When you are sick or injured, you want to know what’s wrong and what can be done. You want a diagnosis. A correct diagnosis reveals what is wrong, what is the preferred treatment and what is the likely outcome. For example, a diagnosis of pneumonia indicates a serious lung infection that can usually be cured with antibiotics.
While medical diagnoses are based on science, psychiatric “diagnoses” are not at all scientific. They do not reveal what is wrong, what is the preferred treatment, and what is the likely outcome. Nor are they reliable. Different psychiatrists who examine the same patient typically offer different “diagnoses.” Moreover, psychiatric “diagnoses” move in and out of favor, depending on a variety of social factors.
Psychiatric “diagnosis” is actually a labeling process, where the patient’s symptoms are matched with a grouping of symptoms listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Psychiatric Disorders (DSM). As we shall see, this psychiatric “bible” was developed and is maintained by financial and political interests.1
Who decides what is normal or healthy and what is deviant or sick?
Before the 20th century, life stresses were generally seen as spiritual problems or physical illnesses, and people turned to religious advisors and physicians for help. Medical doctors treated “hysteria” and “nerves” as physical problems. Psychiatry was restricted to the treatment of severely disturbed people in asylums.2 The first classification of psychiatric disorders in the United States appeared in 1918 and contained 22 categories. All but one referred to various forms of insanity.
In 1901, Sigmund Freud revolutionized psychiatry by breaking down the barrier between mental illness and normal behavior. In The Psychopathology of Everyday Life,3 Freud argued that commonplace behaviors — slips of the tongue, what people find humorous, what they forget and the mistakes they make — indicate repressed sexual feelings that lurk beneath the surface of normal behavior.
By linking everyday behavior with mental illness, Freud and his followers released psychiatry from the asylum. Between 1917 and 1970, as psychiatrists cultivated clients with a broad range of problems, the number of psychiatrists practicing outside institutions swelled from eight percent to 66 percent.4
The social movements of the 1960’s opposed psychiatry’s focus on inner conflict and emphasized the social sources of sickness instead. Dr. Alvin Poussaint recalls the 1969 convention of the American Psychiatric Association (APA).
“After multiple racist killings during the civil rights movement, a group of black psychiatrists sought to have murderous bigotry based on race classified as a mental disorder. The APA’s officials rejected that recommendation, arguing that since so many Americans are racist, racism in this country is normative.”5
Growing the industry
In 1980, the APA overhauled the DSM. The Task Force established to create the new manual declared that any disorder could be included,
“If there is general agreement among clinicians, who would be expected to encounter the condition, that there are significant number of patients who have it and that its identification is important in the clinical work it is included in the classification.”6
In other words, the new DSM was not based on science, but on the need to maintain existing patients and include new ones who might seek help for any number of problems. A profitable and self-perpetuating industry was born. The more people could be encouraged to seek treatment, the more conditions could be entered into the DSM, and the more people could be encouraged to seek treatment for these new conditions.
By 1994, the DSM listed 400 distinct mental disorders covering a wide variety of behaviors in adults and children. Significantly, racism, homophobia (fear of homosexuality) and misogyny (hatred of women) have never been listed as mental disorders. In 1999, the chairperson of the APA’s Council on Psychiatry and the Law confirmed that racism “is not something that is designated as an illness that can be treated by mental health professionals.”7 Homosexuality was listed as a mental disorder until activists campaigned to have it removed.8
The women’s liberation movement condemned labeling symptoms of oppression as mental illnesses. In They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, Paula Caplan explains,
“In a culture that scorns and demeans lesbians and gay men, it is hard to be completely comfortable with one’s homosexuality, and so the DSM-III authors were treating as a mental disorder what was often simply a perfectly comprehensible reaction to being mocked and oppressed.”9
Caplan describes efforts to prevent “Masochistic Personality Disorder” from being included in the DSM. This disorder assumes that women stay with abusive spouses because like to suffer, not because they lack the resources to leave. Despite protest, “Masochistic Personality Disorder” was added to the 1987 edition of the DSM, although it was later dropped.
