The expanding universe of mental illness

James von Brunn, the shooter (do I really need to say “alleged”?) at the United States Holocaust Memorial Museum was odd, even by the standards of his kooky peers. White supremacist Stan Hess met von Brunn in 2004. Hess recalled that the creepy von Brunn was “very angry about society and the Jewish influence on the Federal Reserve”. At that time, von Brunn “alluded to violence”; he was a frustrated artist, who spent a lot of time peddling racist conspiracy theories on the Internet.

Is James von Brunn mad, or bad? Some say mad. Since Hitler’s infernos, psychoanalysts have argued that anti-Semitism or racism was a mental illness. Analysts have proposed several psychosexual theories explaining Hitler’s “lunacy.” Some speculate that he had an illicit affair with his niece. Others propose that Hitler had one testicle which led to feelings of inferiority. His self hatred was projected on to the Jews.

Today, the analysts are gone but the case for defining bigotry as a mental illness remains in a less bizarre form. Led by Harvard psychiatrist, Alvin Poussaint, many doctors have argued that haters have a mental disorder, pathological bias. Some psychologists are even conducting research on bigotry. James von Brunn is Exhibit A for the new mental disorder.

Extreme racism is only one example of the increasing faith in technology to cure our souls and fix our society. In 2012, the American Psychiatric Association (APA) will publish the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). In May 2008, the APA released the names of the work group members. Last April, the 13 work groups reported on their progress, revealing that organized psychiatry is on the verge of including several ancient vices and new time wasters in this Pandora’s Box. Advocates have lobbied to expand the universe of the mentally disturbed with philanderers (sex addicts), spend thrifts (compulsive shoppers), the gluttonous (binge eaters) and internet gamers.

As the release of the new DSM approaches, we will hear more stories about the “psychiatric bible”. While the DSM is as important to mental health providers as a Bible is to a Baptist minister, the similarities end there. No psychiatrist would ever claim that the DSM is inerrant. The DSM is more Sear’s catalogue than Bible, a compendium of sadness, foolishness, madness, and wickedness. Each new edition of the DSM adds more products and pages. The number of mental disorders in DSM-IV is triple the number of disorders in the first edition published in 1952. DSM-IV has 25 per cent more disorders than the previous guidebook released in 1987. The persistence of the bible metaphor reflects the modern fantasy of replacing the preacher with the therapist.

Some hail the addition of new mental disorders as discoveries, triumphs of science over ignorance, moralism and medieval fallacies. The press happily perpetuates the scientific gloss. Last December, the New York Times reported that scientists were “poring over the latest scientific studies”. Psychiatrists interviewed at the annual American Psychiatric Association meeting last May predicted that DSM-V would be more “science based” than previous books.

Being more science based than previous manuals is a low hurdle to overcome. Alan Horwitz pierced the scientific aura surrounding the DSM in a fascinating history of psychiatric diagnosis, Creating Mental Illness. Money and politics, not science, have driven the evolution of the DSM. The disciples of Freud, psychodynamic therapists, constructed the first two versions of the diagnostic handbook. Freud and his followers greatly expanded the field of psychiatry from the insane asylum to middleclass frustrations. By the middle of last century, confidence in the new science to explain and cure any ills extended to criminal and socially unacceptable behaviors such as homosexuality and pedophilia.

In the turbulent 1960s, however, the culture also rebelled against Freud. Psychiatry was threatened as a profession. The biomedical model of mental illness replaced the Freudian, psychodynamic model. In order to further establish psychiatry as a field of medicine, a new generation of mental health researchers decided that the DSM needed a complete overhaul. Scientists trumpeted the third edition, published in 1980, as a triumph of “science over ideology”.

As it happened, the old Viennese ideas were not removed but instead repackaged. Scientists developing the new, medicalised DSM were more concerned about protecting clinicians’ practices than any scientific theories or research. The editors trimmed the old Freudian neuroses into neat categories minus the mumbo-jumbo. The number of diagnoses exploded. Instead of serving science, Horowitz reports, scientists legitimized “current social practices”.

The increasing power of lay groups also became evident with the publication of DSM III. Gay activists and sympathetic professionals successfully lobbied for the removal of homosexuality from the DSM.

Sex remained a contentious issue. In the fourth edition of the DSM released in 1994, deviant behaviors, called paraphilias, were quietly reclassified as being a disorder only if the behavior caused personal distress or impaired social function (i.e. landed you in prison, or grossed out your mother). In other words, pedophilia, exhibitionism, necrophilia and bestiality only became a mental illness if you were caught.

Ironically, the APA was caught out by radio talk-show host, Dr. Laura Schlesinger, who blew a loud whistle on the changes. A political firestorm erupted. Congress became involved; and the APA quickly rewrote their bible.

In 2000, a new edition, DSM-IV TR (text revision) was published and those perversions involving children or other victims were once again mental disorders. However, sexual liberationists had a partial victory. Sex with pets and the dead is no longer a sign of illness. Bestiality as well as other sex acts where consent is not necessary (necrophilia) or freely given (sado-masochism) have been dropped from the catalogue. Despite the past controversy over various sexual behaviors, the task force will likely add “sexual addiction” to the next DSM. Titillating memoirs and exposure through pop med sites like WEB MD have meant both notoriety and legitimacy for sexual addiction.

Nowadays, the concerns over the next DSM are similar to those we might have about any other political operation. Both the Los Angeles Times and the New York Times have covered the controversy surrounding the new book. Besides the expected speculation over who’s in and who’s out, the press has been as pre-occupied with process issues such as transparency and conflict of interests. In May, the New England Journal of Medicine reported that 56 per cent of the task force had industry ties. Some critics suspect that Big Pharm is influencing the task force. The media seems unaware of the contradiction in their portrayal of the rewriting as both a march of science epic and a political drama.

After considering the history of the DSM, it’s tempting to ridicule a pretentious mental health establishment or even to believe that mental illness is a myth. A day at any state hospital for those with severe mental illness will convince anyone that mental illness is real. But can all human troubles be reduced to simple matters of health?

Under the fig leaf of science, the development of the DSM has been dominated by politics and a consumer mentality. The DSM and the Sears catalogue are both manifestations of a secular faith in money and technology as a way to happiness. Many of the new additions to the DSM being discussed involve either illicit or excessive desires. Business aims to temporarily satiate our appetite while stimulating greater hunger. Eventually, the hunger wins. So, if technology cannot satisfy our desires then perhaps it can reign in our appetites.

But will the new DSM have the cure for our souls?

Theron Bowers MD is a Texas psychiatrist.