Are you crazy?
Well, not crazy exactly but _ shall we say _ disturbed? Do you have a condition, a syndrome, a mental disorder?
According to DSM-IV, if you've got a heartbeat, you probably do.
DSM-IV is the newest edition of the Diagnostic and Statistical Manual of Mental Disorders, the shrink's bible, the one book you'll be sure to find on the shelf of every psychiatrist and clinical psychologist in the country.
It also will be the most-thumbed book on the shelf, because it's the book your counselor will consult to decide what code to use to bill your insurance company.
But it's more than that; DSM is one way in which we define ourselves, and a look at its evolution suggests that we are in the process of redefining ourselves in a disturbing _ and disturbed _ way.
With each new edition, the number of mental disorders has multiplied. DSM-IV now includes more than 300 mental disorders, more than three times the number in the first edition, published in 1952.
Mental disorders now include everything from "Nicotine Dependence," suffered by smokers, to the "Disorder of Written Expression," which afflicts people who can't write well.
"We're all crazy. Yeah, it's as common as the common cold," says Herbert I. Kutchins. "And these fellows are telling you that we're all crazy, and we all need a little help, and it's not so bad to be crazy. Crazy is normal."
Kutchins, at California State University, Sacramento, and Stuart A. Kirk, at the University of California, Los Angeles, are professors of social work whose book, The Selling of DSM, lambastes the philosophy and the methodology (or lack thereof) behind the manual.
But in a way, DSM is only a reflection of a growing trend in our society: to pathologize everything.
The American Psychiatric Association, which publishes DSM, warns readers that the manual is "not meant to be used in a cookbook fashion."
But that warning is followed by a series of recipes.
Do your children lose their temper? Argue with you? Refuse to comply with your rules or requests? Deliberately do things to annoy people? Blame others for their mistakes or misbehavior? Get angry or resentful? Act spiteful or vindictive?
If they have exhibited four or more of these symptoms over the past six months, then, according to DSM-IV, they may very well be suffering from "Oppositional Defiant Disorder," code number 313.81.
And how about you? Have you always been bad at math? Did your math scores drag down your SATs and keep you out of the Ivy League?
Then you may be a victim of "Mathematics Disorder," code 315.1.
Do you worry? Feel sad? Bear grudges? Smoke? Drink?
These and virtually any other human emotion or behavior you can think of are all signs of a possible mental disorder. There is even a category for those occasions when no other category seems to apply: Code 300.9, "Unspecified Mental Disorder (non-psychotic)."
True, the manual usually cautions that the subject must exhibit the symptoms more often than normal, but what is normal? That, it seems, remains a judgment call.
"The way this manual is structured," Kutchins says, "you can't identify what you mean by normal, and you can't differentiate between perhaps annoying and disturbing behavior and that which is mentally disordered."
Dr. Allen Frances, who chaired the task force that put together DSM-IV, takes issue with Kutchins' characterization.
"We tried to be very careful to make clear that not only must you have the symptoms described but they must be present in a clinically significant level of impairment or distress to be considered a disorder," he says. "The problem in defining disorders is, on the one hand, you don't want to be cavalier and leave people out who may have a treatable condition; on the other hand, you don't want to diagnose everyone on the street and trivialize the whole concept. So you have to strike a balance to find the middle ground."
Kutchins places too much emphasis on the manual itself, says Dr. David T. Hellkamp, a clinical and consulting psychologist and a professor of psychology at Xavier University in Cincinnati.
"The DSMs are merely guidelines to be used. The critical variable is the diagnostic skill of the provider. What scares me more than anything . . . is not so much the diagnostic system, DSM-IV now, as much as it is a general zeitgeist in our society with regard to health care and certainly mental health care that virtually anybody can do it."
The anybody Hellkamp is referring to includes mental health care workers who are not properly trained and the clerks at insurance companies who sign off on mental health care providers' bills.
Health care, Hellkamp says, is "moving from kind of a cottage system to a factory system. What's happening in terms of how that's getting carried out is that we are producing people that really don't have good diagnostic training."
Those are the people, he worries, who may gloss over DSM's warnings, and use the manual mechanically.
Ironically, the later editions of DSM make that easier to do than it used to be. Because the first two editions of the manual came in for criticism because its diagnostic criteria were so vague, the American Psychiatric Association has tried to make the manual more scientific by basing the criteria on observable behaviors.
But that behavioral bias tends to ignore the personalities of the subjects and other factors that may influence their behavior, says Nicole Barenbaum, a psychologist at the University of the South in Sewanee, Tenn.
And then there is the question of how the psychiatrists who sit on the committees that put together DSM decide what to call a mental disorder.
In an article published in the Journal of Abnormal Psychology in 1991, Dr. Robert L. Spitzer, who oversaw the development of DSM-III and III-R, fretted that the upcoming DSM-IV "will still be based primarily on expert consensus, rather than on data."
Kutchins and Kirk have been quick to point out that Spitzer's prophecy has come to pass, and that, in fact, another, better word for consensus would be politics.
For example, when Vietnam veterans demanded that "Post-traumatic Stress Disorder" be added, it was.
"They did what in my mind is the right thing," Kutchins says, "but in the process they clearly demonstrated that this was a political decision."
The primary use of DSM lies in its code numbers. If you're a psychiatrist and want to be paid for treating a patient, you better supply his insurer with a code number.
And insurance companies, not surprisingly, tend to prefer the quick fix.
"I don't think that there's any doubt that insurance companies are influencing the way we practice," says Paul Kettl, a psychologist at the Hershey Medical Center of Pennsylvania State University. "You end up often putting a patch on the tire where maybe more would be more beneficial in the long run."
That patch is often a drug.
Kutchins uses the example of a couple having marital problems.
"So they go to a counselor. When the counselor says, "Okay, that costs $100 or $125 an hour,' they say, "Well, we have health insurance.'
"OK, but if you look at DSM, you'll see that marital problems are not psychiatric problems, so someone's likely to be depressed because of the marital situation, so I diagnose that person as being depressed and then you get health insurance for it.
"So now you've got someone in depression. Certainly an insurance company's going to say, "But why do you need 50 weeks of counseling for a person who's depressed? We know that if someone's depressed, we can feed him Prozac.'
"Once you're locked into this funding mechanism, first you've got to identify the psychopathology and then the treatment follows from that, and more and more you're pushed to give that treatment."