The inclusion of “Pre-Menstrual Dysphoric Disorder” (PMDD) in the DSM also raised a protest. According to Caplan,
“The problem with PMDD is not the women who report premenstrual mood problems but the diagnosis of PMDD itself. Excellent research shows that these women are significantly more likely than other women to be in upsetting life situations, such as being battered or being mistreated at work. To label them mentally disordered — to send the message that their problems are individual, psychological ones — hides the real, external sources of their trouble.”10
As soon as PMDD was listed in the DSM, Eli Lilly repackaged its best-selling drug, Prozac, in a pink-pill format, renamed it Serafem, and promoted it as a treatment for PMDD. By creating Serafem, Lilly was able to extend its patent on the Prozac formula for another seven years.
A marketing gold mine
The DSM is a marketing gold mine for the drug industry. The FDA will approve a drug to treat a mental disorder only if that disorder is listed in the DSM. Therefore, each new listing is worth millions in potential drug sales. Most of the experts who construct the DSM have financial ties to pharmaceutical companies, and every new edition of the DSM contains more conditions than the previous one.
Once the DSM lists a new mental disorder, drugs for that disorder are heavily marketed for everyone who might fit the symptom checklist. (Doctors are also encouraged to prescribe these drugs for “off-label use,” which means to anyone they think might benefit.) Not surprisingly, the numbers of people “diagnosed” with a mental condition rise rapidly after a drug is approved to treat that condition.
In 2005, a major study announced that “About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life…”11 How is this possible? Has it become normal to be mentally ill, or has the definition of mental illness expanded beyond reason? Both could be true.
Capitalism damages people in many ways. It’s also true that the more people can be labeled as sick, the more profits can be made from selling them treatments. In Creating Mental Illness, Alan Horowitz warns,
“…a large proportion of behaviors that are currently regarded as mental illnesses are normal consequences of stressful social arrangements or forms of social deviance. Contrary to its general definition of mental disorder, the DSM and much research that follows from it considers all symptoms, whether internal or not, expected or not, deviant or not, as signs of disorder.”12
Most people know the difference between normal behavior (such as grief over the death of a loved one) and abnormal behavior that could indicate an internal disorder (such as prolonged grief for no apparent reason). However, the DSM does not consider what happens in people’s lives. With one exception (Post-Traumatic Stress Disorder), the DSM lists and categorizes symptoms outside of any social context. As a result, DSM-based surveys artificially increase the numbers of people suffering from mental disorders and, therefore, the market for drug treatments.
DSM-inflated rates of mental illness are typically accompanied by the warning that not enough people are getting treatment.13 The question of whether or not they are actually sick is never raised.
Psychiatry has a long history of medicating the oppressed, including children, for social control.14
Using DSM criteria, at least six million American children have been diagnosed with serious mental disorders, triple the number in the early 1990’s. The rate of boys aged 7 to 12 diagnosed with Bipolar Disorder more than doubled between 1995 and 2000 and continues to rise.
A 2007 survey of 8- to 15-year-olds discovered that nine percent met the DSM criteria for attention deficit/hyperactivity disorder (ADHD). The survey found that fewer than half of these children had been diagnosed or treated, “suggesting that some children with clinically significant inattention and hyperactivity may not be receiving optimal attention.” Noting that poor children were least likely to receive medication, the authors of the study recommend “further investigation and possible intervention.”15
Instead of addressing the stressful social conditions that agitate children, psychiatry imposes conformity through medication. To force compliance with this oppressive system, access to insurance benefits, medical care and social services depends on “having a diagnosis.”
The psychiatric-pharmaceutical industry treats illness as strictly individual and internal — the result of faulty genes or chemical imbalances. In reality, human problems exist in a social context.
