They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal

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They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal

Ever wonder how certain behaviors are designated a mental illness? How, say homosexuality, can be a mental disorder one year, but not the next? How 77 mental disorders could be newly identified between 1987 and 19947 Psychotherapist Paula J. Caplan, Ph.D., explains it all in her new book They Say You're Crazy (Reading, Massachusetts: Addison Wesley).

All known mental disorders are defined and classified in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (APA). The DSM, as it is called, is the "bible of the mental-health professions" with over a million copies sold in less than six years. All psychotherapists are required by the insurance industry to apply a diagnosis from the DSM in order to receive reimbursement for therapy. Each entry comes with a list of criteria supposedly signifying the presence of the disorder.

The definitions for mental illnesses found in the DSM are widely believed to be firmly based in science. But Dr. Caplan's suspicions to the contrary began surfacing when she served as a consultant to the APA committee, which sets the definitions for the newly identified mental disorders to be included in a revised edition of the DSM.

In observing the process, she found that the decisions about who is normal are riddled with personal biases and political considerations. As she determined during the preparation of this book, there is no scientific evidence to verify the existence of most of the disorders found in the DSM. Many things labeled mental illness, observes Dr. Caplan, can be more accurately described as "problems in living," such as loneliness and mourning.

Two New Disorders

The APA's classification of homosexuality illustrates how the definitions of illness are often a judgment call. Homosexuality was listed as a mental disorder until 1974, when it was eliminated from the DSM. The APA membership had voted 5,854 supporting and 3,810 opposing its removal from the DSM.

Dr. Caplan's involvement with the DSM revision process began in 1985 when she got wind of a plan by the American Psychiatric Association (APA) to create a category of abnormality called masochistic personality disorder. She and other female professionals knew it would primarily be used against women and other marginalized people to claim they brought on their own problems. (Updating this DSM edition evolved into a turf war between two groups of mental health professionals: the mostly male psychiatrists and the mostly female psychologists. The latter offers lower rates and shorter courses of therapy.)

Dr. Caplan and associates were justifiably concerned that the category would be applied to battered women, placing the focus on the behavior of the victim rather than on the abuser who is absolved of responsibility. The masochistic personality disorder theoretically describes the woman who stays with a battering husband because she enjoys the pain, as well as the rape victim who is assumed to have brought the rape on herself.

As Susan Faludi notes in the 1991 best-seller Backlash, "The psychiatric diagnosis of masochism first formulated in the late Victorian era described people who derive sexual pleasure from pain. It soon, however, degenerated into a sort of all-purpose definition of the female psyche; so many women got abused because so many women preferred it that way." The notion had fallen out of favor by the 1970s but was resuscitated by the APA in 1985 for the DSM revision.
None of the nine listed characteristics of the masochistic personality disorder included taking pleasure from pain; instead there was a self-sacrificing theme. An example: "rejects help, gifts, or favors so as not to be a burden on others" Dr. Caplan notes that the chief characteristic of this so-called disorder--putting the needs of others first--has always been the hallmark of the "perfect wife and mother."

PMS a Mental Disorder

Menstrual difficulties became a mental illness once the APA committee designated premenstrual syndrome (PMS) as late luteal phase dysphoric disorder. To receive this diagnosis, a woman needs only one of the following characteristics: "marked" feelings of anxiety, anger, irritability, depression, or emotional liability, plus any four from a list of physical symptoms: among them, such common occurrences as changes in appetite and sleep disturbances. There is no sound empirical basis for designating PMS a mental disorder, according to Dr. Caplan.
She cites a recent study involving women who thought they had PMS and women who said they did not have the condition. All were given the standard questionnaire/checklist of symptoms used to diagnose PMS. No difference was found in the responses from the two groups of women. In fact, some men given the questionnaire reported symptoms no different from the women who thought they had the severest PMS.

Dr. Caplan and associates felt that women were being pathologized by this APA committee of primarily male psychiatrists. (The lone female member was the social worker wife of the chairman.) The opponents lost their battle, despite "massive protests" in terms of letters and petitions from hundreds of mental health professionals challenging the existence of these two categories of mental illness. A minor concession was made: masochistic personality disorder was renamed self-defeating personality disorder and PMS became premenstrual dysphoric disorder.
Both categories went into the 1987 edition of the appendix called DSM-III-R (third edition revised). Inclusion supposedly designated them as "needing further study," yet both received the classification code numbers required for reimbursement. The latter confers official status of a confirmed mental disorder. When the controversies over the new categories spilled into the national media, few reporters bothered to check the APA's assertion that the new entries were well grounded in science.

Mislabeling someone as mentally ill has the potential for great harm, such as denial of health benefits and involuntary hospitalization. Dr. Caplan also points out that the DSM is used by the courts to determine who is incompetent or too disturbed to stand trial or have custody of their own children.
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By Paula J. Caplan, Ph.D.

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