This Is Running for Your Life

by Michelle Orange

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  Of special interest to the state’s Department of Business, Economic Development, and Tourism are your intentions toward the Hawaii Convention Center. Over its four-year construction, begun in 1994, two hundred dollars were spent for every one of its million square feet. The idea, tourism-wise, was that if large institutional bodies held their conferences in paradise, conference-goers might pad out their stay to make the trip worthwhile. State-owned and privately operated, the Hawaii Convention Center is a meringue-tufted monolith about a mile from the Waikiki shore in Honolulu, and for five days in the spring of 2011 it was reserved to host the American Psychiatric Association’s annual conference.

  Officially I was press. Having requested a pass, I was told, after peeling a teal-blue tote bag off a shawarma-like pile of them in the general registration hall, that I had complete access to the symposiums, sessions, seminars, keynotes, and classes that began at six every morning. I felt a little sheepish about this: APA members paid hundreds of dollars for the privilege I was granted with an e-mail. My press badge was an index card printed with my name and slipped into a clear plastic sleeve bound by a thin nylon string. It hung, ignored, around my neck over five days of wandering into general and registered events. Second-tier film festivals run with Pentagon-grade clearances by comparison.

  Unlike, say, the bunkered labyrinth in Austin, Texas, Honolulu’s convention center is filled with light and open air. A warm, saline breeze wends through its wide-slung corridors. The word is pleasant, which is about as excited as it’s possible to get over a convention center. Turning through the halls the afternoon before opening day, as the APA constituency began to file in and form migratory patterns, it seemed a safe and secluded enough place to air out what was festering in our darkest closets back home. As sedentary-workforce members go, psychiatrists have a specifically underutilized look. Moving as a thin, toneless herd through the building’s ceramic-tiled, multitiered savanna, they took on an antelope-like vulnerability: the greater their number, the more defenseless they appeared.

  The APA, a body still adjusting to its own tremendous and unforeseen influence, had come to Honolulu to reveal the shifting outline of its signal creation, the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM. Over its sixty-year history the manual has charted our changing relationship to what is considered normal—socially and individually, emotionally and behaviorally. That its value as a historical document has threatened to outweigh its practical use—helping doctors help patients by identifying and diagnosing their mental illnesses—places the DSM very much in the psychiatric tradition.

  There has always been a conspicuous connection between a culture’s shortcomings and prevailing self-interests and what it defines as crazy. In seventeenth-century Europe the first pangs of globalization seemed to manifest in a Swiss doctor’s diagnosis of nostalgia—Greek for “homesickness”—in students and soldiers who experienced crippling melancholy after time spent far from home. In the mid-1800s, an American doctor named Samuel Cartwright proposed that runaway slaves were suffering from something called drapetomania. “Normal” blacks, Cartwright argued, displayed a childlike love of their masters, and the urge for freedom was “as much a disease of the mind as any other species of mental alienation.”

  The publication of the first DSM in 1952 promoted a new and central scientific order in the taxonomy of mental illness; Joe Doctor could no longer go around fashioning Greek fragments into words and calling them diseases. But consensus didn’t necessarily equate progress: the first DSM classified homosexuality as a mental disorder, as did the second. If the evidence of overt social biases has eased somewhat, the power of putting a name to something inconvenient, uncomfortable, or plainly fraught and calling it a sickness has only intensified in the decades since the DSM was forced to expunge its homosexuality diagnosis. The decline of rigid social roles and rituals reopened the question of what it means to be normal just as the idea of better living through science and technology took seed. If you were looking for answers about what was wrong with you or how to realize some ideal self—and it seemed many of us were—psychiatry was more than happy to oblige, and with the benefit of a shiny new scientific veneer.

  To the extent that a belief in self-direction and personal freedom stands in rejection of collectively defined limitations, inflation of the one equals shrinkage of the other. The less willing we were to acknowledge limits, however—starting with death and working backward—the more desperately we seemed to pursue a sense of them, directly or indirectly, as individuals. The APA’s role in public health is both an example and a reflection of the paradox of personal satisfaction, where the refusal of limits pretty much ensures you will be bound by them in some defining and highly screwed-up way. By the time of the publication of DSM-IV, in 1994, the number of diagnosable disorders had tripled, indicating a rate of about five new mental illnesses a year since they started keeping count.

  The APA has gone by several names over its 167-year history, including the American Medico-Psychological Association, and before that the Association of Medical Superintendents of American Institutions for the Insane. In 1840, shortly before the APA formed under the latter name, a first attempt was made to try to count the number of insane people populating the United States, as part of the census sometimes cited as the origin of the DSM. Statistics, quite fashionable in the mid-nineteenth century, were promoted as a clearer, less biased—that is to say, less political—resource in developing social policy. The 1840 census’s methods were crude and tied largely to mental institutions, and the results were used to demonstrate successful rehabilitation rather than inform diagnosis or classification. At that time, the treatment for insanity reflected a belief in the connection between a rising rate of mental illness and a rapidly modernizing society. Remove the patient from a frenetic environment, the theory went, and her craziness would clear right up.

