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Constructing the Mind: A History and Critique of the DSM Handbook

Alexandra Stohs

ANTH 436

December 2, 2018
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Introduction

In Madness and Civilization, Michel Foucault begins his book with a quote by Pascal:
“Men are so necessarily mad, that not to be would amount to another form madness.” In his first
book, Foucault traces the history of the construction of madness starting from the Middle ages
and discusses how since this time, the Western world has divided the human population into the
categories of “sane” and “insane (Foucault 1964).” In 1952, the American Psychological
Association created the first edition of the Diagnostic and Statistical manual of Mental
Disorders (DSM) which scientifically legitimized these categories of what was defined as
“madness (Blashfield et al. 2014).” This manual is still evolving to this day, shaped by the
economic and social interests of powerful scientific foundations and pharmaceutical companies
(Pilecki 2011). Individuals who do fall under categories of madness are pressured by society to
“fix” these individuals’ behaviors through common treatment methods such as cognitive
behavioral therapy and medication (Hillhouse and Porter 2011). The most common of these
classifications that individuals fall under is Major Depressive Disorder, which are commonly
treated with Monoamine Oxidase Inhibitors, or better known as anti-depressants (Hillhouse and
Porter 2011). This paper provides a brief history of the creation of the DSM handbook and
provides a case study of the international spread of these Western categories of mental illness
through the adoption of Post-Traumatic Stress Disorder in Sri Lanka (Watters 2010). Then, it
discusses the politics and critiques of DSM and looks at the role that marketing by
pharmaceutical companies play in spurring the growth of anti-depressants globally (Watters
2010). This paper is theoretically framed using the critical-interpretative approach to medical
anthropology as proposed by Margaret Lock and Nancy-Scheper Hughes. This paper will first
provide an overview of their approach and its importance to a paper on the construction of
mental illness.

Critical-Interpretive Approach to Medical Anthropology

The field of medical anthropology became popular with the emergence of post-
modernism which accepts that scientific accounts are products of social negotiation and
construction (Erickson and Murphy 2017, 63). Through empirical research, it is often assumed
that a truthful representation of the natural world can be achieved (Lock and Scheper-Hughes
1990, 480). It is believed that the discovery of these “truths” will, eventually, lead to a mastery
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over nature and the human body (Lock and Scheper-Hughes 1990, 480). However, post-
modernism argues that scientific inquiry can never be truly “objective” and that there cannot be
one form of authoritative knowledge that explains how the world works (Erickson and Murphy
2017, 63). In the modern-day, Western biomedicine systems are accepted as the only “valid”
medical systems among most researchers and institutions (Lock and Scheper-Hughes 1990, 481).
Under the influence of biomedicine, other cultural explanations are written off as invalid and
Western knowledge of the body is universally applied (Lock and Scheper-Hughes 1990, 481).
Medical anthropology analyzes how biomedical practices are imposed and shaped by the
dominant groups of Western capitalist society while recognizing other alternative, ethnomedical
systems that exist across different cultures (Erickson and Murphy 2017, 168). Using a critical-
interpretative approach, biomedical knowledge comes to be seen as a product of social and
political negotiation rather than a product of pure scientific research (Lock and Scheper-Hughes
1990, 482).

Margaret Lock and Nancy Scheper-Hughes argue that a critical-interpretive approach is

necessary to take in medical anthropology to understand how knowledge of health and illness is
socially and politically constructed (Lock and Scheper-Hughes 1990, 482). Lock and Scheper-
Hughes warn that researchers who do not follow this critical-interpretative approach to medical
anthropology may fall for certain assumptions of Western biomedicine that limit what they are
able to study and ask about the human body (Lock and Scheper-Hughes 1990, 482). One of the
major assumptions of biomedicine is Cartesian dualism, the epistemological view of the French
philosopher Rene Descartes (Lock and Scheper-Hughes 1990, 482). Cartesian dualism separates
the material body and the human mind into two distinct spheres. This dichotomy frees mankind
from biology through the separation of the rational from the animalistic (Lock and Scheper-
Hughes 1990, 484). The view that the soul and the mind are in opposition has permeated through
much of theory in the Western social sciences and clinical medicine since the seventeenth
century (Lock and Scheper-Hughes 1990, 485). This has led to a materialist, mechanical
perspective of the body that sees human ailments as either confined to the physical body or to the
mind (Lock and Scheper-Hughes 1990, 484). This dualist view traps researchers and creates a
disconnectedness of the human experience (Lock and Scheper-Hughes 1990, 484).
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The critical-interpretive approach begins by describing the symbolic ideas surrounding

