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

by Gary Greenberg

  The good news was that I hadn’t ever committed the old criteria to memory, so at least I wouldn’t have to unlearn them. I was, however, going to have to get accustomed to using criteria to make the diagnosis in the first place. That’s not something anyone I know in this business actually does. Mostly we’re content to find a label that matches people in some vague way and then get on with the business of helping them figure out what’s going on in their lives that landed them in our offices.

  There are exceptions, of course. Take the psychiatrist I will call Dr. Benway. He’s a respected practitioner in my neighborhood to whom I had referred a young woman I’ll call Charlotte. She was thirty-two years old, the daughter of Chinese immigrants, and recently divorced. I’d been seeing her for a little more than a year, and she had just begun to talk about the way her father used to crawl into bed with her and, as the rest of the family slept, force her to have sex with him. She hadn’t told anyone about this before, and she was unraveling in the way people often do when they start to take apart the finely built edifice behind which they’ve hidden their shame and fear and rage. Charlotte was also in the midst of a huge project at work, one that she needed to complete if she was going to keep her job. So it was not a good time for her to be anxious all day and sleepless at night. She had asked me if I could help her get a prescription for Valium from someone other than her family doctor, to whom she did not want to have to explain herself, and that’s where Dr. Benway got involved.

  Returning to me after her visit, she told me that he had given her an antidepressant and a mood stabilizer for her depression and suggested that she try a stimulant for her ADHD; he told her they would explore that possibility more when she returned to him the following week. “Do you think I have ADHD?” she asked.

  I told her I did not think she met the criteria.

  “Then why would he say that?” she asked. “And why did he prescribe Zoloft and Abilify? Do you think I have depression?” She told me about the psychological tests she’d filled out as part of her paperwork for Dr. Benway, the ones that asked her about different thoughts and feelings she’d had over the last weeks or month. Then she asked, “What is my diagnosis anyway?”

  I tried the therapist’s usual evasions, asking her why she wanted to know and what it meant to her to have her professional parent figures disagreeing about her and what it was like for her to think her therapist didn’t know what he was talking about. But she wouldn’t be dissuaded. This was the first time Charlotte had ever been demanding in this way—direct and forthright and confident—and even if it was a demand I was poorly equipped to meet, I felt that I had to meet it. So I fessed up.

  “You don’t have one,” I said.

  “Why not?”

  I explained that therapy, not unlike medication, was really targeted at symptoms, not illnesses, and to the extent that we were surely trying to get at what lay underneath the symptoms, the DSM’s labels and criteria were not particularly helpful toward that goal, that they renamed her suffering without explaining it.

  I didn’t tell Charlotte I’d stolen that line from William James. I also didn’t tell her the other reason I hadn’t given her a diagnosis. But I did tell Dr. Benway, because when I called him (to pester him on her behalf to prescribe the Valium so she could sleep, and maybe to chide him for the cocktail he’d mixed for her), the first thing he asked was what her diagnosis was.

  “She doesn’t use insurance,” I said. “So she doesn’t have one.”

  This could have been Dr. Benway’s moment to go Gregory House on me, to reveal the sign I had missed and the diagnosis it led to, to question how I could possibly treat someone in the absence of a diagnosis. He didn’t do any of this, however. I’m not sure why. It may be because our clinician communication—about Charlotte’s current functioning, her anxiety, her insomnia and difficulty concentrating, her mood swings—didn’t seem hampered by the fact that we weren’t using the language scientifically proven to make our conversation reliable. It may be because when he explained the cocktail he’d prescribed—the way the Abilify/Zoloft combo could “put a floor under her” without agitating her and how adding Ritalin to the mix might just get her neurotransmitters all nicely balanced—I didn’t point out to him that his opportunity to medicate Charlotte exceeded anyone’s knowledge about any of that. Truce, standoff, going along to get along: Dr. Benway’s silence about my diagnostic negligence and mine about his diagnostic exuberance could have been any of those. But somehow I think it might be something else entirely—that we both knew the truth of what I had said: In the absence of an incentive, who would bother with a diagnosis?

  • • •

  But now that I am a Collaborating Investigator, perhaps I should consider giving Charlotte a diagnosis. The DSM-5 with which I am supposed to familiarize myself offers all sorts of possibilities. GAD, for example, with its markeds and excessives providing all kinds of wiggle room for the insurance-dependent, is, despite its many changes, an obvious choice. Major Depressive Disorder has been left mostly alone (other than the absence of the bereavement exclusion, and, no matter what the new criteria said, if presented with a grieving patient, I’m going to pretend to be astute and not add the insult of a diagnosis to the injury of a bereavement), and if Charlotte doesn’t reach its five-of-nine threshold, there is always what has been called Dysthymia in DSM-IV and what the DSM-5 proposes to call Chronic Depression, a two-of-six offering. Adjustment Disorder with Mixed Anxiety and Depressed Mood calls for no more than six months to elapse between the psychosocial stressor to which the patient is adjusting poorly and the onset of symptoms, but if I decide that the stressor is Charlotte’s disclosure of the incest and not the incest itself, then that diagnosis would work just fine.

