Oxford University Press
Source: Oxford University Press

In their 1997 classic Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders, sociologists Stuart Kirk and Herb Kutchins famously noted of the psychiatric manual: “By simply altering slightly the wording of a criterion, the duration for which a symptom must be experienced in order to satisfy a criterion, or the number of criteria used to establish a diagnosis, the prevalence rates in the United States will rise and fall as erratically as the stock market.”

In All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders (June 2012), Allan V. Horwitz and Jerome C. Wakefield, co-authors of the acclaimed study The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007), revisit that claim but insist: “Kutchins and Kirk are only half correct. Prevalence rates in recent epidemiological studies go in only one direction: upward.”

“Thirty years ago,” they elaborate, “it was estimated that less than five percent of the population had an anxiety disorder. Today, some estimates are over fifty percent, a tenfold increase. Is this dramatic rise evidence of a real medical epidemic?”

The short answer to that pressing question is “no.” A longer answer emerges in Andrew Scull’s recent review of the study in the Los Angeles Review of Books, which focuses on what he calls "psychiatry's legitimacy crisis."

Some highlights:

“Horwitz and Wakefield suggest that the efforts of Kraepelin’s late-twentieth century successors to make psychiatric diagnoses more rigorous and predictable have instead enabled psychiatric pathology to get out of hand. They identify two problems: the psychiatric profession’s obsession with simplistic, symptom-based diagnoses, and the looseness of its criteria for defining mental states as pathology. All sorts of anxieties that are in reality part of the normal range of human emotion and experience have been transformed by professional sleight of hand into diseases. The upshot, they contend, is that whereas thirty years ago less than five percent of Americans were thought to suffer from an anxiety disorder, nowadays some widely cited epidemiological studies have decreed that as many as 50 percent of us do so.”

“When Robert Spitzer and his associates created DSM-III [in 1980], they liked to call themselves DOPs (data-oriented persons). In fact, DSM’s categories were assembled through political horse-trading and internal votes and compromise. The document they produced paid little heed to the question of validity, or to whether the new system of categorizing mental disorders corresponded to real diseases out there.”

“Being anxious and fearful is, under some circumstances, a natural and healthy human response to the world. How are we to distinguish between healthy or normal fears—perhaps even fears that are exaggerated but had their origins in an earlier period of our evolutionary history—and pathological forms of anxiety?”

DSM attempted to cope with th[at] problem by insisting that the anxiety had to be ‘excessive’ and ‘prolonged,’ six months in duration or longer, and to be perceived as ‘abnormal’ or disabling by those subject to these emotions. These are inadequate and fallible correctives, but they did something to make it less likely that normal people would be called ‘mentally ill.’ As the manual went through successive editions, however, and as its categories were simplified to make the job of epidemiologists easier and cheaper, the effect, as Horwitz and Wakefield argue, was steadily to enlarge the numbers of ordinary people drawn into the ranks of the mentally unstable, often to a spectacular degree.”

“Psychiatry has indeed lost its way and seems increasingly unable to resist pathologizing ordinary life.”

Scull’s review can be found here.

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