They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal

Sarah Robertson is an associate editor of the Canadian Book Review
Annual.

There is a kind of free-floating consensus in our society that those
members of the mental-health elite who determine who is psychologically
abnormal are guided by a combination of empirical evidence and concern
for the well-being of the patient. Paula Caplan, a clinical/research
psychologist and former consultant to the creators of the influential
American Psychiatric Association’s (APA) Diagnostic and Statistical
Manual of Mental Disorders (DSM), examines in this well-documented,
closely argued, and deeply disturbing book “the shockingly
unscientific basis of the DSM, the politics and arbitrariness involved
in deciding who is normal, and the motives of the major players.”
Specifically, the book focuses on the opposition of Caplan and others to
the proposed addition to the DSM-IV of Self-Defeating Personality
Disorder (SDPD) (whereby female victims of abuse are pathologized for
responding to abuse in self-denying, self-effacing ways—ways that are,
in fact, socially prescribed) and to the retention of Premenstrual
Dysphoric Disorder (PMDD), also known as Premenstrual Syndrome (PMS).

In painstaking detail, Caplan and others conveyed to APA officials the
scientific invalidity of these categories as well as their harmful
consequences, only to be met with evasiveness, outright dishonesty, and
megadoses of obfuscation and doublethink. Ultimately, adverse publicity
forced the withdrawal of SDPD from the DSM-IV; PMDD, however, was not
only retained but upgraded in status. Not surprisingly, the largely
conservative white male APA elite rejected Caplan’s proposed inclusion
of Delusional Dominating Personality Disorder (DDPD), also known as
“Macho Personality Disorder,” even though empirical support for it
far exceeds that for PMDD. The baffling, perverse decision-making
demonstrated by the APA begins to make ugly sense as Caplan explores the
ties that bind big business and organized psychiatry: in particular, the
unholy alliance between drug companies and the APA.

Besides exposing the shifting sands upon which the DSM rests, this book
emphasizes the cultural biases that underscore conceptions of
“normality,” as well as the societal problems that are glossed over
by convenient, quick-fix pathologizing labels. The powerful vested
interests Caplan describes do not point to an imminent reform of the
status quo, but her level-headed, compassionate, and wholly persuasive
wake-up call is an admirable start.