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

by Gary Greenberg

  • • •

  Maybe you’re not smart or sophisticated enough to understand this argument, either. Maybe you think Mirin and Regier were just trying to have it both ways. You might then suggest that those prevalence numbers were still a little fishy. You might wonder out loud what would happen if 25 or 30 percent of the population exceeded the standard glucose or blood pressure thresholds, but only 19 percent of that group—about 5 percent of the population—ever got sick enough to even show up at their doctor’s office. You might then ask what exactly those numbers added up to, whether they measured disease at all, and if the whole idea of hypertension or type 2 diabetes had been created by an industry too interested in selling treatments to people who were actually healthy. You might point out that regardless of whether or not they are diseases in themselves or only risk factors, blood pressure and glucose levels can at least be measured with a high degree of certainty. And you might raise the question of whether or not it’s really fair to compare conditions such as high glucose and blood pressure to mental illnesses, whether or not telling a patient he has hypertension for which he should take diuretics is really the same kind of intervention as telling him he has a chemical imbalance that antidepressants will correct.

  Darrel Regier would have an answer for some of those questions. You think those numbers are high? Well, he would tell you, or at least he told me, you should see the Midtown Manhattan Study17. Regier started his training with the people who ran that project, which began in 1952, took ten years to complete, and was conducted exactly where you think it was. Researchers canvassed 1,911 Manhattanites and concluded, according to Regier, that 85 percent of the population had a mental illness.

  When Regier graduated from Indiana University’s medical school in 1970, the Midtown Manhattan Study still constituted the standard epidemiology of mental illness. “I was just coming out of a residency where I was seeing really sick patients,” he said, “and I’m saying to myself, ‘What are they talking about over here with all of these people who have an occasional symptom but are never going to go into treatment? What is normality if 85 percent have a mental illness?’”

  The Midtown Manhattan Study is a talking point for most defenders of the DSM. They cite that 85 percent number as evidence that even if the DSM is an imperfect document, and even if it catches an improbable number of people in its diagnostic net, at least it’s better than what we had in the old days. We in the mental health business call this a downward comparison, and we sometimes recommend one to our patients to help them put their problems in perspective. “Yes, it’s true your wife left you for your next-door neighbor,” you might say, “but at least your kids won’t have to commute as far as most children of divorce.” It’s usually a pretty lame intervention, as that example indicates, and to the extent that it’s successful, it’s often because you’re actually bolstering the patient’s self-esteem by pointing out that he’s better off than the next guy. Schadenfreudian therapy, you might call it.

  You can’t exactly blame psychiatrists for grasping at this straw. But some straws are flimsier than others. Take that 85 percent number, for instance. The Midtown Manhattan Study team, which was headed by sociologist Leo Srole, never said that 85 percent of its subjects were mentally ill. In fact, Srole and his colleagues hadn’t set out to diagnose New Yorkers at all. Indeed, they wrote, they didn’t want to use the DSM or any other diagnostic system because they were “designed for classifying full-blown pathology18”—and didn’t do such a good job of defining it in the first place. So rather than ask19 about symptoms of mental illnesses, they asked about childhood fears of thunder and strangers, and current attitudes toward drinking and gambling. They solicited subjects’ worries about the atom bomb and old age. They asked whether they thought people talked behind their backs or if they wondered whether “anything is worthwhile” or if they believed that “most people think a lot about sex.” They paid attention to whether the interviewees were sloppy or neat, nervous or relaxed, if they were facetious, dull, or rambling. They attempted, in other words, to capture the everyday experience of the average citizen and to determine how much psychological suffering it entailed.

  To make their assay, Srole’s team devised a six-point classification20 of symptom formation. People at the “healthy extreme” got a zero. At the next two stages were people who had “emotional disturbance without apparent constriction or disability,” and the last three ratings “span[ned] the morbidity range of the mental health spectrum.” These were the people whose symptoms had “crippling effects on the performance of . . . daily life roles”—as close to a working definition of mental illness as Srole’s team ventured.

