Diagnostics: How We Get Labeled

Pardon the personal question, but have you ever had a sexual fantasy involving the use of a nonliving object--Anna Kournikova's tennis outfit, say, or Tom Cruise's Risky Business skivvies? Actually, don't answer that--we really don't want to know--and you should probably think twice before telling your therapist. She might diagnose you with fetishism, which is listed along with schizophrenia and bipolar disorder in a curious but extremely influential book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short.

The DSM lists the criteria used by mental-health professionals to make their various diagnoses, from "mild mental retardation" (the first listing) to "personality disorder not otherwise specified" (the last); there are more than 350 in all. Hence this 943-page doorstop is one of the most important books you've never heard of. And the inscrutable process of writing it is starting up again. The American Psychiatric Association (A.P.A.), the manual's publisher, recently began planning a giant review of the book. The new edition, the fifth--called DSM V--will appear around 2010. Evidently, it takes a long time to figure out all the ways America is nuts.

The first official attempt to measure the prevalence of mental illness in the U.S. came in 1840, when the Census included a question on "idiocy/insanity." From that single category flowered many more disorders, but each asylum classified them differently. The DSM was first published in 1952 so that "stress reaction" would mean the same in an Arkansas hospital as it does in a Vermont one.

The DSM works like this: imagine you are Tony Soprano in the first season of The Sopranos. You have, in DSM-ese, "recurrent, unexpected panic attacks." You also have "persistent concern about having additional attacks," and you fear you're "losing control, having a heart attack, 'going crazy.'" You aren't on drugs (other than all those bottles of Vesuvio's wine), so--presto--Dr. Melfi gives you a diagnosis of panic disorder, DSM No. 300.01. By the way, if you truly think you are Tony Soprano, see No. 295, schizophrenia.

Of course, in the real world, psychiatric diagnosis doesn't--or at least shouldn't--work like a checklist at a sushi counter. Many of the items that appear as diagnostic criteria in the DSM are sometimes symptoms of a disorder and sometimes signs of perfectly normal behavior. An adolescent who "often argues with adults" may have an unusual condition called "oppositional defiant disorder" or a more common condition called "being 14 years old." The DSM includes a cautionary statement saying it takes clinical training to tell the difference. But many nonspecialists use the book too: insurers open the DSM when disputes arise over the proper course of treatment for particular conditions. (If your treatment doesn't jibe with the DSM, you may not get reimbursed.) DSM diagnoses can be used by courts to lock you in a mental hospital or by schools to place your child in special-education classes. A DSM label can become a stigma.