WHY SHOULD the public care how a group of highly specialized doctors identify and describe the disorders they treat? If you feel sick and can discern your symptoms, or if tests indicate that some disorder you're not even aware of is causing harm, what does it matter what the doctors call your illness so long as they can recognize and treat it? In fact, it matters a great deal if the illness is a psychiatric one, as a group of doctors who met in Washington last week can attest.
In 1952, the American Psychiatric Association first published a manual classifying and describing mental disorders. It has since been revised and updated a number of times, and a new edition is now being prepared. In the case of most medical problems, scientists can readily agree ohe nature of the symptoms and the effect the disorder is producing. They can also spot new diseases -- the lat variant of hepatitis, AIDS -- with technical accuracy. But psychiatrists have a more difficult time accumulating data that are specific and regularly disagree over whether a given set of symptoms is even a mental illness. Homosexuality, for example, has at various times been classified as a disorder and as normal behavior. Alcoholism has been viewed as a physical illness and a behaviorial disorder. Clearly something quite different from scientific analysis has gone into the making of these various judgments.
The APA manual is published for use by medical professionals, but the classifications have come to have important social implications. Once a set of symptoms is recognized by the profession as a mental illness, persons exhibiting these symptoms often can claim insurance benefits (both public and private), invoke civil rights protections and even offer the illness as a defense in criminal cases. Public opinion shifts gradually to accommodate these designations and to tolerate behavior once thought unacceptable.
In the course of the current manual revision, three new designations have become particularly controversial. In an early draft, the manual included mental disorders for rapist behavior, self-defeating personality and a form of premenstrual syndrome. Many psychiatrists, among them a number of women, protested these new designations. Accused rapists, they warned, would claim exculpatory illness; abused wives who are victims of crime would be treated as if their own disorders had provoked abuse; women would be stigmatized if premenstrual symptoms were treated as mental rather than physical disorders. Revisions are still under way.
Psychiatrists play a critical role in our complicated and diverse society not only because they treat the ill but because, in many cases, they define the norms. It is important that in their concern for the sick they are mindful of society's need to reinforce moral codes, to hold people responsible -- in most cases -- for their behavior and to provide protection against those who hurt others, acknowledge no rights but their own and destroy the peace of the community.