  Like Karl Menninger and most mainstream psychiatrists and sociologists at the time, Srole and his colleagues subscribed to the Freudian notion that between the dynamics of our psyches and the demands of civilization, virtually everyone was bound to be troubled and that, as they wrote, “mental illness and mental health [differed21] in degree rather than in kind.” So when it turned out that something like 85 percent of the subjects (the actual number is 81.5 percent22) scored more than a zero, the researchers could have been no more surprised than the audience at a Woody Allen movie would be to discover that most Manhattanites are at least a little neurotic. But Srole and his team weren’t making the ridiculous claim that 85 percent of us are mentally ill. Rather, they were reporting the unremarkable finding that if you sit down with people and ask them about their emotional lives, you will find that most of them will confess to some difficulty.

  The abnormal people in this study, as in most studies, were those at the ends of the spectrum—the 15 percent who claimed to be free of psychic turmoil, and the 23.4 percent who scored in the morbid range. This latter finding, Srole noted, was a bit of a surprise. It was more than double the rate of mental illness23 found in an earlier study of Baltimoreans. But it was fully one-third less than the number of people who would, twenty-five years later, turn up as mentally ill in Regier’s ECA study, and surely nowhere near 85 percent.

  Regier knows that Srole’s study didn’t really conclude that 85 percent of its subjects were mentally ill. Indeed, he cited the 23 percent figure accurately24 in a 1978 report to a presidential commission on mental health. He also knows about the Baltimore study, and about a National Institutes of Health study conducted by his mentor, psychiatrist Michael Shepherd, which found a prevalence rate of around 15 percent. That, in fact, was the figure he used in his report to the president: on any given day, he wrote, about 15 percent of Americans were mentally ill25.

  Regier thinks Shepherd’s study is “a classic,” and the 15 percent figure “wonderful.” It’s easy to see why he didn’t lead his presentation to the Post editors with his conviction, based on a quarter century of studying the subject, that prevalence rates had been inflated by the DSM—published, remember, by the organization he was working for—or, for that matter, that the categorical approach to diagnosis didn’t reflect the reality of mental illness. He and Mirin had a guild to represent, and telling the editors that parity laws would force insurers to pay for the treatment of people who didn’t necessarily have illnesses that didn’t really exist would probably not have been the best way to do that.

  Besides, by the time they took on the Post, Mirin and Regier were already beginning to plan for the DSM-5. The book they had in mind was no mere sequel. If it worked out the way they wanted it to, it would be a DSM to end all DSMs.

  Chapter 4

  Steve Mirin took Steve Hyman’s refusal to give the APA money for a new DSM as a challenge. “Steve was putting pressure on the field to start to consider a different approach to diagnosis,” he told me. Mirin shared both Hyman’s wish to put psychiatry on a new footing and an idea about what that foundation should be. “Steve and I had an agenda,” Mirin told me. “To introduce neuroscience into diagnosis.”

  The 1990s had been, by presidential decree, the Decade of the Brain. Billions of dollars
had been spent trying to get the brain to give up its secrets. Much of that money had gone to brain scanning devices, especially the functional magnetic resonance imager (fMRI), a miracle machine that allowed scientists to glimpse the brain at work. No university research lab worth its salt lacked one, and scientists, flush with grant money, slid their subjects inside to perform innumerable tasks. They solved math problems and played video games, remembered sad times and anticipated pleasures, considered moral dilemmas, took drugs, looked at porn, and even (in France, of course) had sex. All the while, the machines whirred and clanked, recording a comprehensive account of the brain at work.