  Despite endorsing the idea that modern life made people nuts, Edward Jarvis, a psychiatrist involved in guiding and interpreting the census-derived statistics over the next several decades, argued that the fact that mental health facilities were filling up as fast as they could build them didn’t necessarily reflect an increasingly deranged population. Jarvis believed that an easing of the social stigma attached to mental illness and the rise in transportation and availability of treatment indicated that the troubled were now more willing to look into treatment.

  Working backward in pursuit of causality, Jarvis used statistics to speculate about the connection between mental illness and everything from education to sex, race, geography, and marital status. Using data derived from already institutionalized patients, the 1880 census identified seven types of insanity: simple, epileptic, paralytic, senile dementia, organic dementia, idiocy, and cretinism. Where medicine’s move into germ theory meant a fever was increasingly no longer just a fever—a treatable affliction with an unknown cause—insanity was still a judgment call made case by case, and population studies remained the most reliable source of information on the when, where, and why of going mad.

  Early in the twentieth century it was war—specifically the connection of circumstance to psychiatric distress—that created a need for a classification system that existed outside the extremes of institutionalization. Having staggered off the battlefields of rural Europe, boys still shy of voting age were suffering in ways previously unknown to humankind. It was a new reality, and homesickness didn’t cover it. Advanced Weaponry—poison gases, machine guns, and artillery shells—was unveiled across trenches of massive, chaotic breadth. The First World War’s seventy million soldiers had little relief from combat, incomprehensible carnage, and gruesome living conditions, and the result was psychic trauma on an unprecedented scale. The psychiatric community earned precious public trust when it moved in to join the effort to help fragile young veterans recover and reintegrate.

  Institution-based psychiatry had ghettoized its practitioners—then called alienists—and
the First World War helped expedite the shift to outpatient care and a more open role in public health. It also created a new language that continues to reverberate through the English vernacular. Shell shock lacks the romance of nostalgia or soldier’s heart—a diagnosis used to describe the severe anxiety observed in American Civil War soldiers—but it fit the times and the men, including my great-grandfather, who might rather have died in the mudflats of France than be perceived as weakened by the fight. Perhaps the most famous diagnosis to emerge from the First World War was that of Adolf Hitler, who was determined to be suffering from hysterical blindness long after the effects of a run-in with a canister of mustard gas had worn off.

  By the time of Hitler’s war, psychiatry had undergone a medical makeover. To Sigmund Freud’s dismay, psychiatry was acknowledged as a medical science in the 1920s, this being considered a strategic (and largely American-led) victory within the profession. The new influx of traumatized soldiers formed a platform for psychiatry’s reinvention in the United States, where younger doctors—many motivated by war experience—opted to enter the field. Psychiatry had stagnated between the world wars, suffering from its undifferentiated approach to diagnosis and continued focus on the institutionalized, so that the army and the navy came up with their own classification systems during World War II to treat the disorders manifesting in their troops.

  The first DSM used the armed forces classifications as a kind of cheat sheet, deviating from them only slightly and in some cases not at all. It divided mental illness into two broad categories: impaired mental function due to brain pathology, and general inability to adjust to the world due to psychiatric impairment. Inflected by psychoanalytic theory, which holds that the defining task of a human psychology is to broker between biological drives and the pressures of the external world, DSM’s military heritage also suggest a fundamental interest in the pathology of mental disturbance—its symptoms and its causes—in otherwise healthy individuals.

  As well as setting down the first official record of our collective psychiatric history, DSM-I elevated the role of diagnosis as part of the psychiatric method. As then chair of the APA’s committee on nomenclature and statistics, George Raines noted that sound diagnosis “is possible only with a nomenclature in keeping with current concepts of psychiatric illness.” Because words were ultimately all the committee had, a huge part of the challenge would simply be finding the right ones to capture the psychosocial zeitgeist. Once a set of intangible symptoms and subjective observations could be reified, in print, as a mental illness, psychiatry’s strange, self-defeating ambition to merge medical certainty with the art of personal storytelling could be pursued in earnest.

  At the end of the century that began with Freud’s vision of psychoanalysis as a form of narrative excavation only tangentially concerned with medicine, descriptive language was still the heart of psychiatric diagnosis. Its nomenclature had, however, come to reflect a more general tendency toward easily repeatable acronyms and the triple-processed language of market branding. That shift began in the mid-1970s, when psychiatry’s image problem reached critical mass. Beyond the homosexuality snafu, research had shown that the diagnostic process had reliability issues beyond what any legitimate medical practice would allow. If a patient walked into five different doctors’ offices presenting the same set of symptoms, the odds that he would walk out with five different diagnoses were intolerably high. Diagnostic patterns also seemed to be consistent with location: British doctors, for instance, tended to see manic depression where their American counterparts saw schizophrenia. Psychoanalysis had already completed a cycle of cultural acceptance and repudiation. By the 1970s, factions within that school were recording sessions and scanning transcripts for algorithmic patterns in the race to prove validity. By the time I was in university, in the late 1990s, Freud’s case history of “Dora,” the nubile hysteric, was being assigned in fiction courses and studied as an example of the unreliable narrator. Modern psychiatry sought to avoid a similar fate.