the human body (Lock and Scheper-Hughes, 482). Then, it looks at how these ideas are applied
in practice using the individual, political, and social body with a theory of emotion as a mediator
(Lock and Scheper-Hughes 1990, 482). This approach attempts to analyze the concept of
“embodied personhood”, or the relationship between cultural beliefs and health and illness in a
human body (Lock and Scheper-Hughes 1990, 482). The individual body is the lived experience
of the body where mind and body are merged (Lock and Scheper-Hughes 1990, 483). Analysis at
the level of the individual body includes how the mind and body are related to each other and
how experiences of sickness differ across bodies (Lock and Scheper-Hughes 1990, 483). In
Western culture, there is an idea that the individual is separate from society (Lock and Scheper-
Hughes 1990, 487). However, in other cultures like the Gahuku-Gama of New Guinea and in
Japan, there is a more collectivist view of society where the individual is never separate from the
group (Lock and Scheper-Hughes 1990, 487).

Analysis at the level of the social body describes the symbolism surrounding the body
relating to natural or cultural roles of that body (Lock and Scheper-Hughes 1990, 483). Symbols
of the body often represent a culture’s views on kinship systems, social relations and values
(Lock and Scheper-Hughes 1990, 491). For example, in matrilineal societies, the female
reproductive contributions are usually emphasized and vice versa for patrilineal societies (Lock
and Scheper-Hughes 1990, 491). Illness and death in a group are often attributed to social
tensions or health of a society (Lock and Scheper-Hughes 1990, 491). A common symbolic use
of the human body is to personify the natural spaces that humans live in (Lock and Scheper-
Hughes 1990, 492). For example, the health of a river ecosystem may be compared to the well-
being of a group of people that use it for fishing and bathing (Lock and Scheper-Hughes 1990,
491). In Western society, Cartesian dualism has created a body alienation that reduces the body
down to a machine that is seen as separate from the self and the rest of the world (Lock and
Scheper-Hughes 1990, 491).

The last level of analysis, the body politic, is used to show how bodies are controlled and
regulated by dominant ideologies of the state (Lock and Scheper-Hughes 1990, 483). This level
explores how individual bodies’ sexuality, reproduction, health, and leisure activities are shaped
by powerful social and political forces and groups (Lock and Scheper-Hughes 1990, 483).
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Societies may try to create and regulate a body that most benefits their own interests (Lock and
Scheper-Hughes 1990, 484). Lock and Scheper-Hughes argue that emotion is the mediating force
between the three bodies (Lock and Scheper-Hughes 1990, 496). They explain that emotions
affect the way health and illness is experienced by the individual and that emotions are used to
represent the functionality of the social body or body politic (Lock and Scheper-Hughes 1990,
496).