  Actually, all the machines were tracking was the movement of oxygen carried by blood through the brain, a record reassembled by computers into images colorized for greater effect. Like kids in the pee-wee league chasing a soccer ball, your blood races around your brain to sites that are becoming active, and scientists inferred from observing this movement that those areas were the parts of the brain responsible for the behavior or experience under study. And so there was an unceasing flow of news reports, accompanied by those increasingly familiar full-color fMRI images, about what the brain did when it thought no one was looking, about which area of the brain gave rise to this faculty or that thought, about the latest secret of consciousness uncovered by science.

  The enthusiasm was contagious. By the time the Decade of the Brain had ended, Nobel laureate Eric Kandel was proclaiming that “the mind is a set of operations1 carried out by the brain, much as walking is a set of operations carried out by the legs.” The fact that the pictures that seemed to prove this were only prettied-up shots of the blood rocketing around in the brain and that they left unobserved the networks that connect these lit-up areas, not to mention that they ignored the enormous philosophical questions begged by these claims—Was the brain causing the experience, or simply responding to the mind’s demand? Could mind be reduced to body? Was the whole of consciousness no more than the sum of its parts?—had disappeared in the enthusiasm of conquering what had only recently seemed to be an impenetrable terrain.

  Kandel, a psychiatrist, believed that scientists now knew enough to say something else with confidence about the mind: that “all mental disorders2 involve disorders of brain function.” He never specified what involve meant, but Thomas Insel, Hyman’s successor at NIMH, didn’t hesitate to turn this idea into something less equivocal—and less tautological. “We can think of mental disorders3 not just as brain disorders but as disorders of brain circuits,” he told psychiatrists at a conference. This equivalence meant that psychiatry would one day be transformed into “clinical neuroscience.” Psychiatrists could finally move beyond the observation of symptoms and signs, and uncover the world behind the world of mental illness, so they could finally say with authority which mental disorders exist and who has them. They would be able to leave behind the approach that was at once its salvation and its scourge: a classification of diseases based on description and observation but with no account of what caused them. And then they would be able to meet the scientific demands of the day.

  • • •

  Neuroscience was not new to psychiatrists. In the 1930s and 1940s, even as Freudian theory was coming to dominate American psychiatry, powerful biological treatments—electroshock therapy, insulin comas, and lobotomies—were convincing many doctors that the brain could be treated like any other organ in the body. Its workings were immensely complex, the biological psychiatrists allowed, but the difficulty of unraveling them was only a formidable technical challenge. There was no reason that the mysteries of consciousness could not be solved by understanding the brain. Long before the first subject slid into the first fMRI machine, at least some doctors thought it was only a matter of time before mental illness was vanquished by the same weapons that had undone pneumonia.

  Other psychiatrists were less sanguine. As early as 1917, Adolf Meyer, director of the psychiatry department at Johns Hopkins and the unofficial dean of American psychiatry, worried that biological psychiatry was a collection of “neurologizing tautologies4.” Sure, the brain was involved in consciousness and its troubles, Meyer said, but to single it out as the cause of suffering was to go beyond the existing evidence, and perhaps beyond any possible evidence. Post hoc, as the logicians say, does not mean propter hoc. That a depressed patient emerged from a shock treatment undepressed does not prove that the cause of depression was in the brain’s electrical activity. Indeed, some shock therapists in the 1930s wondered if they weren’t merely “driving the Devil out5 of our patients with Beelzebub.”

  The doctors’ assertion that they had found the source of mental illness was based on deduction; they had to assume that the brain was the causal agent in order to conclude that mental illness was an effect. They also had to assume that the neurological dysfunction, whatever it was, was both the necessary and the sufficient condition for the psychological problem. Brain-based psychiatry was in this respect no less tautological than symptom-based psychiatry, the brain’s role as a causal agent more myth than science. Scientists and laypeople alike, Meyer warned, should approach these findings with caution.

