In general these stores sold prohibitively expensive versions of what could be had on the cheap two blocks away, on Kuhio. Long, floral dresses and thin, sequined tops, mostly, themselves selling the ineffable stink of quality and the ersatz rewards of retail piety. Every evening, as I made my doleful way down Kalakaua Avenue, I considered whether I had acquired the need for its wares since passing them by the previous day. Every evening the answer was: Possibly. Let’s see.
Along with Sephora and Prada and Bottega Veneta, there is a Macy’s department store. Straddling the sidewalk in front of Macy’s, a sandwich board flanked by two whiskery men advertises the Hawaii Gun Club. Their sign says SHOOT REAL GUNS. Their sketchy, lupine look says, “I shoot real guns.” From a block’s distance they’re a Hells Angels mirage in the midst of a flip-floppy tourist frenzy. An olfactory berth had formed around them despite the heavy flow of shoppers. Upon first sighting, I cut in close in the hopes of a hard sell, or at least the handoff of some literature. But the one was absorbed by the other’s private ranting as I passed. This is all I could make out: “Five, six years old—and in fucking therapy!”
That morning, my first at the conference, I had decided to attend a three-hour session called “Mood Disorders Across the Lifespan: Implications for DSM-5.” A ballroom designed to hold hundreds of people was tipping toward capacity when I shuffled in a few minutes late. The conference’s program was packed with workshops and lectures with names like “Cluster B Personality Disorders and the Neo-Noir Femme Fatale,” “Spies and Lies: Cold War Psychiatry and the CIA,” “Faith and Resilience: Carl Dreyer’s The Passion of Joan of Arc,” and, perhaps most beguiling, “Children of Psychiatrists.”
Those and several military PTSD research sessions were taking place that morning alone. The choice was an object lesson in the modern difficulty of making even the most trivial commitments. All through the afternoon’s discourse on the difference between bereavement and depression (there will be no difference, according to DSM-5), dismantling the connection between self-cutting and suicide (the former will no longer be a criterion for a borderline-personality diagnosis and may graduate to becoming its own disorder), a new mood disorder called late-life depression (they have little data about the unique presentation of major depression later in life, but will try to do better in coming years), and a danger to clinical practitioners called “the fallacy of misplaced empathy” (i.e., relating to a grieving patient instead of diagnosing her with depression), I felt the conference-goer’s remorse flowing strong. Are they having a better time over in “Adult Sexual Love and Infidelity”?
The DSM-5 task force—a group of about two dozen psychiatrists, academics, neuroscientists, and researchers—chose early on to define their work against DSM-IV, which meant that those associated with its writing were relegated to the sidelines of the conference and often to another site entirely, where a shadow conference made up of DSM-5 rejects was taking shape. The new guard was in full effect for the mood-disorders session, which began at the beginning: a psychologist named Ellen Frank’s discussion of “stressors in early life.”
Each presentation opened with the same PowerPoint slides identifying the speaker and his or her conflict-of-interest disclosures. No one had current drug company ties, if only because they were required to sever them in anticipation of moments like this. Frank focused on the changes being proposed to the criteria for bipolar disorder in children. In thirty years, she said, she has never treated a patient who met all of the diagnostic criteria for bipolar disorder. And yet Frank felt the DSM-IV criteria were not too broad but too restrictive; with more mixed specifiers it would be easier to identify the kids at risk of moving from a unipolar to a bipolar disorder. She made what was essentially a usage argument for the descriptive value of energy over mood when diagnosing young people with bipolar disorder. She cited one bit in particular—patients must report “a distinct period of abnormally and persistently elevated, expansive, or irritable mood”—as an insufficiently objective variable. An objective variable, it would seem, is just a turn of phrase that patients will cop to more readily. The words elevated, expansive, or irritable mood felt imprecise to Frank, maybe a little judgy. Why not “a distinct period of abnormally and persistently increased activity or energy”? The appearance of excessive but benign futzing is the most deadly aspect of these semantic shell games; what look and sound like glazed distinctions can have consequences as enormous as they are elusive. My heart might have gone out to Ms. Frank were it not sack-weighted with envy.
