The Book of Woe: The DSM and the Unmaking of Psychiatry (2 page)

But that doesn’t mean I’m sorry. By
apologize
, I mean what the ancient Greeks meant. I mean to explain. Because I think drapetomania is not a historical novelty or an anomaly or an accident. It is not the exceptional error that proves the rule that science is self-correcting and will ultimately punish arrogance and incompetence. The story of drapetomania is a cautionary tale, just as the ones about homosexuality and childhood Bipolar Disorder are, and just as the story about a disorder that sits quietly today in the DSM-5 (my vote is for Internet Use Disorder) will be in some tomorrow. All these stories tell us why our inner lives are too important to leave in the hands of doctors: because they don’t know as much about us as they claim, because a full account of human nature is beyond their ken.

While I’m explaining myself, let me tell you a story.

In 2012, I got a voice-mail message from a former patient; I’ll call him Sandy. I last saw him about ten years ago. I’d worked with him from the time he was in his junior year in high school until he finished his graduate studies. He’d been plagued by anxiety so severe that he was unable to attend school and, eventually, to leave his house at all. Early on in therapy, he’d told me that he was sure he was gay, and that this was what had led him to hole up in his room contemplating suicide as the preferable alternative to what his parents and pastor, who hadn’t deleted homosexuality from their book of sins, called “the gay lifestyle.” We talked about this, and more generally about what therapists and patients talk about: parents, friends, regrets, confusion, and fear. I can’t tell you why, but therapy worked, at least enough to get him to overcome his self-loathing and his parents’ disapproval and to come out, in all senses of that phrase. Last I knew, he had a job and a life in a faraway city. He could work, love, and stay alive, which, by my lights, is about all we can ask for. He kept in touch sporadically via e-mail or phone to tell me what he was up to or to let me know he’d seen something I’d written in a magazine.

The message went like this:

“I know I shouldn’t call you, and I promise I won’t call you again. But you’ve got to help me. They’ve sucked all the bones out of my body. I’m here in this hotel room and my bones are gone. My mother and my father and James. They’ve done this to me. And I don’t want to die. Please don’t let them kill me. Don’t let them. You’re the only one who can help. You know I love you, and I love Ellen Goldstein, too. Good-bye. Good-bye.” (I made up those names.)

He didn’t leave a number, but according to caller ID, he was calling from a Holiday Inn a thousand miles from where, as far as I knew, he had last been living. Sandy had checked out by the time I tried to return the call. I don’t know where he went next. But I am pretty sure about one thing: his parents and James, whoever he was, did not suck the bones out of his body, and they probably weren’t about to cook Sandy up in a stew, or whatever he was sure they were going to do. I would guess they didn’t even know where he was. I’m not even sure Sandy knew where he was. As I write this, I still don’t know what became of him.

Now, if you’re like me and most everyone I know, the first thing that you think when you hear a story like this is that Sandy is mentally ill. But what do we mean when we say this?

The first answer is that he is crazy. That is, he is behaving in a way that is abnormal, bizarre, out of touch with reality. The technical term here is
psychotic
or
delusional
. I think this is self-evident, and even if I didn’t care about Sandy, I wouldn’t think it is benign, a sane response to an insane world, say, or some salutary plunge into the collective unconscious. He was in trouble; he was, as the current jargon goes,
dysfunctional
; his inner life had gone haywire; he needed help.

But what kind of trouble? And what kind of help?

This brings us to the second answer: that his craziness is best understood as the manifestation of a disease that is medical in nature, that is in some essential way no different from all the other diseases that afflict us, and that is best left to doctors to understand and treat.

We have become accustomed to thinking of
disease
in a very specific way: as a pathology of the body, something gone wrong in our tissues or our cells or our molecules. You secrete too much of this or don’t produce enough of that, or the rate of the other thing is too high or low, and that is why you can’t walk up stairs without losing breath, or why you are in pain or are losing weight, and why, if you don’t do what the doctor says to do, if you don’t take his pill or let him plunge his scalpel into your skin or drip poison into your veins, you will continue to suffer, or your suffering will get worse, or you will die.