The critical-interpretive approach is based off theory from previous post-modern thinkers
Michel Foucault and Pierre Bourdieu. The critical-interpretative approach using the three bodies
relates to Michel Foucault’s concept of discourses of power which describe the various ways that
a dominant group maintains dominance over another group (Erickson and Murphy 2017, 160.)
This dominance is primarily achieved through controlling knowledge, or the information that is
linked to these discourses of power (Erickson and Murphy 2017, 161). Foucault argues that
mental illness, or madness, is defined over time and is not something that is intrinsically medical
or biological (Erickson and Murphy 2017, 161). This relates to the analysis at the level of the
body politic and how disease categories and labels in clinical medicine create a sick majority that
fit under one of many clinical labels (Lock and Scheper-Hughes 1990, 495). This is seen through
the creation of the DSM handbook. The critical-interpretive approach relates to Pierre
Bourdieu’s idea that scientific reasoning is constructed by powerful social agents in the form of
institutions or individuals that have a monopoly over capital (Bourdieu 1991, 4). Bourdieu
argues that knowledge is culturally produced and acts as a tool of domination or absolute
authority that is used to maintain a social order that benefits those in charge (Bourdieu 1991, 8).
Within a Western capitalist economy, the domination of biomedical systems benefits powerful
groups such as pharmaceutical companies who make billions of dollars a year selling drugs to
the America people. The ideologies of biomedicine are maintained and produced by the
dominant group and then, legitimized through scientific research (Lock and Scheper-Hughes
1990, 481). These ideologies are internalized and naturalized by individuals who come to see
their bodies similar to machines that are reliant on these medical systems to “fix” their health
when it is poor (Lock and Scheper-Hughes 1990, 484). One of the mechanisms that is used to
legitimize American ideals of mental illness and consequently, create large amounts of revenue
for pharmaceutical companies is the Diagnostic and Statistical manual of Mental Disorders
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(DSM). This manual has been used by mental health professionals to categorize American
people as “sane” or “insane” for 66 years (Blashfield et al. 2014).

History of the DSM

In 1952, the first edition of the DSM was created by the American Psychiatric
Association so that mental health professionals would have a standardized way to diagnose
patients with mental disorders (Blashfield et al. 2014). Before its creation, four systems were in
use in the United States in order to diagnose individuals (Blashfield et al. 2014). This first edition
contained 128 categories, 132 pages and had a hierarchical system in which disorders were
classified under “organic brain syndromes” or “functional” disorders (Blashfield et al. 2014). It
used short, broadly worded prose definitions to describe categories (Blashfield et al. 2014). In
1968, the second edition of the DSM was created after a psychiatrist named Erwin Stengel
became alarmed that all countries had their own classification systems and believed that the
DSM should serve as a model to create a system that would be adopted globally (Blashfield et at.
2014). This led to the creation of the ICD-8, the almost identical international version of the
American DSM-II, by a committee funded by the World Health Organization (Blashfield et al.
2014). This version had 193 categories, 119 pages and expanded on categories of relevance to
outpatient mental health efforts such as anxiety disorders, depressive disorders, and personality
disorders (Blashfield et al. 2014).

In 1980, the DSM-III was published after a study by David Rosenhan found that
psychiatrists were inaccurately diagnosing patients with “schizophrenia” which suggested that
psychiatrists could not recognize the “sane” from the “insane” with the current handbook
(Blashfield et al. 2014, 30). Clinicians felt that these misdiagnoses were due to overly broad and
“nonspecific diagnostic definitions” in the DSM-II (Blashfield et al. 2014, 31). A group of
psychiatrists from Washington University in St. Louis built the foundation of the DSM-III
through a paper that argued there were 15 mental disorder categories that had sufficient evidence
to be valid. These categories included schizophrenia, manic-depressive disorder, homosexuality,
and hysteria (Blashfield et al. 2014, 31). The DSM-III used more in-depth definitions then
previous editions and included a description of the typical demographic profile of patients
experiencing each disorder, an explanation of the category, how to distinguish it from other
similar disorders, and about the course of the disorder (Blashfield et al. 2014, 31). In this edition,
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there was 228 categories of mental disorders discussed in 494 pages and the price increased from
around $3.00 to $31.75 (Blashfield et al. 2014, 32). It was organized into 19 families of disorders
remained relatively consistent with the latest ICD (Blashfield et al. 2014). The DSM-III was then
updated to the DSM-III-R after research on diagnostic criteria became inconsistent. This version
has 253 categories and caused political controversy between feminists activists and committee
members after members called for “premenstrual syndrome” and masochistic personality
disorder as new categories (Blashfield et al. 2014, 35). Starting in the mid-1980s, a large number
of studies of gender bias in diagnoses were published (Blashfield et al. 2014). They found that
clinicians tend to pathologize women more relative to men (Blashfield et al. 2014, 36). In 1994,
the DSM-IV was published under the leadership of Allen Frances (Blashfield et al. 2014) This
version had 383 categories, 886 pages, cost $74.95 and contained an appendix for seventeen
categories needing further study (Blashfield et al. 2014). This version of the handbook led to
debates surrounding how to incorporate models of personality into the next version, the DSM-5.
At first, this new version proposed replacing all categories of Personality Disorder (PD) with
dimensional models of personality (Blashfield et al. 2014). However, political pressures proved
too great and PDs remained in the DSM-5. Drafts for the DSM-5 began in 1999 and the APA
posted their drafts on the internet to call for comments and suggestions from by the public
(Blashfield et al. 2014). The first draft, published in 2011, resulted in 8,000 comments. In 2013,
the final draft was published with 541 diagnostic categories, 947 pages and cost $199 per copy
(Blashfield et al. 2014, 41).

