetics, brain imaging, and cognitive science.
This idea—that we might be able to strip away all subjectivity from the diagnosis of mental illness and render psychiatry truly scientific—is intuitively appealing. But there are a couple of problems with it. The first is that the science simply isn’t there yet. A functional neuroscientific understanding of mental suffering is years, perhaps generations, away from our grasp. What are clinicians and patients to do until then? But the second, more telling problem with Insel’s approach lies in its assumption that it is even possible to strip culture from the study of mental illness. Indeed, from where I sit, the trouble with the DSM— both this one and previous editions—is not so much that it is insufficiently grounded in biology, but that it ignores the inescapable relationship between social cues and the shifting manifestations of mental illness.
- Are you ready for the new DSM-V? (bldust.wordpress.com)