How We Get Labeled

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If the DSM is all we've got, why is it inherently flawed? Because many forces besides science shape it, including politics, fashion and tradition. The A.P.A. actually once held a vote among its members to see whether an alleged disorder — homosexuality — existed. (In 1974, being gay was deemed sane by a vote of 5,854 to 3,810.) Women's groups helped excise "self-defeating personality disorder" from the book. The revised third edition, in 1987, said the typical sufferer "chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available." But feminists successfully argued that battered women could unfairly fit this category.

Other questionable diagnoses stay in the book because no one fights hard enough to remove them. Thus heterosexual men can be diagnosed with a supposed disorder called "transvestic fetishism" if they meet only two criteria: they have sexual fantasies about cross-dressing, and those fantasies cause "impairment in social, occupational, or other important areas." In other words, someone is sick not if he has the fantasies but if he gets caught having them — for instance, if his boss reads a kinky e-mail he sent at work, which then leads to a pink slip ("occupational impairment").

"For some of these, there is an issue of grandfathering," admits Dr. Michael First, editor of DSM IV. "The onus is on the person who wants to change it to prove that we should do so." First also acknowledges that the A.P.A. does not subject every criterion to rigorous scientific testing, "for practical reasons of continuity." Which may be another way of saying some old-timers still bill sessions for "transvestic fetishists," and they don't want to lose the DSM stamp of approval needed for insurance reimbursement.

To be sure, a few disorders are dropped from each edition. First notes that a supposed childhood condition called identity disorder was excluded from DSM IV even though many child psychologists wanted to keep it. Kids could qualify for that disorder if they were "uncertain" about long-term goals, career choice and friendship patterns. "We said, 'Wait a minute. This looks like normal adolescence,'" says First, "and so we eliminated it."

The DSM's critics say this sit-around-the-table-and-jawbone method isn't really science. Jerome Wakefield, a Rutgers professor of social work, says that while the DSM's authors do try to eliminate errors so that normal emotional reactions aren't diagnosed as disorders, "there's no systematic process here. Changes are made on a very ad hoc basis, where people say, 'Oh, my god, we forgot X.'" Others have even harsher criticism. Dr. Paul McHugh, who chairs the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, says the DSM has lost its usefulness partly because it has "permitted groups of 'experts' with a bias to propose the existence of conditions without anything more than a definition and a checklist of symptoms. This is just how witches used to be identified." He cites multiple-personality disorder as an example of an "imagined diagnosis"; while much of the evidence supporting its existence has been debunked, multiple-personality disorder is still listed in the DSM, though today it's called "dissociative identity disorder."

New controversies have already erupted over what to put in DSM V. For instance, the A.P.A. is considering adding "relational disorders"--severe problems between spouses or siblings — to the fifth edition. Relational-disorder sufferers are completely sane except when they are around, say, their spouse. Skeptics contend that marital spats shouldn't be considered mental illnesses. A group of Stanford researchers wants to put "compulsive shopping disorder" into DSM V, but First doesn't seem to like the idea. While a number of studies have shown that pathological gambling exists and can be measured, he says, compulsive shopping "has received virtually no research attention to date." (The same goes for sex addiction, according to other psychiatrists: it's just Clinton-era pop psychology thus far, not a documentable illness.)

How could the DSM be improved? Critics say the A.P.A. should start by holding every diagnosis to tough scientific standards. Antiquated notions about deviant sexuality should be brought up to date or scrapped altogether. McHugh of Johns Hopkins suggests that the DSM become more than a laundry list of symptoms — some of which are always going to be ambiguous — by organizing psychiatric conditions around what he calls their "fundamental natures." Accordingly, he would use four categories of disorders: those arising from brain disease, those arising from problems controlling one's drive, those arising from problematic personal dispositions and those arising from life circumstances. While such groupings are imperfect — is alcoholism caused by a brain disease or a problem in controlling one's drive, or a little of both?--they at least get clinicians focused not only on the symptoms of an illness but on its possible causes as well.