But before you will submit to the cure, you have to believe that the doctor knows something about your pain that you do not, that she can identify that disease, that she is on familiar terms with it, that she knows it by name. She must, in other words, give you a diagnosis.

Diagnosis
, not unlike
drapetomania
, comes from two Greek words, meaning “to learn” and “apart.” It is a knowledge that sorts one thing from another. The Greeks understood how hard it is to parse the world, especially when it comes to complex experiences. “
Love is a madness
¹⁹
,” Socrates tells Phaedrus, and to understand that madness, to untangle it from other experiences, he says that two principles must be upheld. “First, the comprehension of scattered particulars in one idea” that is clearly and consistently described. But, Socrates continues, we can’t gather the particulars together under just any idea. No matter how vividly described or comprehensive the categories, and no matter how well they seem to cohere, they must also be fashioned “according to the natural formation, where the joint is, not breaking any part as a bad carver might.” A good diagnosis must be more than the fancy of the diagnostician, more than merely deft. It must also be accurate. It must carve nature at its joints.

What is true for the madness that is love is true for any madness at all—or, for that matter, any suffering that doctors purport to understand. The diagnostician’s job is to find the disease that unites the scattered symptoms and makes them manifest in precisely the way they do, to say with certainty that this distress is the result of that illness and no other. The diagnostic enterprise hinges on an optimistic notion: that disease is part of a natural world that only awaits our understanding. But even if this is true, nature gives up its secrets grudgingly, and our finite senses are in some ways ill suited to extracting them. More important, our prejudices lead us to tear nature where we want it to break. Science, especially modern medicine, is founded on this equally optimistic idea: that experts can purge their inquiry of prejudice and desire, and map the landscape of suffering along its natural boundaries.

Greek doctors, as it turned out, were not so good at this. They had some ideas about what those natural formations were, largely having to do with four bodily humors—blood, bile, phlegm, and melancholy—that, if thrown out of balance, could cause illness. But humoral theory was more metaphysics and wishful thinking than truth. Even Hippocrates and his disciples seemed to know this, as they traded mostly in
empiricism
—the painstaking observation of the way symptoms appeared to the doctor’s senses, the courses they took, the outcomes they reached, and the interventions that affected them.

In the nineteenth century, most doctors still believed that humoral imbalances caused disease.
Before John Snow
²⁰
could persuade the local government to close the infected well that caused the 1854 cholera outbreak in London, he had to overcome the common idea that the disease was carried by a
miasma
, bad air that could upset humoral balance.
Louis Pasteur and Robert Koch
²¹
had to work hard to convince their colleagues that germs caused diseases like rabies and anthrax, and that they (the germs, not the colleagues) could be targeted and killed. As the microscope and the chemical assay provided incontrovertible evidence of germs and their destruction, doctors were won over to the germ theory, and soon it seemed that they had begun to fulfill Socrates’ dictum to find the natural joints that separated our ills from one another.

By the turn of the twentieth century, doctors were stalking disease like Sherlock Holmes stalked criminals. Under the magnification of their microscopes, syphilis, diabetes, and streptococcus, to name just a few, soon yielded their secrets and their terrifying hold on us. With their newfound ability to parse suffering, to track it down to the bodily processes causing it, and then to dispatch it with a potion or a surgery, doctors gained prestige—and with it, money and power. They were rewarded as much for their prowess in relieving suffering as for the promise they now embodied: that they could use science to give a name to someone’s suffering and then, having named it, to relieve it.

This revolution in medicine accounts in part for the immense appeal of considering craziness to be just another disease. If scientific understanding and cure were possible for the suffering of the body, then why not for the suffering of the mind? If Sandy’s conviction that his bones have been sucked out of his body is some kind of metaphor, if the content of his delusion brims with meaning—an expression of impotence, a lack of backbone, an inability to hold himself up—then it is out of the reach of the microscope and the X-ray. It requires what the ancient doctors offered: interpretation and the invocation of metaphysics, of something beyond the symptom. But if the delusion is only another symptom, if it is not, in principle, different from the malaise and relentless thirst of an untreated diabetic, or the narrowing of vision of a glaucoma patient, or the fever of someone with malaria, then it can be brought under the physician’s purview. It doesn’t need to be understood in itself any more than fever or thirst does. It can be explained, it can be treated, and it can be cured.