Next was David Shaffer, a pediatric psychiatrist at NewYork-Presbyterian and the ex-husband of Vogue editor Anna Wintour. Shaffer, a Brit with recessive white hair and a typically awkward take on the “aloha casual” dress code, affected a wry tone while describing the psychiatric community’s response, in the 1970s and ’80s, to the discovery that depression was rare to obsolete in children. They just shifted the criteria around to make it so, he said, and began calling things like bed-wetting and nail-biting “masked depression.”
With symptoms like disinhibition and irritability, childhood itself is a cause of attention-deficit/hyperactivity disorder, a diagnosis first associated with children and then extended into adulthood as the first wave of patients grew up. The opposite was true of bipolar disorder, which was drawn back from adulthood into childhood after a child psychiatrist named Joseph Biederman proposed that certain ADHD-diagnosed kids were actually suffering from bipolar disorder, the latter generally held to be a lifelong illness. Because those kids could be wedged into a DSM-IV diagnosis for bipolar, a mood disorder, rather than ADHD, an anxiety disorder (sidestepping comorbidity, which is the medical way of saying you have two disorders at once, and it is impossible to tell which one flows from the other), they could be prescribed the standard complement of antipsychotic and antiseizure meds. Adolescent bipolar diagnoses have increased 400 percent since 1994, Shaffer told us; more youth are now diagnosed than adults. Young adulthood is the prime onset stage, although most of those diagnoses follow a first encounter with drugs or alcohol, further complicating the question of causality.
Of all the overlaps discussed that afternoon, to me the most compelling was the “get ’em young” mentality that the APA shares with every other big-ass brand in the country, including Vogue. More and more children, those mysterious miniatures, are being evaluated for their risk of mental illness and medicated according to prophylactic wont. Biederman’s pitch hinged on the idea that ADHD kids sometimes develop into bipolar adults.
It was an argument over a new DSM-5 disorder then called psychosis risk syndrome, since renamed attenuated psychosis symptoms syndrome—the “maybe your kid will be crazy but at the moment he’s just unbearable so how about some Depakote” disorder—at the APA’s 2009 convention in San Francisco that caused DSM-IV chair Allen Frances to light the torch he has since been waving in the general direction of everyone involved with DSM-5. Retired for almost a decade, Frances now spends much of his time thumbing off blog posts on his BlackBerry (he claims not to understand computers; his wife handles the back-end labor) and giving interviews about where psychiatry went wrong from his beachside perch on San Diego’s Coronado Island. By far the most authoritative, consistent, and specific opponent of DSM-5, Frances claims that the current rate of bipolar and autism diagnoses resulted from the exploitation—mainly by drug companies and social programs—of a manual he spent much of his career devising.
Another DSM-5 proposal, something called disruptive mood dysregulation disorder, is designed to offset the epidemic bipolar numbers. DMDD is an increasingly common example of a symptom of a more serious diagnosis coming into its own, as “hoarding” is being emancipated from OCD to acquire disorder status. Its full name will be misremembered and misrepresented many times throughout the conference, presumably because it was known as temper dysregulation disorder until that name bombed in a parental focus group. (My heart still lies with oppositional defiant disorder, a fabulously butch variation on the theme.) A
key part of introducing new classifications is nailing that perfect combination of prosody and mouth feel.
Midway through some oppressive ADHD statistics, I realized that staying upright while riding the Olympian half-pipe of learning curves in extremely windy conditions would be the secondary challenge of the next five days. The first would be dodging a diagnosis myself. It’s a not-uncommon fear where DSM-5 revisions are concerned: instead of locking down existing diagnoses, the APA is extending their bounds by adding disorders, making the criteria for existing ones less specific, and furthering the idea that mental illnesses are defined on a spectrum. Introducing shades of gray has created a future scenario in which half of us will be diagnosed with an anxiety disorder by age thirty-two. Although the spectrum helped give shape to broad diagnoses for depression, autism, and bipolar disorder, it also opened up a stretch of bad road in the thinking about such things as schizophrenia, compulsive disorders, and our atomized attention spans. The resulting diagnostic creep, some say and studies suggest, will ultimately land on one spectrum or another anyone who has ever gone on a bender, had a bad month, or drifted through the day transfixed by cat videos.
