The Book of Woe: The DSM and the Unmaking of Psychiatry

by Gary Greenberg

  Freud might not have minded that first DSM, which was issued in 1952, thirteen years after his death. He might have recognized his legacy in the names of the sections—“Disorders of Psychogenic Origin” and “Psychoneurotic Disorders”—and of diagnoses such as anxiety reaction and sexual deviation. He might have been pleased by the literary descriptions, steeped in psychoanalysis, which turned up, for instance, in the definition of depressive reaction as the result of “the patient’s ambivalent feeling29 toward his loss.” Buoyed by the continued presence in the book’s 132 pages of his notion that the mind was a host of inchoate and often contradictory feelings, Freud might have been willing to acknowledge that his forecast of a hostile takeover of psychoanalysis by medicine had been wrong. He might even have admired his descendants for their cleverness in avoiding that fate and yet still claiming the perquisites of the doctor, for having figured out how to have it both ways.

  But Freud might also have predicted that it was only a matter of time before the strain between the reductive impulse of medicine and the expansive nature of psychoanalysis raised internal havoc. The problems began in 1949, before the first DSM was published, when a psychologist showed30 that psychiatrists presented with the same information about the same patient agreed on a diagnosis only about 20 percent of the time. By 1962, despite various attempts31 to solve this problem, clinicians still were agreeing less often than they disagreed, at least according to a major study. In 1968, at just around the time the second edition of the DSM came out, research showed that for any given psychotic patient, doctors in Great Britain32 were more likely to render a diagnosis of manic depression than schizophrenia, while doctors in the United States tended to do the opposite—a difference that was obviously more about the doctors than the patients.

  In the meantime, one of psychiatry’s own had turned against it. Thomas Szasz, an upstate New York doctor with a libertarian bent, argued in The Myth of Mental Illness (1961) that psychiatrists had mistaken “problems of living”—the age-old complaints that characterize our inner lives—for medical illnesses, and the result was a loss of personal responsibility (and a sweetening of the pot for doctors). Also in the early 1960s, Erving Goffman and Michel Foucault33, among other academics, chimed in with their view that mental illness was more sociological than medical, and that psychiatrists were pathologizing deviancy rather than turning up genuine illness—which they (along with Szasz) believed existed only in cases where physiological pathology could be identified as the source of the trouble.

  The arguments about diagnostic agreement and the nature of mental illness might have remained arcane academic topics had it not been for a Stanford sociologist, David Rosenhan, who, in 1972, sent a cadre of healthy graduate students to various emergency rooms with the same vague complaint: that they were hearing a voice in their heads that said “Thud.” All the students were admitted with a diagnosis of schizophrenia, and although they acted normally once they were hospitalized (or normally for graduate students; they spent much of their time making notes, behavior that was duly jotted down in their charts as indicative of their illness), the diagnosis was never recanted. Some were released by doctors, and others had to be rescued from the hospital by their colleagues, but all were discharged with a diagnosis of Schizophrenia, in Remission.

  Rosenhan’s recounting of his exploit, “On Being Sane in Insane Places,” appeared in the January 1973 edition of Science. Later that year, gay activists, including some psychiatrists, after years of increasingly public and contentious debate, finally persuaded the APA to remove homosexuality from the DSM—a good move, no doubt, but one that, especially after what had happened to the graduate students, couldn’t help but reveal that even when psychiatrists did agree on a diagnosis, they might have been diagnosing something that wasn’t an illness. Or, to put it another way, psychiatrists didn’t seem to know the difference between sickness and health.

  Forty years, two full rewrites, and two interim revisions of the DSM later, they still don’t. Psychiatrists have gotten better at agreeing on which scattered particulars they will gather under a single disease label, but they haven’t gotten any closer to determining whether those labels carve nature at its joints, or even how to answer that question. They have yet to figure out just exactly what a mental illness is, or how to decide if a particular kind of suffering qualifies. The DSM instructs users34 to determine not only that a patient has the symptoms listed in the book (or, as psychiatrists like to put it, that they meet the criteria), but that the symptoms are “clinically significant.” But the book doesn’t define that term, and most psychiatrists have decided to stop fighting about it in favor of an I-know-it-when-I-see-it definition (or saying that the mere fact that someone makes an appointment is evidence of clinical significance). Instead, they argue over which mental illnesses should be admitted to the DSM and which symptoms define them, as if reconfiguring the map will somehow answer the question of whether the territory is theirs to carve up.

  This kind of argument leads to all sorts of interesting drama, much of which you will soon be reading about, but none of it can answer the question I posed about Sandy: Is disease really the best way to understand his craziness? How much of our suffering should we turn over to our doctors—especially our psychiatrists?