If you’ve gotten sick or injured and a doctor has restored you to health or if you’ve seen this happen to someone else—and who hasn’t?—then you know the lure of this promise. If you’ve watched your child descend into psychosis or your husband spin out into mania or yourself struggle to get off the bed onto which depression has laid you, then you know it even better.

On the other hand, if you’ve been involved with the mental health industry, then you probably also know that the promise is not always fulfilled. Even if doctors can settle on a name for Sandy’s illness—and this is not a sure thing; they are likely to be torn between Schizophrenia and Bipolar Disorder—they will not be able to scratch out a prescription, tell him to take two and call in the morning. He may end up taking a drug indicated for a different diagnosis, or a cocktail of pills—one to quell his hallucinations, one to temper his agitation, one to relieve his depression, and one to help him sleep—and the combination may change monthly or even weekly, or it may work for a while and then stop. No one will be able to explain why that happened, any more than they will be able to explain why the drugs worked in the first place. No honest psychiatrist will claim that she cured Sandy’s, or anyone’s, mental illness; and while she is being honest, she may acknowledge that, for the most part, her treatments are targeted at symptoms, not diseases, and that she selects them as much by intuition and experience as by scientific evidence.

But psychiatry’s appeal is not just about the possibility of cure, which is why the profession continues to flourish even when it cures nothing and relieves symptoms only haphazardly. It’s in the naming itself. What Wallace Stevens called the “
blessed rage to order
²²
” is so deep in us that it is in our origin story: the first thing the Bible’s authors have
Adam and Eve
²³
do to establish their dominion over Eden is to name its flora and fauna. That story doesn’t have a happy ending, and neither does the one I’m about to tell you (although in the latter case, there is good reason for that). But the rage itself is surely blessed, or at least as blessed as we humans can be, and as noble. Give a name to suffering, perhaps the most immediate reminder of our insignificance and powerlessness, and suddenly it bears the trace of the human. It becomes part of our story. It is redeemed.

•   •   •

But what kind of story? And what kind of names?

The DSM-IV, the most recent edition of the manual,
*
sorts psychiatric problems into chapters like “Mood Disorders” and “Feeding and Eating Disorders” and from there into individual illnesses like Major Depressive Disorder (MDD) or Bulimia Nervosa, each of which might have its own specifiers, so that a complete diagnosis might read Major Depressive Disorder, Recurrent, Severe, with Melancholic Features. For each disorder, criteria are listed. There are, for instance, nine criteria for a Major Depressive Episode; if you meet five of them, then you have fulfilled the necessary condition for that diagnosis; and if you meet four others in addition, then you have sufficient symptoms to earn the MDD label. In addition to the criteria, the DSM supplies
text
, a not-quite-narrative account of the prevalence, family and gender patterns, and other associated features of the disorder, and instructs doctors how to differentiate among disorders that resemble one another. Depending on how you count—whether or not you consider each subtype its own disorder, for instance—the DSM-IV lists around three hundred disorders in its nearly one thousand pages.

You could think of the DSM as a handbook designed to help doctors recognize the varieties of psychological travail, not unlike the way Audubon’s field guides help ornithologists recognize birds. You could think of it, as some people (especially its critics) do, as the Bible of psychiatry, providing a scriptural basis for the profession. You could think of it—and this is what the APA would like you to do with the DSM-5
*
—as a living document, akin to the U.S. Constitution, a set of generalizations about the present, flexible and yet lasting enough to see an institution into the future. Or you could think of the DSM as a collection of short stories about our psychological distress, an anthology of suffering. You could think of it as the book of our woes.