By way of introducing his talk on removing the so-called bereavement exclusion from the diagnosis for major depression, Dr. Sidney Zisook asked the room to diagnose a patient reporting a persistent lack of “get-up-and-go” and an inability to think straight. The room played along and was soon prepared to confirm that this imaginary fellow was majorly, clinically depressed. What if, Zisook then ventured, we learned that the patient had just been diagnosed with cancer? Would that change things? After some concessionary points about medicalizing a “normal” person, Zisook’s conclusion was: not really.
Dr. Zisook then cited his own experience with grief as an example of healthy bereavement. “I don’t think I was ever funnier than I was at my mother’s funeral,” he mused, adding that he had missed his deceased parents “for about two minutes” at a recent event honoring his child. This, it was implied, was a normal response to the loss of a loved one. You make the best of a tough situation, spend a couple of minutes with your memories on major occasions, and get on with your life. It sounded clean and hygienic and a little unhinged. It must be odd, anyway, observing and managing your own mental health, ensuring your civilian counterpart makes good time transitioning from acute to integrated grief. I imagined Dr. Zisook reflecting on his own emotional journey through his daughter’s birthday—on the drive home or maybe in the shower the next morning—and feeling soothed by the results.
The data suggests removing the bereavement exclusion so we can call depression depression, Zisook said, and get on with it. He also noted that patients are generally relied upon to decide for themselves whether they are bereaved or clinically depressed. This makes sense for a number of reasons, but chiefly because once you wind up in a doctor’s office, the diagnostic process—in this case by making a clear rejection of causality—will sink you every time. If you have been feeling lower than a flea on a sewer rat for more than two weeks (the current time frame for a diagnosis of major depression), it doesn’t really matter what’s happening in your life, or if the natural course of grief or other stressors have adaptive benefits. You may as well have caught pinkeye and will walk out with a prescription. I drifted into a daydream about Dr. Zisook killing at his mom’s funeral that was interrupted by his offhand but memorably phrased observation that everybody knows “being female is a validator for depression.”
A few minutes into the Q&A, a psychiatrist in the far reaches of the auditorium stood up to tell us that he has been suffering from what he called “complicated grief” since the day his wife died, seven years ago. His mother’s recent passing had triggered a relapse, and he was terrified to feel himself slipping away. The room grew more cavernous somehow; there was shouting for him to speak up. As his monologue continued, the audience began grappling with a secondary concern—whether to obey the impulse to turn their eyes onto this poor creature. A middle-aged Indian man, he appeared exactly as distraught as he said he was. The misery began at day one, he insisted. It turned on like a switch and now he can’t get past it. How is that depression? Who will help me?
Technically that was his question. As a keen approximation of the kinds of crises presented in psychiatry offices thousands of times a day, it couldn’t have felt more out of place. You could sense the hostility that prickles through a room when someone has shown bad form, in this case bringing his own, impossible problems into a tidy discussion about data and outcomes. In reply Dr. Zisook mentioned the study groups looking into the possibility of including “prolonged grief disorder” as a new diagnosis in DSM-5. I would soon learn that the suggestion of study groups is the APA version of a brush-off. And yet this news was more important to the widower than it might first have seemed: putting a name to his suffering had become its own imperative. It was at least a point of order in the chaos.
* * *
Although David Kupfer, the chair of DSM-5, had congratulated the presenters for hitting all the major controversies, “Mood Disorders Across the Lifespan: Implications for DSM-5” was a pretty sleepy affair. When mildly challenged by questioners from Brazil, Finland, and Canada during their Q&A sessions, the presenters had been quick to defer to an absence of full knowledge about everything up to and including the topic they were discussing. By contrast, the next day’s personality-disorders symposium was a straight-up riot, where practicing psychiatrists bared hind molars over DSM-5’s plan to wipe half the PD diagnoses from the books.