  I don’t know the answer to that question. But neither do psychiatrists. Even in a case as florid as Sandy’s, they cannot say exactly how they know he has a mental illness, let alone what disorder he has or what treatment it warrants or why the treatment works (if it does), which means that they cannot say why his problem belongs to them. That’s no secret. Any psychiatrist worth his or her salt will freely acknowledge (and frequently bemoan) the absence of blood tests or brain scans or any other technology that can anchor diagnosis in a reality beyond the symptoms. What they are more circumspect about is the disquieting implication of this ignorance: that if a physician wants to claim that drapetomania and homosexuality and, as the DSM-5 has proposed, at one time or another, Hypersexuality and Internet Use Disorder and Binge Eating Disorder are medical illnesses, there is nothing to stop him from doing so and if he is shrewd and lucky and smart enough to persuade his colleagues to follow him, the insurers, the drug companies, the regulators, the lawyers, the judges, and, eventually, the rest of us will have no choice but to go along.

  So while the psychiatrists who author the DSM and I share an ignorance about how much of our inner travail should be considered illness, only the psychiatrists have the power to decide, and only the American Psychiatric Association claims those decisions as intellectual property that is theirs to profit from. That’s why I think you should be more disturbed by their ignorance than mine. After all, if the people who write the DSM don’t know which forms of suffering belong in it, and can’t say why, then on what grounds can the next instance in which prejudice and oppression are cloaked in the doctor’s white coat be recognized? Or, to put it more simply, why should we trust them with all the authority they’ve been granted?

  • • •

  That’s a question that psychiatrist Allen Frances has been asking recently. Frances knows a great deal about power and psychiatry. Indeed, The New York Times once called him “perhaps the most powerful psychiatrist in America35.” That was in 1994, when Frances, who then headed the psychiatry department at Duke University School of Medicine, was chair of the DSM-IV task force, the APA committee responsible for that revision. He’s retired now, and not as powerful, but he’s a lot more famous, mostly because he has spent the last four years waging a scorched-earth campaign against his successors, largely on the grounds that they are abusing their power. He’s warned anyone who will listen that the DSM-5 will turn even more of our suffering into mental illness and, in turn, into grist for the pharmaceutical mill.

  Frances is seventy years old, a big, swarthy man with a prominent brow set off by a shock of white hair. I once heard a bartender tell him he looked like a cross between Cary Grant and Spencer Tr
acy. The bartender may have been flirting or fishing for a bigger tip, but he had one thing right: Frances, like those stars, exudes charm and authority in equal measure. He’s soft-spoken, his voice high and reedy, and his patter is compulsively self-effacing, but like certain dangerous animals, he’s unpredictable, and always ready to spring.

  I hadn’t known Frances for very long before he said something to me that he came to regret. It was just before dawn on a morning in August 2010. He’d finished his workout and cracked open his first Diet Coke of the day in the kitchen of the California home he shares with his psychiatrist wife, Donna Manning. The jihad Frances had launched against his former colleagues had made him appealing to magazines like Wired, which had sent me to get the skinny on this loyalist denouncing the new regime. Since I’d arrived the day before, he’d been giving it to me, volubly and forcefully; and now we returned to one of the recurring themes of yesterday’s conversation: the way the DSM seemed to grant psychiatrists dominion over the entire landscape of mental suffering, a perch from which they could proclaim as a mental disorder any aberration they could describe systematically. I asked him whether he thought a good definition of mental disorder would establish the bright boundary that would sort the sick from the unusual, and thus keep psychiatry in its proper place.

  “Here’s the problem36,” Frances said. “There is no definition of a mental disorder.”

  I mentioned that that hadn’t stopped him from putting one into the DSM-IV, or the people who were then making the DSM-5 from fiddling with it.

  “And it’s bullshit,” he said. “I mean you can’t define it.”

  This was the comment that Frances would come to regret—or at least, when it appeared in the lead of the Wired article37, to regret having said to me. He soon found himself explaining it—to other writers, to his mildly titillated grandchildren, to attorneys who used it to discredit his testimony as a forensic expert, and, worst of all from his point of view, to Scientologists and other opponents of psychiatry who used it to draft Frances into their cause. Frances never quite blamed me for having turned his words into aid and comfort to the enemy. But even so, he was pretty sore about it, especially, he said, because my use of his words might encourage mentally ill people to go off their medications. I had turned him into my Charlie McCarthy, he complained—not by putting words in his mouth, but by throwing my tone into his voice.

  I’m sure Frances would have used a different phrase if he’d thought about it. He didn’t intend to dismiss the diagnostic enterprise, let alone all of psychiatry, but rather to say only that it is impossible to find that bright line and probably not worth the bother, that a good clinician can be trusted to determine significance and then, with the help of a decent diagnostic manual, figure out which disorder to diagnose and get on with the treatment. He was shooting from the hip, and even though I don’t regret reporting his comment, I can see why he wishes I hadn’t.

  On the other hand, metaphors often have significance beyond their author’s intent, although, as Freud pointed out, sometimes analysis is required to ferret it out. Fortunately for us, there is a philosopher of bullshit. His name is Harry Frankfurt, and he’s taught at Yale and Princeton, and in 2005 he published a tiny gem of a book called On Bullshit. “Bullshit is unavoidable38 whenever circumstances require someone to talk without knowing what he is talking about,” writes Frankfurt. “Thus the production of bullshit is stimulated whenever a person’s obligations or opportunities to speak about some topic exceed his knowledge of the facts relevant to that topic.” Filling in the gap between opportunity and knowledge requires the bullshitter to stand “neither on the side of the true39 nor on the side of the false,” he adds. “His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says.”

