After bruising and embarrassingly public bureaucratic battles, the protestors got what they wanted. In April 1973, an APA committee recommended deleting homosexuality from the DSM, then in its second edition. As part of the decision, the APA nominated a new disease, ego-dystonic homosexuality, which occurs when a gay person is distressed by his or her sexual orientation. Later that year, the APA’s board of trustees voted in these changes to the DSM-II. In 1974, after a rearguard action had forced a referendum, a majority (58 percent) of the voting membership ratified the decision. This may have been the first time in history that a disease was eradicated at the ballot box.
Some psychiatrists, mostly those who opposed deletion, pointed out the obvious problem raised by this solution. “Referenda on matters of science makes [sic] no sense,” said one dissenter. “If groups of people march and raise enough hell,” another observed, “they can change anything in time…Will schizophrenia be next?” These doctors understood that they were dealing with a much different problem from the one uncovered by Katz. It was one thing to say that psychiatrists couldn’t agree on which illness a given patient had, that, in the parlance of experimental science, diagnosis was not reliable. But it was another matter entirely to say that even when psychiatrists achieved reliability, the diagnosis they rendered was not valid because the condition in question was not a disease. The lack of reliability may have been shameful, but it was correctable; all that was needed, most thought, was a tightening of standards, better education, more research. But the validity problem was a downright disaster. What kind of doctor doesn’t know the difference between sickness and health?
The answer, it seemed, was psychiatrists. And as humiliating as they might have found their lack of reliability, the possibility that the best they could do was to reliably diagnose illnesses that didn’t really exist was even worse.
Some psychiatrists had noticed the validity problem long before gay people started raising hell—notably Britain’s R. D. Laing and Thomas Szasz, an American. Laing focused on schizophrenia, which he argued was the result of people finding themselves in a social environment that didn’t make sense to them; the insane place in which they were sane was not an asylum but a world filled with nuclear weapons, economic exploitation, ecological degradation. Szasz, less explicitly political, had a different idea, one that was less fanciful but that struck closer to the heart of the validity question. Psychiatric problems are not medical problems at all, he argued in The Myth of Mental Illness, but “problems of living.” This didn’t mean that people shouldn’t seek therapy or that therapists did not provide a valuable service. But that service was not, properly speaking, a medical one, the illnesses psychiatrists claimed to treat were not valid, and most of their patients were not, strictly speaking, sick.
Psychiatrists may have hoped that deleting homosexuality from the DSM would strengthen their validity case—the fact that they had read an impostor out of the kingdom overshadowing the fact that he’d slipped past the gatekeepers in the first place—and that better training would solve the reliability problem, but their important patrons saw it differently. A 1978 presidential commission with influence over federal funding decisions warned that “documenting the total number of people who have mental health problems…is difficult not only because opinions vary on how mental health and mental illness should be defined, but also because the available data are often inadequate or misleading.” In 1975, a Blue Cross executive told Psychiatric News that his industry was reducing mental health treatment benefits because “compared to other types of services, there is less clarity and uniformity of terminology concerning mental diagnoses,” and added that because “only the therapist and the patient have direct knowledge of what services were provided and why,” the insurers couldn’t be sure they were even paying for the treatment of an illness.
To make matters even worse for psychiatrists, all kinds of non-medical professionals—social workers, psychologists, counselors, even nurses—were claiming (and getting) the right to deliver psychotherapy services. This was an indication that Freud had been correct about lay analysis, and that whatever else therapy was, it wasn’t strictly speaking medicine. The diagnosis was obvious, the prognosis grave: as the president of the APA put it in 1976, the biopsychosocial model, “carrying psychiatrists on a mission to change the world, had brought the profession to the edge of extinction.”
