From Affect to Disorder: Pills and Personality in the Age of DSM-III

It is curious that the authoritative text governing psychiatry makes almost no explicit reference to the biological turn that has utterly transformed the field. The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952 and soon to go into its fifth edition, is often referred to as the "bible of psychiatry." Yet recent editions of the volume largely sidestep questions about what causes mental illness or personality disorder, what happens to the brains of those who experience such disturbances, and what are the best treatments for particular conditions. This is in large part because the text's designers wanted to steer clear of arguments that would inevitably arise between recent biologically minded researchers and others (notably psychoanalysts and behaviorists) trained under and still committed to older models of mental illness.

Nonetheless, since the printing of its third edition (DSM-III, 1980), the manual has been broadly credited with bringing new scientific rigor and diagnostic precision to the field. As Robert Spitzer, DSM-III's chief designer, puts it in his foreword to Allan V. Horwitz and Jerome C. Wakefield's The Loss of Sadness, his was "the first edition of the Manual to offer explicit symptomatic criteria for the diagnosis of each mental disorder" (vii). In the 1960s and '70s, popular and scientific critiques of psychiatry often focused on the astonishing lack of agreement among clinicians on what constituted a mental illness. In contrast (and partly in response), DSM-III's comprehensive taxonomies of mental illness have led to a much more orderly process of diagnosis. Researchers have also benefited from the consensus on the nature of the chief problems to be studied.

But fundamental questions persist. The categories may be agreed upon, the rules for application may be clear, they may be consistently applied (although some reports suggest that this is not the case), and patients may feel more confidence in the accuracy of their diagnoses. But what if the categories and diagnoses are wrong? If the official arborists' manual classified as oaks all trees having more than four branches, arborists would reach rapid consensus on which trees were oaks, but many of their identifications would be wrong. In the same way, Horwitz and Wakefield suggest, DSM makes the rules for identifying depression quite clear, but in the process it sweeps all manner of nondepressive "sadness" under its definition. Worse yet, what if identifying and classifying mental illnesses by symptoms, and using those identifications as the basis of treatment, is like identifying trees by observing which kind of dog pees on them? As Christopher Lane has it in Shyness, identifying symptoms is hardly the royal road to the unconscious; instead it leads to shoddy research and drug-company profiteering. Finally, Lennard J. Davis and Emily Martin don't so much object to the classifications of their chosen disorders as contextualize classification through social and cultural analysis, in which the tree and its observer are placed in their complex social and natural ecologies. Their bold interdisciplinary approaches construe mental illness as only partly a medical and psychological issue; they suggest that culture, history, and economics both profoundly shape and are in turn shaped by how we tell the story of madness.

Each of the authors under review here responds to psychiatry in the age of DSM-III not only by questioning and contextualizing the manual's logic and effects, but also by mirroring its structure. Whereas Michel Foucault's History of Madness (1961) initiated...