Diagnostic and Statistical Manual
of Mental Disorders

Fourth Edition
Text Revision

Published by the American Psychiatric Association

Reviewed by Mira de Vries

Don’t laugh. This review is about the DSM. It’s not a general description, as readers of this site will surely already know what the DSM is about. Nor is it a critique like those by authors such as Blom, Boyle, Caplan, Horwitz, Kutchins & Kirk, and Walker. Rather, it is an attempt to deflate some of the mystery surrounding the DSM.

For many years I refused to buy it, not wishing in any way to contribute to the APA. But, finally I relented when I wanted to check for myself whether what critics say about the DSM is true. So I went to my local bookstore in a suburb of Amsterdam, in Holland, you know, wooden shoes, tulips, windmills, etc. “Can you order the DSM for me?” I asked at the order desk. The salesman pointed to the shelf behind me and said, “We have it in stock.” “In stock? Is there that much demand for it, that you keep it in stock?” “Yes,” said the clerk, “mainly psychologists and psychotherapists are in here asking for it all the time.”

Of course the book on the shelf was a Dutch translation. Mark Twain warned us tongue in cheek, “Be careful of reading health books; you may die of a misprint.” Fearing I may likewise go crazy from a mistranslation, I asked the salesman to order the original version, emphasizing that I want it in American English, not British. The result was that I had to wait three months for it to arrive. I paid €68.61 for it, including tax. This was back in 2003. It may be more expensive by now due to inflation, or perhaps cheaper due to the weak position of the dollar to the euro.

My first impression of the book was its size. Wow, is it ever big. It’s 9.9” (25.1cm) high, 6.9” (17.5cm) wide, and a full 1.8" (4.6cm) thick according to my double-edged ruler. It contains 943 pages, not counting the unnumbered blank pages in the back. I wouldn’t claim that it’s actually a small book, but there’s not as much text in it as the first impression suggests. The letters are surprisingly large and the lines widely spaced. This is normal for books that are written to be read straight through, like novels, but for medical manuals this is quite unusual. I took several off the shelf and compared them, to make sure I wasn’t imagining this, but the other manuals all have much smaller print. In fact, the first book I took off the shelf that has slightly larger letters than the DSM was Alice in Wonderland. However, the DSM’s cover is prettier, a shiny gray that looks almost like silver. The cover design shows a lot of restraint: no picture or anything.
The title page mentions only the name of the book, not a writer or editor. On the back of it is the usual gobbledygook about the copyright, being printed on acid-free paper, Library of Congress cataloguing, etc. Then comes a surprise: a dedication page. Again, I checked all of the other medical manuals on my shelf, and not one of them has a dedication. The dedication is “To Melvin Sabshin, a man for all seasons.” Melvin Sabshin was director of the APA for nearly a quarter of a century, and retired shortly before publication of this edition of the DSM.

Next comes the table of contents, written in letters that your optometrist might use to check your eyesight from across the room. After that is a list of names called “Task Force on DSM-IV”. This goes on for only seven pages, as opposed to appendices J and K in the back of the book, listing the names of the contributors, advisers, etc. which go on for 27 pages. Yet more names appear in the acknowledgements. By now I’m beginning to suspect that people paid or were paid to have their name appear in the DSM.

Next come 13 pages of introduction, which is normal for the type of book that the DSM pretends to be. But after that comes another surprise: a disclaimer. In essence it says that there may be disorders that the book left out, and that “…mental disorders may not be wholly relevant to legal judgments...” Then come twelve pages of instructions on how to use the manual.

Skipping over 733 pages which form the body of the DSM, we arrive at Appendix A, decision trees, which look a lot like the ones on my tax forms. The Dutch Tax Service’s motto is: “We can’t make it more fun, but we can make it easier.” (They don't.)

Appendix B is “Criteria Sets and Axes Provided for Further Study.” That goes on for sixty pages. It seems to me that rather than study axes, they should use them to chop off big parts of the book.

Appendix C is a ten-page glossary. Appendix D is 15 pages of discussion on the changes made in this edition. Appendix E lists all the diagnoses in alphabetical order, and appendix F lists them in numerical order, leaving one wondering in just what order they are listed in the body of the work.

Appendices G and H provide the codes in the ICD, a rival publication by the WHO (World Health Organization). It’s no secret that the DSM writers specifically aimed to have their list of diagnoses correspond with the ICD, in fact, they say so. They only don’t add that the discrepancies in previous publications were embarrassing.

Appendix I is about “culture-bound syndromes.” If you are a man (women don’t get it) from Papua New Guinea, a perceived insult could provoke you to become sick with a disorder called amok. Indian men (only, I assume, though here it doesn’t specifically say so) might go crazy from a discharge of semen. This mental disorder is called dhat. American Indians can get ghost sickness. Eskimos get pibloktoq, which includes tearing off clothes, eating feces, and fleeing from protective shelters. The Chinese get another apparently male only disorder, shenkui, caused by excessive semen loss from frequent intercourse or masturbation. Central and Latin Americans are subject to susto, which is when the soul leaves the body. Zar, which occurs in parts of Africa and Asia, is possession by spirits. Although recognized by the DSM as a mental disorder, the local population do not consider it pathological. But then they don’t have the benefit of science like the APA does...

I’ve already mentioned appendices J and K. After that comes the index, and at the end, eleven blank pages.

Along with the DSM, I received an advertisement for 16 other APA publications. One of them is, believe it or not, a book called Infant and Toddler Mental Health, Models of Clinical Intervention With Infants and Their Families, edited by J. Martin Maldonado-Durán, M.D. The accompanying blurb reads: “Written by clinicians who work with infants and children and their families every day, this eminently practical guide illustrates what to do in numerous clinical situations, and addresses the most common and important problems in infant psychopathology.”

Heaven help the babies of this world. Heaven guard us all from psychiatry.

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