The second edition of the DSM appeared in 1968. The spiral-bound 132-page manual tried to be user-friendly. It offered a handy listing, in numerical order, of all 158 official mental illnesses, a set of sample tables for clinicians who might wish to keep track of their diagnostic habits, and even a postage-paid card on which users could send “criticisms and recommendations” back to the APA. The book also included, as its last chapter, “A Guide to the New Nomenclature,” which explained, among other things, how this edition differed from the earlier one. Of particular note was the elimination of the word reaction from the diagnostic labels. Schizophrenic reaction had become schizophrenia, manic-depressive reaction was now manic-depressive illness, depressive reaction had been rechristened depressive neurosis, and so on. This explanation came with a reassurance. “Some individuals may interpret this change as a return to a Kraepelinian way of thinking, which views mental disorders as fixed disease entities,” the authors wrote. “Actually, this was not the intent of the APA Committee on Nomenclature and Statistics.”
It’s possible that Robert Spitzer, lead author of the chapter, really meant that Kraepelin was the farthest thing from his mind and only subsequently came to see the old German’s wisdom. Or that he was splitting hairs by writing about the committee’s intent while remaining silent on his own; he, after all, was only a consultant to the committee. Or that his denial was, as any psychoanalyst would suspect, an unconscious affirmation of his wishes, his protestations of peaceful intent really a warning of impending hostility. But this much is certain: when the smoke cleared twelve years later to reveal Spitzer’s magnum opus, the DSM-III, with its more than 225 diagnoses, its symptom lists, and its differential diagnoses (and no comment card), psychiatry had indeed returned to a Kraepelinian way of thinking. It had also, not coincidentally, been plucked from the precipice and restored to respectability—although some argued, and continue to argue, that Spitzer had destroyed the profession in order to save it.
Spitzer’s affinity for Kraepelin might well have been personal. They shared a distrust of inner life, saw it as too raw and unruly to be of much use to doctors. The reasons for their antipathy differed, however. While Kraepelin thought the patients were untrustworthy, for Spitzer the doctor was the culprit. “I was uncomfortable with not knowing what to do with their messiness,” he once said. “I don’t think I was uncomfortable listening and empathizing—I just didn’t know what the hell to do.”
Spitzer did know what to do about diagnostic messiness. The problem was obvious. A manual that defined, say, depressive neurosis, as “an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object” was bound to get its users into trouble. What’s a neurosis? What does depression mean? Isn’t that the term the diagnosis is supposed to define? How much of it is excessive and how should that be measured? And what is the guarantee that one clinician’s internal conflict or identifiable event will match another’s, or that the same patient will provide the same story to two different therapists? Too much depended on the rendering of inner life into language, the ineffability of the one compounded by the approximations of the other, and both entirely dependent on a prior theoretical understanding of how the mind worked.
The solution was also obvious. As Kraepelin had discovered, there’s no need to go on a Nantucket sleighride while the patient—who is, after all, sick in the head—sounds his woes. A doctor is much better off with pure description of what he sees and hears, which is presumably what any other person with trained eyes and ears will see and hear. If you want reliability, in other words,
you have to stick with observation; a mental illness is no more or less than the group of symptoms that a careful observer has noted—perhaps by sorting index cards—to occur together.
That’s not the kind of psychiatry Spitzer had learned while training at the Columbia Psychoanalytic Institute. If the Kraepelinian approach had come up at all, it would have been as a cautionary case, an example of how not to eliminate messiness in service of an account of suffering that, while tidy, does not get at the real nature of the problem. Psychiatry had, or so its practitioners thought, long ago left Kraepelin’s therapeutic nihilism and dry categorizing behind in favor of the Freudian/Meyerian synthesis, its promise that with a little hard work and introspection, and a great deal of money, suffering could be treated at its source in the mind.