  But there’s another possibility in the DSM, one that doesn’t ask me to look for the symptoms of ersatz diseases, but to pay attention to what Charlotte actually brings into my office: herself. Because Charlotte may be anxious and depressed and failing to adjust, but she is also the kind of person who arrives late for her appointment and then, as the clock approaches the end of her time, says, “You’re not going to throw me out of here now, are you?”

  I tell her that we have to stop at the usual time, regardless of when we started. “Why does that feel like being thrown out?” I ask her.

  “I can’t believe it. I killed myself to get here on time. Really, almost. I drove like eighty miles an hour. I can’t help it if the traffic was bad,” she says. “And anyway, what’s so important that you have to do?”

  I don’t answer.

  Her voice rises. “You don’t care about me, any more than a whore cares about a john,” she says. “And why would you? This is just your job. But why would anyone listen to me if it wasn’t their job? Look at me.” She sweeps her hand along her body, like a salesman demonstrating his product. “I’m fat and ugly and disgusting.” (She is actually trim and pretty, but this isn’t the moment to tell her that.) She has been fiddling with her hair the whole session, but now she’s tearing at it with such force that I can hear it ripping from her scalp and see strands falling onto the couch. “And you just pretend, and you’re not very good at it. You can’t wait to get rid of me.”

  Which, at that moment, you wouldn’t blame me for saying, is sort of true.

  That’s how Charlotte wants me to feel: like she feels, unloved and uncertain of herself and the others around her. And now that she’s landed her blow, she’s pulling even more frantically at her hair. “Okay, I get it. I’ll go,” she says. “And you don’t want me to come back, do you?” She rummages angrily in her purse, pulls out her checkbook, scrawls the check. But she is not only rebuking me. She’s also imploring me to assure her that her outburst hasn’t made me want to kick her out or punish her for being mean. Having made herself unlikable, she’s waiting for me to tell her that I like her.

  Now, I might not go that far, but on the other hand, I didn’t kick he
r out of therapy. I’ll take a lot. Not because I’m a saint, but because this is what she is paying for: not indulgence exactly, but acceptance, the peculiar kind of love conveyed when I stand back from the action and participate in it at the same time, when I watch Charlotte flail and let her land her blows and respond to the pain she inflicts without taking it personally. And what I’m seeing when Charlotte is launching her attacks on both of us is not a disease. Neither is it an assortment of symptoms. It’s who she is, her character, forged out of the crucible of the family, that strange little enclave where we raise our young, each on our own, behind closed doors or in homes where, if you were lucky, there were the resources and the courage and the love that it takes to send a person into the world more or less intact, but if you were not lucky, if your parents were like Charlotte’s, so distracted by the exigencies of life in a strange new country, or so adept at ignoring what they could not afford to acknowledge, that a father could see his daughter as a sexual object and a mother could turn a blind eye—a lapse made even more unlikely, and yet somehow more inevitable, by the fact that the mother and her mother’s mother, as Charlotte found out recently, also grew up in incestuous families—if all those stars lined up and crossed you, then you too might have come to think that the disgusting thing that was happening was happening because you were disgusting, so disgusting that no one would care what was being done to you, you too might have figured that the best you could do was to shut up and take your lumps, and you too might have been seething all the time you were submitting. You might have been left desperate for love, and sure that you’d found it, until one little thing—an encounter with the tyranny of the therapist’s clock, his exercise of power over you, his disregard for your wishes—leaves you raging and unable to do anything but pour out the rage in a way that gets you rejected, unable to stop yourself, even as you watch yourself tumble, for maybe the millionth time, through that trap door in yourself and land in your own self-hatred.

  Or you could be like the man whom Charlotte had married—Joe, I’ll call him. I met the two of them together when they came to see me about two years before the conversation I just described took place. Actually, they weren’t supposed to see me as a couple. Joe—eight years older, tall, good-looking, a wealthy businessman who wore his success on his monogrammed, gold-cuff-linked sleeve—had been referred by his lawyer, who thought it would look good to the judge if he was in counseling when his case came up. Of course, the lawyer didn’t put it that way. He just said something like “This guy could really use to be seen, if you follow my logic.”

  It was hard to argue with that. Joe had been arrested after he’d punched a parking lot attendant in the face. He thought the worker had shown insufficient respect when he’d told Joe he couldn’t park where he wanted to. “Like it really mattered. Fucking moron!” Joe told me soon after he sat down, and before I’d had a chance to ask about the incident.

  “That’s why you coldcocked him?” I asked. “Because he was a moron? Or just because he told you what to do?”

  “Look, the space was empty. If he had bothered to think about it, if he wasn’t just going by some other stupid fuck’s stupid rules, then he would not have been hassling me,” he said. “It’s what’s ruining the country, the way people just follow rules without thinking, without figuring out if they should make an exception.”

  “And he should have made an exception for you?”