Tougher to understand and more comprehensive as diagnoses, personality disorders as they are defined perhaps get closest to Freud’s psychic schema of id, ego, and superego—a trio that threatens a kind of moral chaos when out of balance. Like psychoanalytic conflicts, personality disorders emphasize a patient’s inability to exist peacefully in the world, as opposed to her own skin. The names—antisocial, avoidant, borderline, histrionic, narcissistic—suggest a failure to engage and consequent crisis of identity. Freudians claimed successful psychoanalysis as a safe passage into adulthood; Carl Jung believed the personality only reaches perfection in death. It’s classically rich terrain, but as psychiatry continues to narrow its focus on the individual and his scientific profile, the whole concept of having a personality—a way of being formed symbiotically, over time and in relation to others—is politely being ushered to the land of the obsolete, where it will rest between chivalry and laser-disc players.
Five out of the ten personality disorders are currently on the cutting block: narcissistic, paranoid, schizoid, histrionic, and dependent. The proposed changes and consolidations left angry clinicians like Thomas Widiger, the head of research for DSM-IV, trying to illustrate major ideological points with frustrated micro-critiques of the newly proposed dimensions, traits, and criteria. What, for instance, does a weird, self-canceling criterion like “(lack of) rigid perfectionism” have to do with the diagnosis of schizotypal personality disorder? With fewer disorders and blurry criteria, all personality disorders will blend together—which, in a system built around the appearance of discrete classifications, amounts to a form of sabotage. But giving up on the category, Widiger told us, means giving up on a branch of psychiatry that has devised successful treatments for patients with strong suicidal tendencies. If anything, why not get rid of “personality disorder not otherwise specified”—a junky diagnosis used to capture those who don’t fit cleanly into an APA mold. Most disorders, including depression and bipolar, have NOS contingencies that ultimately negate all the tortured wordsmithing that goes on at conferences like this one.
NOS can also be used as a weapon. In the last decade, thirty-one thousand troops have been discharged from the U.S. military on the grounds of a personality-disorder-NOS diagnosis. The New York Times reported in early 2012 that military commanders have specifically requested a PD-NOS diagnosis in order to purge unwanted individuals from their ranks. It’s also a money-saver: because personality disorders are trea
ted as preexisting conditions (if anything can be said to have an early onset, it’s probably your personality), veterans’ benefits are waived and the military is no longer responsible for the treatment of service-related injuries, including the costly and pervasive post-traumatic stress disorder. With its clear delineation of cause and effect, PTSD is the most prominent vestige of the DSM’s roots. Treating it the modern way—including powerful opiate and psychotropic prescriptions—has been a conspicuous, catastrophic failure. A couple of months after the Honolulu conference, the army reported a record high of active-duty and reserve suicides. A 2009 study found that an American veteran commits suicide every eighty minutes, doubling the combined total of Iraq and Afghanistan casualties each year.
Practically speaking, it may not make much difference to responsible clinicians if personality disorders and their criteria are cut in half. With experience and an engaged heart, psychiatrists develop their own Tao of disorder, what Jung called “a real knowledge of the human soul.” Everything from familiarity with Woody Allen types to first gut impressions were cited as valid litmus tests for neuroticism—or “negative emotionality,” as it’s now called—a trait of almost every personality disorder. (“If you give me a pony,” one presenter offered by way of example of a classic Debbie Downer–ism, “that means I’ll wind up shoveling horse shit.”) The problems begin, another presenter noted, when you have to put this stuff into a book. But for DSM-5 to be accepted by insurance companies, general practitioners, and the public, as Widiger ruefully pointed out, it has to make sense.
One of the new criteria proposed for borderline personality disorder was singled out for PowerPoint scrutiny. The checklist will now inquire into the patient’s “sense of a self that is unique and grounded in personal history.” What’s tricky about people who fit the profile for a personality disorder is that they are often—you might even say by definition—not the best judges of their own character. More so than other mental illnesses, to have a personality disorder is to be perceived as having a personality disorder. Alone in her room or with her thoughts, a toxic narcissist gets along just fine. It’s when she tries to exist out in the world that things go pear-shaped.
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