Which is why Spitzer, in perhaps his first act of what he would come to call “nosological diplomacy,” had to issue his denials in the first place. He knew that reaction was central to the way that psychiatrists viewed and assessed mental illness—as the various, highly individualized ways that mental disorder manifests itself when a dynamic psyche is exposed to a traumatic environment. To eliminate that word was to eliminate an entire view of suffering—and, by extension, of human nature. But, Spitzer protested, nothing could have been farther from the committee’s mind. To the contrary, it had only purged reaction as part of an overall attempt “to avoid terms which carry with them implications regarding either the nature of a disorder or its causes” (emphasis in original). The problem with reaction was that it implied both nature and causes: that mental disorder was the result of “Man in transaction with his universe,” as Karl Menninger had put it, that there was a healthy way of conducting that transaction, and that psychiatrists knew what it was. These notions didn’t pass scientific muster. If psychiatry wanted to remain in the scientific camp, reaction and all its attendant metaphysics would have to go.
Editing a single word out of the DSM proved much easier than eradicating the idea that our discontents are the result of the interaction between psyche and world, and the committee’s reassurances that they meant no harm did not buy off professional resistance forever. But by the time the battle was joined, Spitzer had a huge advantage. Up until the mid-1970s diagnostics was a sleepy backwater of psychiatry, a subject of interest to most doctors only as the key to the insurance treasury, its professional discussions relegated (according to Spitzer) to poorly attended late afternoon sessions at professional meetings. While his colleagues were getting a head start on cocktail hour, however, Spitzer and a small group of researchers were busy at work, creating a reliable nosology. And when it came time to write a third edition of the DSM, in the late 1970s, these doctors were ready with their diagnostic criteria—lists of observable symptoms, cleansed, presumably, of any ontological implications, that would define mental illnesses in a way that was reliable.
Rank-and-file psychiatrists did eventually figure out that a big change was afoot, and much of the ensuing consternation focused on another word slated for elimination—neurosis, which, the new Committee on Nomenclature argued, should not appear in DSM-III because it “assumed…an underlying process of intrapsychic conflict resulting in symptom formation.” In other words, you needed a theory about mental illness, about what caused it and where it came from, to diagnose a neurosis, and theory—especially the Freudian theory in which neurosis played a central role—was exactly what had gotten the profession into its reliability troubles in the first place. It had to go.
Eradicating neurosis was not as easy as getting rid of reaction had been. Neurosis, and especially depressive neurosis, was the psychiatrist’s stock in trade, the general label for the everyday discontents that Meyer had long ago said were a proper indication for outpatient psychotherapy. The proposal to erase the word crystallized opposition to the remaking of DSM-III. Some doctors took a historical approach, pointing out that neurosis had been first described not by Sigmund Freud, but by Scottish physician William Cullen in 1769, and thus had earned a place in medicine. But others got right to the point. “DSM-III gets rid of the castles of neurosis and replaces it with a diagnostic Levittown,” one psychiatrist said; most psychiatrists knew where they would rather live. Another colleague dispensed with metaphors and appealed directly to doctors’ self-interest. Without neuroses of various kinds, he wrote, “many patients who are not in prolonged therapy will be said to have no disorder.” The whole world could not be insane, at least not reimbursably insane, if the net were cast so much more narrowly.
But that was exactly the committee’s intent—to prune the taxonomic tree of its less reliable branches, of which neurosis, weighed down with the Freudian idea of a dynamic inner world, was perhaps the most rotten. So when a psychiatrist lamented that proposed changes would turn the DSM into “a straitjacket and a powerful weapon in the hands of people whose ideas are very clear…and the guns are pointed at us,” he wasn’t as ready for his own straitjacket as he sounded. Indeed, Donald Klein, a pharmacologist and prominent defender of DSM-III, only confirmed those suspicions when he proclaimed that opponents of DSM-III “wish [neurosis] reinserted because they wish a covert affirmation of their psychogenic hypotheses.” Taking such malcontents seriously could only spell disaster for “scientists attempting to advance our field via classification and reliable definition.”