  “Of course he should have. I could have fit my car in there without any trouble. I know how to drive, for chrissakes. Any swinging dick can get into a car and step on the gas. But I’ve been trained. I did one of those week-long courses for Mercedes owners.”

  Five minutes with this guy and I was already hating him. I changed the subject.

  “Whose idea was it for Charlotte to come today?” I’d been surprised to discover her in the waiting room, the two of them perfectly dressed and groomed, flipping through back issues of Home & Garden. I was even more surprised when she followed him into my office.

  “Both of us,” Joe said.

  “But you didn’t tell me you wanted to bring your wife with you when you made the appointment.”

  “Why? Is that a rule of yours?”

  I guess I hadn’t changed the subject after all.

  After I didn’t answer, Charlotte spoke up. “Actually, it was my idea to come. Joe was so upset about getting arrested and all, and then it got worse when he heard he had to come here. I thought there were certain things you needed to know, because you’d get totally the wrong idea if all you knew was that he’d punched some random dude. I thought you needed to know that Joe is a special guy, and how well he can treat people.” She put her hand on his knee.

  “Don’t you think Joe can speak for himself?” I asked.

  “Of course I can,” he said. “But I thought you would need proof that I wasn’t that kind of man.”

  “Okay, well, it is a rule of mine. Not that spouses can’t be here, but that if you are here as a couple, then we’re going to be talking about your marriage or something like that. A joint business, a problem with your kid, a disagreement about your in-laws, or that you just can’t get along. But not as a character witness. My understanding,” I said to Charlotte, “is that Joe is here because he’s had this fight and this arrest,” and then I turned to Joe to say, “My guess is that this isn’t the first time someone who failed to appreciate you took it on the chin, Joe.”

  “So what are you saying?”

  “That if what you want to do is to figure out why this kind of thing happens to you, other than the fact that everyone else in the world is a moron, and what you can do about it besides punch their lights out, or why you are so afraid that everyone is going to dislike you, then I’m your guy. But if what you want is for me to help you or your lawyer win a case, or to make you feel like you deserve to be able to assault people, then I’m not. Because I’m sure there are reasons you feel that way, but I don’t think you deserve that.”

  Joe stared at me for a second, probably the same way he stared at the kid in the parking lot. He stood up, pulled a money clip out of his pocket, tore off a hundred-dollar bill, and dropped it on my desk. “This ought to cover it,” he said. “I’ll tell my lawyer to find someone who can help.” Without a word, Charlotte stood up, too, and the two of them breezed out of my office. I can’t say I was sorry to see them go.

  When she called me about a year later to tell me Joe had left her for a twenty-two-year-old woman and she needed to see me (“Because you were right,” she said. “You nailed what an asshole he was”), Charlotte was in the kind of agony that goes along with being a self, with having no choice but to be at the center of your world, and of finding nothing there but fear and self-loathing. But even as she began to get over Joe, and to understand that there is only the slightest difference between fitting another person like a hand fits a glove and sharing a pair of handcuffs, the anxiety and depression didn’t go away. They seemed less and less related to what had happened with Joe, more like the inevitable if regrettable outgrowth of who she was.

  So I could diagnose her with GAD or MDD—she more or less fit those criteria—just as I could have diagnosed Joe, had he stuck around, with Intermittent Explosive Disorder, for he was surely a walking IED. But diagnoses like these don’t quite seem to do Charlotte or Joe justice, especially not when it seems so clear that what they suffered from wasn’t anything like the kind of illness that comes and goes like the common cold, or comes and stays like diabetes. Troubles such as theirs seem to arise out of their troubled selves. And as it happens, there is an entire section in the DSM devoted to describing those troubles, which the book calls personality disorders and defines this way:

  A Personality Disorder is an enduring pattern8 of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over tim
e, and leads to distress or impairment.

  The ten personality disorders listed in the DSM come last in the book. They also have their own diagnostic duchy, known as Axis II (as opposed to Axis I, where the rest of the disorders reside). This segregation, the book explains, “ensures that consideration will be given9 to the possible presence of Personality Disorders . . . that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders.” But I think the real reason lies in a more fundamental difference between the two axes. An Axis I disorder is what you have. An Axis II disorder is what you are. (Personality disorders share Axis II with mental retardation.)

  Despite this crucial difference, personality disorders look like the other disorders in the DSM. Borderline Personality Disorder (BPD), for instance, the diagnosis Charlotte would qualify for, is a five-of-nine affair, with criteria like “frantic efforts to avoid real or imagined abandonment” and “markedly and persistently unstable self-image or sense of self.” Narcissistic Personality Disorder (NPD), another five-of-niner (including “grandiose sense of self-importance,” “sense of entitlement,” and need for “excessive admiration”), matches Joe pretty well. (And it’s not at all rare to find a borderline married to a narcissist.) But you can’t miss the Freudian echoes in these disorders. Borderline refers to the border between neurosis and psychosis, and narcissistic is a nod to Freud’s observation that some people treat the world as a mirror that they must shatter when they don’t like what it reflects.