Critique of the DSM: Global Application

One common critique of the DSM is that it claims that the categories of mental disorder
created by the handbook are not discrete entities with “absolute boundaries dividing it from other
mental disorders or from no disorder (Summerfield 2008).” However, these categories have often
been treated by mental health physicians as such, like they universal truths that can be applied
globally and act as authorities for defining an individual’s state of being (Summerfield 2008).
Psychiatric categories evolve or disappear based on the Western social and cultural trends, rather
than on biology (Summerfield 2008). For example, homosexuality was taken out as a disorder
and PTSD was added as a disorder in the DSM-III in 1980 (Summerfield 2008). These categories
do not take culturally-distinct conceptions of health and body that exist around the world
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(Summerfield 2008). Although, the DSM represented a “best effort” rather than a “ground truth”,
students often memorize the DSM, ignoring the individual person’s problems and the social
context and complexities of their disorder (Andreasen 2006). This is demonstrated in Ethan
Watters discussion of the spread of PTSD in Sri Lanka after a devasting tsunami in 2004.

Case Study: Spread of PTSD in Sri Lanka

In the book, “Crazy Like Us”, Ethan Watters discusses the globalization of the
“American Psyche.” In his chapter, “The Wave that Brought PTSD to Sri Lanka,” Watters
describes how Western therapists and traumatologists brought the concept of “Post-Traumatic
Stress Disorder” (PTSD) to Sri Lanka after a tsunami struck Sri Lanka in December 2004 and
killed a quarter of a million people (Watters 2010). PTSD was originally developed by
psychoanalysts after the Vietnam to describe and diagnosis a state of mind that was unique to
Vietnam war survivors (Watters 2010, 115). These soldiers’ felt they had been betrayed by the
United States’ government which was the primary reason for their damaged psyche (Watters
2010, 115). However, some began to advocate for post-Vietnam syndrome to gain official
diagnostic status in the DSM and made alliances with researchers to extend the definition of this
disorder to include those who suffered psychologically from any kind of physical or mental
trauma (Watters 2010, 115). By the time of the Sri Lanka tsunami, PTSD had been widely
accepted as an inevitable result of trauma faced by any individual universally (Watters 2010).
Thus, Western mental health workers arrived in Sri Lanka days after the tsunami to conduct
“Critical Incident Debriefing” to train the locals about how to recognize the signs and symptoms
of PTSD using checklists created from the DSM (Watters 2010). However, this neglected the
culturally distinct ways that Sri Lankans experienced trauma and their methods of healing
(Watters 2010). Sri Lankans’ experience of trauma differed from Americans experience in that
they felt more physical pain after experiencing trauma rather then feeling internal states of
suffering such as anxiety or fear (Watters 2010). Rather, they reacted to trauma in terms of the
damage it did to their social relationships (Watters 2010). Thus, Sri Lankans’ experience of
trauma was external rather than internal (Watters 2010). Watters argues that this shows how
there is not a universal experience to trauma and how the DSM is not able to be applied
universally (Watters 2010). Conceptions of health and illness must be understood in the distinct
culturally, economic, and historically contexts that exists in (Watters 2010).
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Politics of the DSM