  But it was hard to argue with the biological psychiatrists6 when their schizophrenic patients awoke from insulin-induced comas coherent and rational (if only temporarily) or when their shock machines roused depressed people from their torpor. It was even harder to argue with the doctors who in the early 1950s experimented on themselves and lab animals with LSD, discovered that the drug was closely related to a recently discovered brain chemical—serotonin—and, based on the profound alterations of consciousness the drug induced, concluded that the brain conducted its business in an electrochemical currency. Most persuasive of all, however, was the serendipitous discovery of drugs that seemed to target specific mental illnesses, presumably by targeting those chemicals—Thorazine for schizophrenia, for instance, and imipramine for depression. These developments were all accidental, and scientists could not fully explain any of them, but even so, they could not help but reinforce the idea that mental illnesses existed in nature, specifically in the brain, and that they were not unlike infectious diseases—the result of a biochemical process that could be found and turned into a target for one of medicine’s magic bullets.

  By the mid-1960s, biological psychiatrists thought they were zeroing in on the process in question: deficiencies or surpluses in the chemicals known as neurotransmitters. In 1965, Joseph Schildkraut, a National Institutes of Health scientist, claimed to have reverse-engineered antidepressants and found that they worked by increasing levels of dopamine and adrenaline in the brain; depression, he announced, must be the result7 of deficiencies in those two neurotransmitters. Within a decade, however, scientists had determined that Schildkraut was wrong, and they settled on another possibility, their old friend serotonin. What seemed never to be in doubt as the doctors rushed from theory to theory was the idea that one brain chemical or another was the cause of mental suffering, just as one bacterium or another must be the cause of infection.

  By the early 1990s, millions were taking Prozac for their serotonin deficiencies. Biological psychiatry had established a foothold deep in the popular and professional culture. Our everyday understanding of ourselves now included the idea that we are neurotransmitter-powered thinking and feeling machines. All that was left was to figure out the particulars.

  But these details were especially devilish. By the time Mirin and Hyman began dreaming of a DSM-5, near the end of the Decade of the Brain, there was still not one biological test for a DSM disorder. The idea that a lack of serotonin caused depression had been abandoned for lack of evidence (and for contradictory findings) almost as quickly as it arose, except in doctors’ offices, where it proved immensely useful to physicians trying to persuade reluctant patients to take their drugs. The attempt to find the genetic underpinnings of mental disorders had also been frustrated.

  In part, of course, the failure to find
the pathological anatomy of psychological suffering could be blamed on the complexity of our neurochemistry and genetic architecture, especially when it came to the brain. But Hyman thought there was an additional problem. “The gold standard was the DSM criteria8,” he told me. “It struck me as a fool’s errand to try to develop a biomarker for a fictive category.” The lack of molecular evidence only reinforced what doctors like Mirin and Hyman already knew—that the DSM-III’s nosology only looked scientific, that the empire of psychiatry was still built on air.

  • • •

  In 2002, the APA officially announced that Spitzer’s mutt had had its day. In A Research Agenda for DSM-V, a book that kicked off the official revision effort, the APA acknowledged that the reification of the DSM-IV’s categories, “to the point that they are considered9 to be the equivalent of diseases,” had most likely “hindered research.” Nor was “research exclusively focused on refining the DSM-defined syndromes [likely to] be successful in uncovering their underlying etiologies.” Searching for the causes of the illnesses listed in the DSM was proving to be not unlike a drunk looking for his car keys under a streetlight even if that’s not where he dropped them. Scientists were unlikely to find the causes of Generalized Anxiety Disorder or Major Depressive Disorder or any of the other DSM categories—as descriptive psychiatrists had been promising to do since Kraepelin—because it increasingly seemed unlikely that they really were the equivalent of diseases.

  So the APA did what organizations everywhere do when they find themselves flummoxed. They convened a committee. To be exact, they convened thirteen committees that, beginning in 2004, held a series of “planning conferences” at APA headquarters. Because the conferences were explicitly devoted to finding that new paradigm—which, according to the Research Agenda, was “yet unknown10”—the NIMH helped pay for them.