The slated 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) wobbles like jello. It can’t tell the difference between psychopathology, normal misery, or bad habits. When you know there is something definitely wrong and need help, it won’t necessarily confirm your problem. Allen Frances, MD gives a good breakdown of some of the DSM’s worst proposed revisions, such as pathologizing grief and childhood tantrums, and the likelihood that changes to the Autism diagnosis would reduce access to school services. But the greatest obstacle to creating a relevant DSM may be that we can no longer rely on a 20th century model of mental illness in the 21st century.
The world has changed exponentially since the DSM first surfaced in the 1950s, and we have changed with it. Our psyches and lifestyles are even less reliable than the DSM. With the expansion of the internet and easy access to health information, we are diagnosing (and re-diagnosing) ourselves at a rate that makes the DSM’s attempts at revision seem not only colossally slow, but at times downright silly. Identities have also become one of our most prized possessions, and we cautiously trust others with their care, especially when the caretaker has a poor track record like the mental healthcare industry.
In his book, The Geopolitics of Emotions, Dominique Moïsi made a useful distinction between the 20th and 21st centuries, one that the architects of the DSM would benefit from:
“In the ideological atmosphere of the twentieth century, the world was defined by conflicting political models: socialism, fascism, and capitalism. In today’s world, ideology has been replaced by the struggle for identity. In the age of globalization, when everything and everybody are connected, it is important to assert one’s individuality.”
Moïsi’s characterization fits with Thomas Friedman’s famous assertion about Globalization 3.0:
“the dynamic force in Globalization 3.0—the thing that gives it its unique character—is the newfound power for individuals to collaborate and compete globally.”
The shift from ideologies to identities parallels a shift of responsibility (and risk) from institutions to our own shoulders. We are now each the guardians of our own mental health and well being. And the DSM has become one more tool used by savvy consumers to access services, along with identifying potential threats to the identities we work so hard to create.
The DSM’s unreliable diagnoses are in part the result of attending to a new era’s problems with an old era’s ideology—and one that barely passed muster even when ideologies ruled. Diagnoses in the DSM are typically seen as chronic disorders and lifelong conditions, and thus according to the norms guiding medicine, require continual treatment, usually with medications. Research shows this approach in psychiatry has led to worse outcomes, more illness, and shorter lifespans. Those are enough reasons to scrap the project and look for a replacement. But even if we only consider its usability as a resource for understanding the nature of psychological suffering, the DSM doesn’t serve people who need malleable identities to navigate a rapidly changing world. Using the distinction between the modern and postmodern, Simon Gottschalk made this observation:
“if we posit postmodern selfhood as a mutable, liminal, multiple, interdependent, and interactive process, then relying on DSM-IV diagnoses will prevent us from understanding it, since DSM-type diagnoses rest on—and reproduce—the idea of a stable, self-contained, and isolated modern self. If the modern self is an obsolete construct … and if the DSM is the most authoritative tool which evaluates such a construct for its ‘deficiencies,’ then, logically, this tool is inappropriate to develop an understanding of postmodern selfhood.”
At best, the DSM serves psychiatry, which has a long history of seeking validation as a bona fide medical field (and thus has its own identity issues to contend with).
Along with identities in flux, the nature of emotions are changing. In a relatively slow-paced world, one with reliable institutions and the support of extended kinship systems—not to mention affordable housing, universal healthcare, nutritious food, access to nature, time for play, and soul-affirming work—we might enjoy a more “natural” flow of the cornucopia of emotions that are our birthright: feelings of both love and hate, joy and fear, anger and hurt, envy and admiration, and so on—a mixture of feelings flavoring our days and spicing our relationships.
Instead, states of overwhelm and intensity are becoming new emotional norms. These states are often mixed with a sense of uncertainty, and at times, a wish to avoid feeling anything at all. According to Kathleen Woodward, author of Statistical Panic: Cultural Politics and Poetics of the Emotions, we are often caught bouncing between statistical panic and statistical boredom:
“I understand statistical panic not as a psychological emotion (anger, jealousy, and grief are notable examples of psychological emotions), but rather as a sensation or intensity, one that is at base a charged anxiety. At the other pole of this structure of feeling is statistical boredom, a state characterized by lack of emotion—one devoid of sensation or intensity.”
Woodward associates statistical panic and statistical boredom with how we story our lives, especially around illness. Through chat rooms, blogs, social networks, and health information sites, we compare personal worries about our mental health to statistics, symptom lists, and others’ stories of illness that we use not only to commiserate around shared fears, but also to find ways to avoid the risks that contribute to others’ suffering. Given all the information available, this is often a rapid search process that lacks depth, skimming the surface over deep pools of hurt. What might start as an effort to self soothe can become a state of exhaustion and emptiness. In the search for feeling better, we risk feeling nothing at all.
Should Woodward be correct about the 21st century emotional landscape—flat emotions intermittently interrupted by emotional intensity that is quickly forgotten—then the DSM suffers worse than irrelevance; it stands in the way of creating depth in our emotions and our relationships just at those moments when awareness of their absence grabs our attention and we ask ourselves, Is there something missing? Is there something the matter with me?
Friedman, Thomas L. 2005. The World is Flat: A Brief History of The Twenty-First Century. New York: Farrar, Straus and Giroux.
Gottschalk, Simon. 2000. “Escape from Insanity: ‘Mental Disorder’ in the Postmodern Moment.” In Pathology and the Postmodern: Mental illness as discourse and experience, edited by Dwight Fee, 18-48. London: Sage Publications.
Moïsi, Dominique. 2009. The Geopolitics of Emotion. New York: Doubleday.
Whitaker, Robert. 2010. Anatomy of an Epidemic. New York: Crown Publishers.
Woodward, Kathleen. 2009. Statistical Panic: Cultural Politics and Poetics of the Emotions. Durham: Duke University Press.
© 2013 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).