Spitzer did take seriously the “pro-neurosis forces”—in the infelicitous term used by one of them—at least seriously enough to offer any number of compromises. He suggested allowing psychoanalytic-minded doctors to insert an N after the diagnostic code, indicating that the clinician thought the problem had something to do with conflict in the psyche. He floated the idea of adding neurotic as a descriptor after certain labels, but only in parentheses. He promised to allow the pro-neurotics a large role in “Project Flower,” which would produce a companion volume to DSM-III that would allow theoreticians to fill in the diagnostic picture beyond the criteria lists—and whose name, Spitzer said, was inspired by Mao’s aphorism, “Let a thousand flowers bloom.” He even invited psychoanalysts to add some of their Project Flower material to the DSM’s introduction.
In due course, however, the N modifier disappeared, the introduction idea was dropped as “extremely embarrassing and extremely divisive,” and Project Flower somehow failed to bloom. After their trip to the diagnosis wars, all that the pro-neurotics ended up with were lousy parentheses: anxiety disorder became anxiety disorder (or anxiety neurosis) and depressive neurosis became dysthymic disorder (or neurotic depression). And in April 1979, after five years of diplomatic nosology, after the Talbott Plan and the Offenkrantz Complaint and Washington Challenge and the Modified Talbott Plan, after the APA’s assembly elected to approve the DSM-III, the APA’s board of trustees once again voted on the existence of diseases. This time, the stroke of their pen didn’t eliminate a single illness but rather a whole class of them, even as it created some fifty more that hadn’t previously existed. But these were new and improved diseases, the kind that could be reliably diagnosed without recourse to theoretical notions about how the mind works.
The DSM-III was a huge hit. Purged of theory, of any pretense to saving the world, and of any claim to know how the mind worked or what caused mental illnesses, the book was invaluable to psychiatrists’ attempt to secure their place in “real medicine.” Thanks to the descriptive approach, there would no longer be any question about who was schizophrenic and who was manic-depressive, or, for that matter, who had major depressive disorder (MDD), as it was now called, and who was merely unhappy. Nine out of ten doctors using the criteria agreed on diagnoses, a spectacular improvement over the old days of theory-laden nosology.
The DSM criteria for MDD were straightforward: take one from column A (“dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes…sad, blue, hopeless, low, down in the dumps, irritable”), four from column B (“poor appetite or significant weight loss…or increased appetite or significant weight gain�
��insomnia or hypersomnia…psychomotor agitation or retardation…decrease in sexual drive…fatigue…feelings of worthlessness, self-reproach, or excessive or inappropriate guilt…diminished ability to think or concentrate…recurrent thoughts of death, suicidal ideation, wishes to be dead or suicide attempt”), and rule out the symptoms in column C (“mood-incongruent delusion…[or] bizarre behavior,” which are indications of other disorders), and you’ve got your diagnosis. A similar process could lead to dysthymic disorder or adjustment disorder with depressed mood. “Clerks rather than experts can make this kind of classification,” one psychiatrist grumbled. But of course that was exactly the point.
These criteria weren’t original to the DSM. In fact, Spitzer and his committee had lifted them, sometimes word for word, from the Feighner criteria, invented by a group of researchers at Washington University in St. Louis who, in 1972, had developed descriptive diagnostic standards for depression (and fourteen other psychiatric disorders). The Washington team was the first to achieve those excellent reliability numbers, and other researchers were soon scrambling to hitch their wagons to the Feighner star, using the criteria to back their own studies or as a model for their own tests. By 1989, the paper introducing the criteria had become the single most commonly cited article in the psychiatric literature.
What the Feighner criteria didn’t address was the old Kraepelinian problem, the one about the symptoms constituting the diseases and the diseases comprising the symptoms. All the reliability in the world does not add up to validity. That’s an especially glaring omission when you consider that the paper came out at the height of the battle over homosexuality, a condition whose presence doctors could reliably agree upon even without fancy criteria. Not to mention that in the particular case of MDD, the Feighner criteria bore a strong resemblance to the items on the Hamilton Depression Rating Scale, whose own author had long cautioned that his test was not valid for making diagnoses.
Manufacturing depression Page 26