  The 1980 publication of DSM-III is widely acknowledged as a turning point for the APA. A task force led by Robert Spitzer sought to rewrite the DSM in the language of checklists and codes, eliminating theories of causation altogether and redefining diagnosis in terms of criteria, traits, and axes derived from statistical patterns and identifiable according to a clear and ostensibly less biased system of evaluation. The more binary approach was well-suited to a health- and numbers-crazed culture at home, and the new standardized formulations went international. The media was now doing much of the filtering for the public, which learned to speak OCD and ADD before it could spell the acronyms out. While psychiatrists agreed to use its labels and codes to set insurance mechanisms into motion, the new five-hundred-page manual proved too unwieldy for scrupulous use. As Allen Frances, the chair of DSM-IV, told me, “DSM is like the Bible or Origin of the Species: much discussed but little read.”

  That few of us have taken a good look at it might explain how the manual became a load-bearing pillar of the pharmaceutical industry. DSM-IV marked a new era in our understanding and treatment of mental illness, one that rewarded psychiatry’s desire to be recognized as a medical science and Big Pharma’s dream of filling the Aral Sea basin with cash. Although we have adopted the language of war to describe the nature of modern well-being—how we fight and struggle and battle with ourselves, win and lose, face demons, destruct and rebuild—the DSM’s military origins, along with their vested interest in causality, have been buried deep under half a century of proselytizing for mental health as a biomedical concern and its treatment a medical transaction.

  This new framework for understanding how we feel had rational lines but plenty of interpretive room, and a renovated psychiatric infrastructure was inlaid with its first prescription. Not even the interested parties predicted what happened next. Depression, especially, proved to be a pandemic gold mine. Since Prozac was patented in 1988, antidepressants have become the fourth-biggest-selling drug in the country. Alone in the market in the early days, Prozac sales jumped 20 percent in 1993. At its peak, Prozac outdid Eli Lilly’s projections forty-five times over, bringing in three billion dollars in a single year. Last year Americans consumed over ten billion dollars’ worth of antidepressants.

  Like every other late-twentieth-century capitalist enterprise, the mental health industry was soon in cancerous thrall to perpetual growth. Soon pharma-sponsored studies were indicating antidepressants as an effective treatment for “generalized anxiety,” “social phobia,” and all manner of compulsive disorders and substance addictions. The search for new disorders was consolidated, so that scientific studies, the illnesses they identify, and the drugs designed (or retrofitted, as the case may be; the why and how of the way antidepressants work are that rare unknown known) to treat them might debut together. After “pre-menstrual dysphoric disorder” was introduced in DSM-IV, Prozac was quickly rebranded as Sarafem and marketed to women whose severe menstrual cycles now fell under the rubric of mental illness. Billions of dollars were funneled into advertising campaigns after the Food and Drug Administration let out its already generous direct-to-consumer advertising legislation in 1997, and doctors were the targets of separate but equally extravagant marketing blitzes. Outside of New Zealand, the United States is the only country in the world that allows such advertising, and millions of Americans were diagnosed by their television sets during the evening news or an episode of Road Rules. Just ask your doctor.

  The fifth version of the DSM, in the works for over a decade, is at least a year behind its original publication schedule. After a series of delays, the APA has committed to a drop-dead of spring 2013. The psychiatric community is bitterly divided over revisions that will shape both the culture and a multibillion-dollar business. The problem is the APA claims its first allegiance is to scientific research; whatever comes of that research cannot be their concern. They shouldn’t be punished for relaying the story of who we are and what we have; is it their fault that s
tory now serves as both a holy text and a guide to surviving the world we’ve created?

  From a narrative standpoint, it’s tough to argue with that. The APA is subject to the insanity it documents—if anything, its confusions are highly symptomatic. The story and the storyteller have merged into one big book of crazy, and now we’re all mixed up in this thing together. The writers of DSM-5 have claimed that the switch from Roman to Arabic numerals reflects its status as “a living document” subject to frequent updates, like software, to five-point-one and so on. In the name of transparency, the APA opened up a comments section on its DSM-5 site, and throughout the conference the eight thousand comments logged thus far are frequently cited as valuable to a process that is described in terms of consensus and yet defined by the convolutions of soft, commercial science.

  The plight of the DSM reflects that of psychiatry’s bedeviled identity: driven toward scientific validation despite essentially humanistic aims and means, the field has come to embody the modern refusal of art and science to meet for anything but a fight to the death. If War is the only winner when two great nations seek to destroy each other, Business appears poised for victory in the battle between psychiatry’s polar interests. That they were supposed to be fighting for us seems easily forgotten.

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  Something about the Aqua Waikiki Wave, my hotel on the strip, did not agree with me. Every morning in Honolulu I woke up with marbled, swollen eyes and a body that appeared to have been baked in ruby sprinkles overnight. If this was paradise’s idea of a rejection slip, I had to admire its gothic flair. I would begin to recover human form by late afternoon, around the time I was expelled from the convention center’s great glass facade, with nowhere to go but back to my mysterious allergen chamber, and no way to get there but through Waikiki’s gauntlet of high-end stores.