Making Us Crazy: DSM, the Psychiatric Bible and the Creation of Mental Disorders.

By Herb Kutchins and Stuart A. Kirk The Free Press, $27.50

According to a recent news story, "road rage" is a psychiatric disorder that deserves to be recognized and added to the Diagnostic and Statistical Manual of Mental Disorders, or DSM, the sacred canon of the American Psychiatric Association. Dr. Arnold Nerenberg, a California (where else?) psychologist, claims that more than half of all Americans suffer from "road rage," which is clinically characterized by rude gestures, horn blowing, and generally aggressive behavior toward other drivers. Once "road rage" has been officially baptized, then pharmaceutical companies can market drugs to reduce its symptoms, sufferers will be eligible for special consideration by their employers under the Americans With Disabilities Act, and (most importantly) Dr. Nerenberg will be able to get reimbursed by insurance companies for doing psychotherapy with such individuals.

"Road rage" made the news too late to be included in Herb Kutchins and Stuart Kirk's Making Us Crazy, but the authors do facetiously propose including "Excess Motorized Speed Disorder" as a psychiatric disorder. But while Kutchins and Kirk's suggestion is all in good fun, the velocity with which equally absurd ideas are being transformed into serious proposals is a sad measure of the depths to which American mental health professionals have fallen. DSM, it is now clear, really stands for Dimwitted Sychiatric Muddle.

Making Us Crazy does a good job of stressing the lack of reliability of many psychiatric diagnoses and tracing the history of this intellectual haze. The chapter on homosexuality--including an account of how U.S. psychiatrists actually voted in 1974 on whether or not it was a disorder--is especially entertaining. Other chapters on post-traumatic stress disorder, self-defeating personality disorder, masochistic personality disorder, and borderline personality disorder contain useful historical anecdotes. On the other hand, a section on the history of racism in psychiatry is of questionable relevance to the book, and the book's style in general is rather pedantic.

Most disappointing, however, is the failure of the authors to deal with the consequences of DSM in more than fleeting fashion. DSM-IV, published in 1994, includes as mental disorders such behaviors as "disorder of written expression," "childhood conduct disorder," "pathological gambling," "adjustment disorder with anxiety," and "avoidant personality disorder." The boundaries of such "disorders" are so vague that I can find a DSM-IV diagnosis to fit everyone I know--except of course my wife.

It was precisely this mishmash of vague psychiatric categories that in the 1980s enabled the Psychiatric Institutes of America (PIA) and National Medical Enterprises Inc. (recently reborn as Tenet Healthcare Corp.) to imprison adolescent children in private psychiatric hospitals until their insurance ran out (brilliantly chronicled by Joe Sharkey in Bedlam). It is these same vague categories that frighten state legislators being asked to vote for insurance parity to make "mental disorders" equal with physical disorders. And these categories terrify employers who are now required by the Americans With Disabilities Act (ADA) to make "reasonable accommodations" for an individual with a "psychiatric disability" that is "substantially limiting." Amorphous DSM categories virtually guarantee interminable legal challenges and provide a permanent jobs program for lawyers.

Kutchins and Kirk do point out some fiscal aspects of DSM. When DSM-IV was published in 1994, the American Psychiatric Association (APA) made $18 million on its sales within 10 months. Given the tenuous economic status of the APA, DSM essentially keeps it solvent. And by labeling more and more human behavior as "mental disorders," the APA provides an ever-increasing market for the pharmaceutical industry. Eli Lilly probably already has tests underway to show that Prozac decreases "road rage."

Perhaps most importantly, Making Us Crazy completely ignores the issue of legitimate psychiatric diagnoses. In recent years evidence has become overwhelming that conditions such as schizophrenia, bipolar disorder, severe depression, panic disorder, obsessive-compulsive disorder, and autism are biological brain disorders. Such disorders should be covered by insurance parity and the ADA. The important question that needs attention is how to separate such disorders from "disorders of written expression" and "avoidant personality disorder." DSM completely fails to make such distinctions, and kutchins and Kirk are no better. Perhaps the authors are suffering from a wait-for-my-next-book disorder. Eli Lilly, take note!

E. Fuller Torrey, M.D., is a research psychiatrist in Washington, D.C., and author of Out of the Shadows: Confronting America's Mental Illness Crisis.