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All of which raises a pressing question: What actually goes into defining a disorder? A.P.A. officials take this question seriously, and they understand the high stakes of a DSM diagnosis. That's one reason they so often revise the book to keep it current with the latest research. (Three editions have been published since 1986.) According to Dr. Darrel Regier, chief of A.P.A. research, roughly 1,000 mental-health professionals will help produce DSM V. The A.P.A. will host at least a dozen conferences, review unending piles of literature and conduct new studies to see whether proposed changes would work in clinical settings.
But like the conditions it helps diagnose, the DSM is more than the sum of its symptoms. As the American storehouse of insanity--the dictionary of everything we consider mentally unbalanced--it's a window into the national psyche. And so it bears close reading, and close questioning, by those outside the psychiatric establishment. Why is caffeine intoxication included as a disorder when sex addiction isn't? Why is pathological gambling apparently crazy when compulsive shopping isn't?
More important, can even a thousand Ph.D.s gathered at a dozen conferences ever really know the significance of such vague symptoms as "fatigue," "low self-esteem" and "feelings of hopelessness"? (You need only two of those, along with a couple of friends telling the doctor you seem depressed, to be a good candidate for something called dysthymic disorder.) Though it's fashionable these days to think of psychiatry as just another arm of medicine, there is no biological test for any of these disorders. While imaging techniques have shown abnormalities in the brain of some people with schizophrenia, no scan can diagnose even that severe condition, let alone something opaque like "histrionic personality disorder." (For which the DSM lists the following as a sign: "consistently uses physical appearance to draw attention to self." So I'm sick if I exchange my Aunt Thelma's drab sweaters for flashier ones every Christmas?)
If the DSM is all we've got, why is it inherently flawed? Because many forces besides science shape it, including politics, fashion and tradition. The A.P.A. actually once held a vote among its members to see whether an alleged disorder--homosexuality--existed. (In 1974, being gay was deemed sane by a vote of 5,854 to 3,810.) Women's groups helped excise "self-defeating personality disorder" from the book. The revised third edition, in 1987, said the typical sufferer "chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available." But feminists successfully argued that battered women could unfairly fit this category.
Other questionable diagnoses stay in the book because no one fights hard enough to remove them. Thus heterosexual men can be diagnosed with a supposed disorder called "transvestic fetishism" if they meet only two criteria: they have sexual fantasies about cross-dressing, and those fantasies cause "impairment in social, occupational, or other important areas." In other words, someone is sick not if he has the fantasies but if he gets caught having them--for instance, if his boss reads a kinky e-mail he sent at work, which then leads to a pink slip ("occupational impairment").