  For the last fifteen years, some of the smartest psychiatrists in the world, people who have studied diagnosis for their entire careers, people motivated, at least in part, by the desire to relieve suffering, have worked longer and harder, and taken more fire, than they ever expected as they revised the DSM-IV. But if you ask any one of them (and I have asked many) about the DSM’s diagnoses and criteria—new and old—he or she will tell you they are only “fictive placeholders” or “useful constructs,” the best the profession can do with the knowledge and tools at hand. They are fully aware, in other words, that their opportunity (although they may call it an obligation) to name and describe our psychological suffering far exceeds their knowledge. They have intentionally, if unhappily, stood on the side of neither the true nor the false, and for the sixty years since the first DSM was published, they have gotten away with it.

  I don’t mean to say that the DSM is nothing more than bullshit, or that the APA is merely trying to hoodwink us in order to maintain its franchise or make a buck (or a hundred million of them, which is what the DSM-IV has earned it). That would be as glib as tarring the entire diagnostic enterprise with Dr. Cartwright’s brush. And as uninteresting: finding bullshit in a professional guild’s attempt to strengthen its market position would be no more remarkable than discovering gambling in Casablanca. But what are neither glib nor uninteresting are the circumstances that make it necessary and possible for the 150 men and women on the DSM-5 task force and work groups to have it both ways, to manufacture fiction and yet act as if it were fact. If the story of the DSM-5 has any redeeming value, if it is more than a story about parochial disputes and internecine warfare, it is that it can reveal the conditions that motivate the publication of the DSM and the interests that another revision serves.

  Some of those circumstances are straightforward enough, and depressingly banal. If fully 10 percent of your guild’s revenue, and an uncountable amount of your authority, depend on a single book, a book that once saved your profession from oblivion and since then has brought it fabulous riches, you don’t give it up easily. But other circumstances are less obvious and more dangerous, and the idea that gives psychiatry the power to name our pain in the first place—that the mind can be treated like the body, that it is no more or less than what the brain does, that it can be carved at its joints like a diseased liver—is perhaps the most important of all. It reflects what is best about us: our desire to understand ourselves and one another, to use knowledge to relieve suffering, even if it results in a kind of reductionism that insults our sense of ourselves as unfathomably complex and even transcendent creatures. It also reflects what is worst—the desire to control, to manipulate, to turn others’ vulnerabilities to our advantage. The first impulse demands a search for truth at all costs. The second makes it imperative to get away with whatever you can in order to exploit a market opportunity. When those impulses collide, commerce—and often bullshit—will prevail.

  Chapter 2

  Allen Frances is not the first psychiatrist to draw a bead on his profession’s inability to distinguish between illness and health. Neither is he the first to worry about the effects of this uncertainty on public confidence in his profession. The two concerns have gone hand in hand since at least 1917, when Thomas Salmon gave a talk in Buffalo, New York, to the American Medico-Psychological Association (the new name for the Association of Superintendents, which would later be renamed the American Psychiatric Association).

  “The present classification of mental diseases is chaotic1,” Salmon told his colleagues. “This condition of affairs discredits the science of psychiatry and reflects unfavorably upon our association.” He proposed a solution: a classification of twenty different mental diseases “that would meet the scientific demands of the day.”

  Although his organization was already seventy years old, Salmon’s list was one of the first proposals for a psychiatric nosology, or classification of diseases. Earlier psychiatrists had kept track of their patients, but their concerns ran much more to the statistical than to the diagnostic. In part, this was because they were making their count a
t the behest of the Census Bureau, which, starting in 1840, had wanted to know just how many people were “insane,” but not which forms of insanity they had. When those numbers increased dramatically throughout the mid–nineteenth century—especially in neighborhoods where new asylums had been built—their explanations were more sociological than physiological or psychological. “It cannot be supposed2 that so many people were suddenly attacked with insanity when these establishments were opened or enlarged,” said Massachusetts doctor Edward Jarvis, head of his state’s Commission on Lunacy. Rather, he explained, “the more the means of healing are provided and made known to the people, the more they are moved to intrust [sic] their mentally disordered friends to their care.” Supply, at least when it came to mental hospitals, could create demand.

  But what had driven these recently discovered patients insane in the first place? “Within the last fifty years3, there has unquestionably been a very great real increase of the malady [insanity] in the progress of the world from the savage to the civilized state.” Not that “these two great facts, the development of mental disorder and the growth of human culture, stand as cause and effect,” he added quickly. But then again, Jarvis was more than just saying. There were two types of causes of insanity—physical (as in “palsy, epilepsy, fever, and blows on the head”) and moral, “those which first affect the mind and the emotions.” This second type of cause was surely on the increase, a by-product of all that progress and the brave new world it had ushered in.