Most of the symptoms listed in the DSM describe human responses to deprivation and oppression (anxiety, agitation, aggression, depression) and the many ways that people try to manage unbearable pain (obsessions, compulsions, rage, addictions). Depression is strongly linked with poverty,16 and alleviating poverty can lift depression.17
Under capitalism, addressing the social causes of misery is politically risky and unprofitable. So psychiatry extracts the individual from society, splits the brain from the body, severs the mind from the brain and drugs the brain.18
A sick society
Capitalism is a system that requires the majority to have no control over their lives and to believe that this condition is normal. Therefore, all reactions to inequality and deprivation must be viewed as signs of personal inadequacy, biological defect, mental illness — anything other than reasonable responses to unreasonable conditions.
During slavery days, experts argued that Black people were psychologically suited for a life of slavery, so there must be something wrong with those who rebelled.19 In 1851, the diagnosis of “drapetomania”(runaway fever) was developed to explain why slaves try to escape.20 Not much has changed. Today, exploitation and oppression are considered normal, and those who rebel in any way are considered to be sick or deviant and in need of medication or incarceration.
What’s the diagnosis for a sick society? We know what’s wrong. Most people are kept in sick social conditions so that a few can maintain their wealth and power. What is the treatment? Putting human needs first would eliminate most human misery. Who will deliver the medicine? The majority must organize to take collective control of society.
I don’t expect this diagnosis to appear in the DSM anytime soon.
- Kirk, S.S. & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine De Gruyter. [↩]
- Horowitz, A.V. (2002). Creating mental illness. Chicago: University of Chicago Press. [↩]
- Freud, S. (1901/1991). The psychopathology of everyday life. New York: Penguin [↩]
- Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York: John Wiley & Sons. [↩]
- Poussaint, A.F. & Alexander, A. (2000). Lay my burden down: Suicide and the mental health crisis among African-Americans. Boston: Beacon Press, p.125. [↩]
- Spitzer, R.L., Sheeney, M. & Endicott, J. (1977). DSM III: Guiding principles. In Psychiatric diagnosis, (Eds). Rakoff, V., Stancer, H. & Kedward, H. New York: Brunner Mazel. [↩]
- Egan, T. (1999). Racist shootings test limits of health system and laws. New York Times, August 14, p.1. [↩]
- “DSM and homosexuality: A cautionary tale.” in Kirk, S.A., Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine De Gruyter p 81-90 [↩]
- Caplan, P. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. New York: Addison-Wesley, pp.180-181. [↩]
- Caplan, P.J. (2002). Expert decries diagnosis for pathologizing women. Journal of Addiction and Mental Health. September/October 2001, p.16. [↩]
- Kessler, R.C., Berglund, P., Demler, O., Jin, R. & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Vol.62, No.6, pp.593-602. [↩]
- Horowitz, A.V. (2002). Creating Mental Illness. Chicago: University of Chicago Press. p.37. [↩]
- Talen, J. (2005). Survey says nearly half of all Americans will be affected by a mental illness, some before adulthood. Newsday, June 7. [↩]
- Breggin, P.R. & Breggin, G. R. (1994). The war against children: How the drugs, programs, and theories of the psychiatric establishment are threatening America’s children with a medical ‘cure’ for violence. New York: St. Martin’s Press. [↩]
- Froehlich TE, et.al. (2007). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med. Vol.161, pp.857-864. [↩]
- Duenwald, M. (2003). “More Americans Seeking Help for Depression.” New York Times, June 18. [↩]
- Costello EJ, Compton SN, Keeler G, Angold A.(2003). Relationships between poverty and psychopathology: a natural experiment. JAMA. Oct 15, Vol.290, No. 15, pp.2023-9. [↩]
- Ross, C.A., & Pam, A., (1995). Pseudoscience in biological psychiatry: Blaming the body. New York: Wiley. [↩]
- Poussaint, A.F. & Alexander, A. (2000). Lay my burden down: Suicide and the mental health crisis among African Americans. Boston: Beacon Press. [↩]
- Cartwright, S. (1851). Report on the diseases and physical peculiarities of the Negro race. New Orleans Medical and Surgical Journal. May, p. 707. [↩]