The SkepDoc

Who’s Crazy Now?: DSM-5 and the Classification of Mental Disorders

BY HARRIET HALL, M.D.

WHAT DOES IT MEAN TO BE CRAZY? WE use the word loosely. In casual conversation we might say “He’s crazy” or “That’s insane!” but that doesn’t mean we really think the person is certifiable. Sometimes all it means is “He doesn’t agree with me.” What does it take to be formally diagnosed with a mental illness?

Medical diagnoses like broken bones and diabetes are pretty straightforward. They depend on objective findings from diagnostic tests, but diagnosis of mental disorders is mostly subjective. There’s no blood test for schizophrenia. Psychiatry is arguably the least evidence-based of all the medical specialties.

Mental health diagnosis is guided by rules. The problem is that the rules keep changing. A person who’s crazy now might not be considered crazy in 2050. A person who’s considered sane today might have been locked up in an insane asylum in 1850. So, who’s crazy now, and how do we decide?

Even psychiatrists are not very good at knowing whether a patient is crazy. In 1973, Robert Rosenhan published the study called “On Being Sane in Insane Places” that became an instant classic in psychiatry lore (http://bit.ly/1JMX6D0). Fake patients got themselves admitted to 12 different psychiatric hospitals by briefly claiming to have auditory hallucinations; once admitted, they acted normally and said they no longer heard voices. Every one of them was diagnosed with schizophrenia and they were kept in the hospital an average of 19 days. In order to get released, they were forced to admit to having a mental illness, and forced to take antipsychotic drugs.