DSMV reviewed as a work of dystopian literature

Michael sez, "The American Psychiatric Association recently released a new version of its Diagnostic & Statistical Manual - basically a catalogue of the categories into which they divide suffering. This entertaining review treats the text as a sprawling dystopian novel."

If the novel has an overbearing literary influence, it’s undoubtedly Jorge Luis Borges. The American Psychiatric Association takes his technique of lifting quotes from or writing faux-serious reviews for entirely imagined books and pushes it to the limit: Here, we have an entire book, something that purports to be a kind of encyclopedia of madness, a Library of Babel for the mind, containing everything that can possibly be wrong with a human being. Perhaps as an attempt to ward off the uncommitted reader, the novel begins with a lengthy account of the system of classifications used – one with an obvious debt to the Borgesian Celestial Emporium of Benevolent Knowledge, in which animals are exhaustively classified according to such sets as “those belonging to the Emperor,” “those that, at a distance, resemble flies,” and “those that are included in this classification.”

Just as Borges’s system groups animals by seemingly aleatory characteristics entirely divorced from their actual biological attributes, DSM-5 arranges its various strains of madness solely in terms of the behaviors exhibited. This is a recurring theme in the novel, while any consideration of the mind itself is entirely absent. In its place we’re given diagnoses such as “frotteurism,” “oppositional defiant disorder,” and “caffeine intoxication disorder.” That said, these classifications aren’t arranged at random; rather, they follow a stately progression comparable to that of Dante’s Divine Comedy, rising from the infernal pit of the body and its weaknesses (intellectual disabilities, motor tics) through our purgatorial interactions with the outside world (tobacco use, erectile dysfunction, kleptomania) and finally arriving in the limpid-blue heavens of our libidinal selves (delirium, personality disorders, sexual fetishism). It’s unusual, and at times frustrating in its postmodern knowingness, but what is being told is first and foremost a story.

This is a story without any of the elements that are traditionally held to constitute a setting or a plot. A few characters make an appearance, but they are nameless, spectral shapes, ones that wander in and out of view as the story progresses, briefly embodying their various illnesses before vanishing as quickly as they came – figures comparable to the cacophony of voices in The Waste Land or the anonymously universal figures of Jose Saramago’s Blindness. A sufferer of major depression and of hyperchondriasis might eventually be revealed to be the same person, but for the most part the boundaries between diagnoses keep the characters apart from one another, and there are only flashes. On one page we meet a hoarder, on the next a trichotillomaniac; he builds enormous “stacks of worthless objects,” she idly pulls out her pubic hairs while watching television. But the two are never allowed to meet and see if they can work through their problems together.

Book of Lamentations [Sam Kriss/New Inquiry]

(Thanks, Michael!)

Notable Replies

  1. Grrrrr. Making prostitution a subset of "sexual acting-out" behaviors common in girls with conduct disorder infuriates me (Granted, this isn't new to DSM 5). Minors engaged in prostitution are not acting out, they're being preyed upon. Some of the behaviors, like running away and staying out all night at an early age, can make one more vulnerable to predators who are looking for unprotected children to abuse. But listing the selling of underage people for sex as a symptom of a certain disorder (for the underage people, not the perpetrators!) is absurd and almost... dystopian?

  2. bzishi says:

    Here, we have an entire book, something that purports to be a kind of encyclopedia of madness, a Library of Babel for the mind, containing everything that can possibly be wrong with a human being.

    No. That is not what it claims to be. It claims to be a scientifically validated way to diagnose mental disorders that are accepted by the medical community.

    DSM-5 arranges its various strains of madness solely in terms of the behaviors exhibited.

    It is not a textbook. It is a scientifically validated way to diagnose mental disorders. This is done via observations of behavior. It is designed so a clinician can use it to diagnose a condition, consult the appropriate scientific literature about the condition and treatments, and prescribe treatment based on those studies.

    Unusually for what purports to be a dictionary of madness

    It is not a dictionary of 'madness', whatever that may mean. It is a diagnostic manual.

    The scene this prologue sets is one of a profoundly bleak view of human beings; one in which we hobble across an empty field, crippled by blind and mechanical forces whose workings are entirely beyond any understanding.

    This is where the review starts to become disturbed. Mental illness is a disability, not a moral judgement. You can treat bipolar disorder and be a happy person just as much as you can treat diabetes or asthma and be a happy person.

    The rest of the review is worthless. It just plays on stereotypes and makes jokes at the expense of people suffering from disabilities while ignoring the purpose of the work. I'm sure the author of this piece was trying for humor but didn't realize his bigotry. Would such a dystopian work have ever been contemplated for any other medical disorder, such as skin lesions or cancer? Of course not. Disabilities are not a subject to be gawked at and used for humor.

    The author obviously considers the DSM-5 to be worthless and uses these twisted arguments to sink his point home. The 'normality' argument is the core of the thesis. But would the author also use the 'normality' argument for a diagnosis of cancer or arthritis? And in the context of considering a mental illness to be a disability, wouldn't it be counterproductive to make a definition of 'normal'? A diagnostic manual is not supposed to define normal. It is designed to treat illnesses. Again, a mental disorder is not a moral judgement or 'madness', but a disability that is causing impairment. It is offensive to demand a definition of 'normal' in this context since this implies that there is some goal of a perfect human being instead of a goal to treat an impairment or disability.

  3. It's easy to make fun of the DSM-5, but it is a necessary object. We need a way to diagnose people in a way that isn't subject to the diagnoser's whims and intuitions. Diagnosis can be useful for some people as a way of pinning down what is causing their suffering. But yes, it can turn into a hammer for people who see nothing but nails. But the most important reason we have the DSM-5? Insurance companies. They need a diagnosis before they're willing to shell out the dough.

    It doesn't suggest causes; it doesn't suggest treatments. It's just a descriptive tool. An equally amusing dystopian novel could be made out of a phonebook, where everyone has been reduced to a name and a few numbers.


  5. clifyt says:

    Thank you for posting this.

    People have no clue what the DSM is. I do disagree with your assessment as a 'Text Book'...since the IV-TR ('text revision), it has striven to be as useful in the classroom as it is in the field. The V is no different. That said, it isn't intended to be the sole text book, which confuses the hell out of people that think they can just pick it up and start diagnosing. The #1 thing most of us are taught in grad school is that if actions / thoughts are not affecting the person or those around them negatively, it ain't a disorder. And even then...how bad does it affect someone? Sometimes a quirk is a quirk. Someone that is eccentric with a support network of their choosing that keeps them running is not the same as a person with the same traits and no resources to deal with it.

    However, folks with no training will read the book and make judgements without any real understanding of the field of mental health.

    Again, thank you for writing this. There are too many people with uninformed 'opinions' of the field. (That said, I don't work directly in the industry despite graduate degrees in it...I do think the industry is at times preoccupied with defining normal instead of getting people to embrace their own crazy so long as it isn't hurting anyone).

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