Doctors have been trying for decades to classify mental illnesses. So why do precise definitions still elude us?
Theories of human psychology influence not only how we treat mental illness, but how we understand ourselves. The ancient Greek notion of the four humours remains with us in our idea of sanguine or phlegmatic personalities. Freud’s ideas gave us unconscious motivations, egomaniacs, narcissists and more.
These days, if you know someone who’s suffered from major depression, or think you may have social anxiety disorder, or know a child with attention deficit disorder, you’ve been influenced by a more modern psychological viewpoint – one put forth by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders (DSM), which describes all recognized mental disorders. Psychiatrists in North America, and also elsewhere in the world, rely on the DSM to make their diagnoses and communicate them with others in the health-care profession.
But the manual’s immense influence is a problem says Edward Shorter, the Hannah Professor of the History of Medicine at U of T. He thinks that many of the disorders described in the DSM are not actual diseases discovered through the scientific method. Instead, they resulted from political deal-making among different factions in the professional community, each with conflicting ideas about causes and treatments of psychological problems. The result, he says, is a description of mental disorders with too little relation to real diseases.
In Shorter’s opinion, the manual sometimes pathologizes perfectly normal behaviour, while actual diseases get lost in a thicket of non-existent syndromes and disorders. And as the association works through a new revision of the DSM, it looks like things will only get worse, he says.
“The DSM continues to run off the rails in terms of its ability to come up with true disease entities that exist in nature,” Shorter says. “The problem is that the document itself is profoundly unscientific.”
Shorter is a social historian of medicine. He has written books on obstetrics and gynecology, the doctor-patient relationship, psychosomatic illness and psychiatry. His books include Written in the Flesh: A History of Desire, and Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness (which he wrote with psychiatrist David Healy). One reviewer, Dr. Nassir Ghaemi of Tufts Medical Center in Boston, called his A History of Psychiatry from the Era of the Asylum to the Age of Prozac (John Wiley & Sons, 1997) “the best single volume to read on that topic.”
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Illustration by The Heads of State.
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I thank Rev. Dr. Roger Cann for bringing this article to my attention.