The Changing Face of Madness

Eric Lis

Modern medicine has traditionally had a very difficult time deciding, not merely what is normal, but who gets to decide what is normal.

May 2013 is an interesting time for the world of medicine, because later this month, there's going to be a major paradigm shift in the field of mental health. In North America, and to a lesser extent in most of the rest of the world, the bible of psychiatry is a book known as the diagnostic and statistical manual of mental disorders, or, the DSM. First published in the 50's, the DSM aspires to be the be-all-and-end-all of mental health, listing every known mental disorder and codifying each disorders characteristics so that symptoms which might otherwise be very subjective can be rated the same way by two different clinicians. It's far from being a perfect book, and it's evolved with the times. For example, in the very first edition of the DSM, homosexuality was listed as a psychiatric disorder; it was removed in later versions, as society evolved, values changed, and copious research showed that it wasn't pathologic. Since 1994, psychiatrists have been using the DSM IV as their handbook, but in late May, the DSM V is going to come out. While the field of psychiatry won't be changing hugely, the diagnostic criteria for a number of disorders are going to change slightly, and more significantly, several current disorders will cease to exist while some new disorders will suddenly appear. There are people walking around right now, living happy lives in spite of mental health issues, whose diagnoses will magically change between now and June 1st. In some cases, this is going to improve their care. In most, it won't make a meaningful difference. For all of them, it will raise the very important question, how was something normal yesterday and abnormal today, and whose decision was that?

The DSM was originally conceived to be a tool exclusively for researchers, so that people conducting two studies in different cities could be confident that they were examining the same disorder. Unfortunately, due to the influence of bureaucracies, the pressures to have universally-similar paperwork, and the desire of insurance companies to have hard and fast guidelines they can apply with a minimum of wiggle room, the last 50 years have seen it adopted as more or less the official list of psychiatric disorders. This isn't necessarily a bad thing. For one thing, it means that doctors can't just decide arbitrarily whether someone is or is not depressed; in theory, they have to stick to an established checklist of common symptoms and variants. The downside is, it limits flexibility. The DSM isn't comprehensive; it doesn't include every symptom known to medical science, and it doesn't include every presentation of illness. The DSM isn't accepted universally, either; in certain important cases, it conflicts with analogous disorders in such disease classifications as Europe's International Statistical Classification of Diseases and Related Health Problems (the ICD) and the Chinese Classification of Mental Disorders (the CCMD). Medical students in American and Canadian universities are generally being taught that the DSM is the absolute authority of psychiatry, much to the consternation of psychiatrists who are all too aware of its limitations. And by the end of this month, huge portions of the book will have changed. It makes me glad I'm not writing any exams this year... who knows whether the answers would come from the DSM IV or V?

The big question remains, who makes these decisions? The second question is, how might this affect my gaming? The point of all this is, the DSM isn't handed down from on-high by stone tablets, directly from the god of Mental Healing. It's written by human beings. The human beings in question are often respected researchers in their area, which means that they have theories to which they've dedicated their lives and, as a result, biases in those areas. A significant number of these writers, brilliant though they are, have done paid for work pharmaceutical companies and other corporate entities who may have a vested interest in the book being written a certain way. The first thing you learn when you study journalism is that there's no such thing as a truly objective reporter, and when you study the history of medicine and medical research, you're forced to confront the fact that there's no such thing as a 100% open-minded scientist, especially one's who's dedicated 50 years to a particular question. Intelligent and fallible people are writing this book, and as a result, the book is both intelligent and imperfect. The DSM V isn't out yet, but entire books about what it does right and what it does wrong are already available on Amazon.

The implication for your game world should be obvious: the line that separates "normal" and "sick" is placed there by people. Two different people may place it in a slightly different point between the two extremes, and as society changes, that line shifts too. Fallible people with political agendas decide whether being gay is a sickness in one generation and normal in another. In your game world, people decide whether magic use is a symptom of psychosis and whether "adventurer" is a diagnosable, maybe even treatable, mental disorder. "Normal" and "sick" are defined by the masses and by the people in power, not merely from generation to generation but often from moment to moment. And that opens up a lot of story opportunities for a clever storyteller.

And if you think this is only true in the subjective and poorly-understood field of mental disorders, you should read a bit about how we differentiate between different forms of cancers, pneumonias, and progressive muscle disorders.

Four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on May 4, 2013. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system