Another common critique of the DSM is that is has been shaped by political and
economic interests of pharmaceutical companies rather then solely for the sake of scientific
progress (Pelecki et al. 2011). The DSM has often changed their contents based on whether the
included disorders and descriptions are considered fundable or not (Pelecki et al. 2011). With the
DSM-IV, the majority of the categories listed in the manual were found to have associations with
drug companies and 56% of the committee members have one or more financial links to a
company in the pharmaceutical industry (Pelecki et al. 2011). In 1962, congress passed the Food,
Drugs, and Cosmetics Act of 1962 which stated that pharmaceuticals must be safe and
demonstrably helpful for specific disorders (Pelecki et al. 2011). Thus, the creation of distinct
categories of illness with listed symptoms in the DSM was more desirable for
psychopharmalogical financial endeavors because new drugs could be sold that targeted specific
symptoms rather than the entire disorders (Pelecki et al. 2011). Drugs were made to correct
chemical imbalances and one drug could be used to a variety of disorders that were related to
certain chemicals (Pelecki et al. 2011). New disorders were often created after the medication
“cure” had already been created (Pelecki et al. 2011). This approach, then, led to the theory that
depression is marked by a serotonin deficiency and led to the creation of Monoamine oxidase
inhibitors (MAO inhibitors) and Selective Serotonin Reuptake Inhibitors (SSRIs) as anti-
depressants (Pelecki et al. 2011). MAO is an enzyme that is involved in the creation and
dissemination of various neurotransmitters such as serotonin, melatonin, noradrenaline, and
adrenaline (Hillhouse and Porter 2015). While Serotonin reuptake creates a chemical reaction in
the brain that causes serotonin to stay in the brain longer then it usually would (Hillhouse and
Porter 2015). Serotonin-deficiency has also been found in other disorders such as premature
ejaculation and gastrointestinal symptoms (Pelecki et al. 2011).

Case Study: Mega-Marketing of Anti-Depressants in Japan

In chapter four, “The Mega-Marketing of Depression in Japan”, Watters discuss the rise
of depression in Japan in the 1990s (Watters 2010). Watters argues that this increase is partly the
result from the actions of GlaxoSmithKline, the producers of the anti-depressant Paxil, who
sought to introduce the multi-billion-dollar industry of SSRIs to Japan by creating new
conceptions of sadness and grief that did not currently reside there (Watters 2010). Before this
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time, incidences of depression were low in Japan and sadness was seen as a natural part of
human life (Watters 2010). Japanese doctors only recognize a very severe type of long-term
depression that often resulted in institutionalization (Watters 2010). However, an economic crisis
at the end of the twentieth century cause Japan to be vulnerable to financial, ideological schemes
such as the one created by GlaxoSmithKline (Watters 2010). Marketers began advertising
depression as kokoro no kaze or “cold of the soul” instead of the harsh, earlier diagnosis of
utusbyo (Watters 2010). This created an image of depression in Japan that individuals could
relate to on a wide-scale of discomforts and like the common cold, the symptoms of depression
could be alleviated with a simple medication (Watters 2010). Watter’s discusses how scientific
studies written about anti-depressants drugs such as Paxil were ghostwritten by drug companies
claiming that depression was caused by imbalance of serotonin in the brain (Watters 2010).
However, the scientific evidence for this continues to remain inconclusive and Paxil, along with
other anti-depressants, have been shown to have side effects ranging from nervous system
problems to increased suicide rates in young adults (Watters 2010).

Conclusion

In conclusion, the DSM has helped mental health physicians to legitimize categories of
“sane” and “insane” in the United States and around the world starting with its conception in
1952. However, these categories do not take culturally-distinct experience of illness and health
into and attempt to apply culturally and socially defined Western categories globally. The
categories of the DSM have been shaped by the interests of pharmaceutical companies and then
marketed by these companies to other countries in order to increase drug revenue. Medical
anthropology can help combat this widespread disregarding of cultural context by advocating for
mental health physicians to take the cultural and social context of an individual in consideration
when treating them. Using the critical-interpretative approach of Nancy-Scheper Hughes and
Margaret Lock, medical anthropologists can begin to critique the current biomedical assumptions
that pervasive through Western mental health practices and research conceptions of the mind and
body within the cultural, historical, and political context from which is derives from.
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