dsm-5 3DWhy do doctors use the DSM? To anticipate and contain by categorizing and “labelling” madness.

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was made public recently at the American Psychiatric Association conference in San Francisco. It is a text addressed to psychiatrists in need of terminology for measuring human distress. The simplifications and limitations introduced by the DSM–first in the USA and then around the world–to the development of concepts, designations and practices, as well as to the organisation of preventive  measures and treatment, are considerable. As all scientific attempts to understand living matter need to think and to classify, the DSM system has its legitimacy, particularly in the field of research, but only if its limits are respected.

As part of these limits, classifying must come after thinking and not vice versa. The DSM system is culturalist, as is psychiatry.  What drives it is not primarily the assumed choice of a way of life and status, which only comes later, but what the American writer John Updike [1] called “abominable American innocence”. As if to say that in America, the world as it is, might not merely be analysed but must always be experienced (the percept as opposed to the concept), and that this  world is composed of a series of events without any possible links to deep historical connections  and so  without underlying motivations. This as always is accompanied by a fascination for biological causality and a profound disregard for psychological effects.

Psychoanalysis passionately wants us to take history and culture into account. The DSM believes in “the end of history” whereas psychoanalysis fears “the end of culture” and the defeat of thought. If history is at an end, then everything is possible and in particular, the reactivation of  the pulsating backdrop which inhabits  the inner space of the structure of American society . . . God and Justice . . . Good versus Evil.

The DSM’s achievement in  objectifying and quantifying  implicitly shows the influence of Anglo-Saxon societal norms which have become dominant in the Western world, are infiltrated by an ecology (rather than a culture), appear to sanctify certain norms (rather than values) and are supposed to define someone who is “sane”, that is to say someone who can “adapt”. These have been marked by the promotion of individualism; the fascination for performance; the valorisation of success at all costs; the control of sexual aggressiveness and the channeling of sexuality ; as well as the obsessional explanation of all affect in terms of statistical and biological norms related to a notion of pain which it would be amoral not to relieve.

Regarding the so called “normal” or “sane” subject, a mentally ill person (someone who is unproductive or aggressive, liable to lose control of their sexuality, a person who has difficulty being honest or sincere, and is probably suffering from biological vulnerability) appears on the one hand as a threat and on the other as a loser. Before being accused of primitive anti-Americanism or of superstition in the face of modernity, let us recall that these are the same norms being presented in health policies that make Barack Obama fear the implementation of  “barely hidden Darwinism” by the Republicans.

We ourselves believe that the DSM, the bible and the Trojan horse of laboratories and health insurance companies, might in all innocence and without any Manichaeism, become an ideological and economic taxonomy,  seeking  to standardize collective thinking and to convince us that  there is some biopower present in  all mental pathologies as well as presenting an elitist code claiming to define “normality”.

Why do doctors fall for these simplifications? Maybe for a fundamental reason: to anticipate and contain, to categorise and to label. The anxiety inherent in the encounter with madness, with the Other, in their otherness; the other as opposed to oneself and the other in oneself that some politicians rush to stigmatise or qualify as inhuman. The madness of the other and the madness in oneself; the freedom which opens the way to contingency and  therefore to disorder and destruction but also potentially to creativity. That is the danger which needs to be contained both in the other and in oneself.

On the key questions surrounding the diagnostic thresholds for defining mental disorders, Dr. Regier, Vice Chair of the DSM-5 Working Group, has insisted on the need to specify “grey areas” in clinical practice. Which grey areas? Or even, which grey matter?  The grey area between good and evil, mad and sane, black and white, forbidden and allowed, just and unjust, guilt and innocence. Does this “specification” involving a “reduction” of grey areas, come from science or from moral conscience? The question needs to be debated before it infiltrates health policies. Whether we like it or not, it is important to insist upon the complex, disturbing, and unpredictable character of individuals and groups.

Primo Levi, writer and chemist [2], claimed:

Only a schematic rhetoric can claim that the space (between victims and persecutors) is empty.  It never is. It is studded with abject or pathetic figures (sometimes they possess both qualities simultaneously) which it is essential to know  if we want  to know the human species, if we want to know how to defend our souls when a similar test should once more loom before us.  

Suffice to say, the inhuman is still human. He also stated that we must be wary of the almost-the-same or the almost-identical:

Differences, no matter how small, can lead to radically different consequences, like a railway’s switch points, the chemist’s trade consists in large part in being aware of these differences, knowing them close up, and predicting their effects. And not only the chemist’s trade. [3]

Let us recall that Mr. Hyde could never become Dr. Jekyll again because he put all his energy into finding a miraculous formula which he thought had to be pure. We all have a Mr. Hyde in us, Dr. Regier.

References

(1)   Navigation Littéraire. Essais et Critique (Hugging The Shore. Essays) : Gallimard. 1983.

(2)    « La Zone Grise » (“The Grey Zone”) » Ch.2,  In Les Naufragés et les rescapés (The Drowned and The Saved) : Gallimard, 1989. p.81. Paris.

(3)    In Le Système périodique  (The Periodic Table), Patassium, p. 77.

(4)    « Conversation et Entretiens » : Robert Laffont, Paris, 1998.

Maurice Corcos

About Maurice Corcos

Chef de Service du Département de Psychiatrie de l'Adolescent et du Jeune Adulte de l’Institut Mutualiste Montsouris, Paris 14ème Professeur en psychiatrie, Université Paris 5, René Descartes. Docteur en Psychologie, Université Paris VII Denis Diderot (1999) Psychanalyste *** Head of Department, Department of Psychiatry Adolescent and Young Adult Institute Mutualiste Montsouris, Paris 14th Professor of Psychiatry, University of Paris 5 René Descartes. Doctor of Psychology, University of Paris VII Denis Diderot (1999) Psychoanalyst