The Book of Woe: The DSM and the Unmaking of Psychiatry (27 page)

•   •   •

The paradigm shifters had long ago stopped responding to Frances. But he was no longer their only nemesis.

His fellow critics included at least one person who was as surprised as anyone to find herself on the same side as Frances. Paula Caplan, a psychologist affiliated with Harvard, had been a consultant to the DSM-IV personality disorders work group, a position from which she had tormented Frances as relentlessly as Frances was now tormenting Regier. Her main complaint back then was about Self-Defeating Personality Disorder. While Frances thought it was poorly conceived and had little empirical support, Caplan thought it was just plain sexist. Frances thought Caplan’s critique was “
too polemical
¹⁰
” and warned her that since the proposal was sure to be rejected, there was no need for “heated controversy.”

Frances’s dismissal seemed only to inflame Caplan, who submitted her own DSM-IV diagnosis: Delusional Dominating Personality Disorder (DDPD). Among the fourteen proposed criteria were “
a tendency to feel inordinately threatened
¹¹
by women who fail to disguise their intelligence” and “the presence of . . . delusions that women like to suffer.” DDPD was, she wrote, “most commonly seen in males,” often in “leaders of traditional mental health professions, military personnel, executives of large corporations, and powerful political leaders of many aims.” It was a “modest proposal,” she wrote, “an antidote to . . . the institutionalized sexism in the mental health system.”

“
I really wasn’t sure
¹²
what to make [of ] your ‘delusional dominating personality disorder,’” Frances responded. “How serious are you about it?” Much as he thought the proposal was a provocation, the reason he gave for rejecting it out of hand was the standard DSM-IV demurral: that there wasn’t enough evidence for DDPD even to be considered. But when Caplan asked for funds to develop that evidence, Frances refused. “
It is disruptive to constantly tinker
¹³
with the classification,” he wrote, adding, in case she didn’t get the hint, “if this sounds discouraging, I’m afraid it is meant to.”

After Caplan quit the work group, she wrote
They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal
, a broadside against DSM-IV, in which she cast the affair as an instance of the good-old-boy politics that powered the DSM. So even if
Caplan did give Frances a shout-out
¹⁴
for “bravely com[ing] forward with a mea culpa,” it was very unlikely that she was in cahoots with him when she came up with a modest proposal for the DSM-5: Toxic Psychiatric Drug Syndrome. In her letter to the task force, she also made some recommendations: that the APA “join an initiative to hold Congressional hearings about psychiatric diagnoses,” that it add a black-box warning to the actual DSM-5 emphasizing that the diagnoses were not to be used as “the basis for any professional or legal decision that may limit the liberty, or discriminate against, any individual,” and that, “because of . . . ongoing significant problems in the process,” publication be indefinitely delayed.

The APA swatted away Caplan as summarily as Frances had, although without his personal touch. They used a public relations firm, which arranged a conference call between representatives of “consumer groups”—Caplan was positioning herself as a champion of people given unwarranted diagnoses and prescriptions—and the DSM leaders. Caplan heard that there would be twenty others on the hour-long call, so she tried to coordinate with the others on the questions that would be asked, but the hired guns refused to disclose the participants or forward a list of proposed questions to them.
On the appointed day
¹⁵
, according to Caplan, after Carol Bernstein assured the callers that the APA needed “the expertise of patients, families, and their advocates,” Kupfer and Regier, along with a task force member, used the first half of the call to give their talking points. Participants who wished to ask questions were then instructed to dial a code, and after a silence during which a queue was constructed, six were allowed to ask a single question each; their phones were muted as soon as they delivered it. The APA representatives stuck to their script and, after promising (but refusing to schedule) further discussion, said good-bye.

The new bosses were no different from the old bosses, Caplan concluded. They might give the “impression of openness to debate,” she wrote in her
Psychology Today
blog, but in real life, critics like her would be “largely ignored,” their evidence “shoved aside,” and the world’s latest most powerful psychiatrists would once again “put in the next edition of the manual whatever they pleased.”

If Caplan was railing against the psychiatrists’ process, the British Psychological Society was going right for the content of what displeased them. In a twenty-six-page manifesto released in June, the BPS accused the APA of “
the continued and continuous medicalisation
¹⁶
of . . . natural and normal responses.” These responses, the BPS went on, “undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.” Attenuated Psychosis Symptoms Syndrome (APSS), for instance, “looks like an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis,” leading in turn to more drug treatments. The overall thrust of the manual, the BPS complained, was to identify the source of psychological suffering “as located within individuals,” rather than in their “relational context,” and to overlook the “undeniable social causation of many such problems.”

The APA could hardly deny any of this. As Regier had told the consumer groups on the conference call, the manual’s new organizational structure was designed to reflect “what we’ve learned about the brain, behavior, and genetics during the past two decades.” It doesn’t get much more “within the individual” and outside the “relational context” than that. And, as proposals like APSS and the elimination of the bereavement exclusion made clear, one of the purposes of the DSM-5 was to make sure that no one who was suffering would be deprived of the benefits of diagnosis.

On the other hand, the APA couldn’t ignore the British Psychological Society or treat it as a mere “consumer group.” But that didn’t mean they would acknowledge the actual criticisms, as
Regier made clear in his official response
¹⁷
. The BPS had cited a “well known member of the ‘Critical Psychiatry Network,’” he wrote, one “that has largely adopted the Thomas Szasz approach to mental illness.” These critics, Regier reminded his readers, think “we shouldn’t consider any mental disorder, including individuals whose psychosis renders them mentally incompetent, to have a brain-based illness.” Antipsychiatry was once again deluding people into thinking that the APA was making grievous errors.

Compounding the BPS’s ideological excess, Regier went on, was plain ignorance.

What seems to be missing is an appreciation of mental disorders as the result of gene-environmental interactions that would trigger abnormal neuronal function in the brain. Why the brain should be exempt from pathology when every other organ system is subject to malfunction is left unaddressed.

To question the APA’s insistence that psychological suffering was always the result of brain pathology was to deny that the brain could malfunction at all.

“It should be recognized that mental disorders are by no means a modern construct,” Regier wrote. “Psychiatric disorders have existed since the beginning of recorded history.”

Regier didn’t offer any evidence for this extravagant claim, nor did he try to square it with his insistence in other venues that psychiatric disorders were constructs that clinicians reified at their own peril. But then again, he probably thought he was saying something nonextravagant (and self-evident): that mental suffering has always existed, and that throughout recorded history it has only been awaiting psychiatrists like him to elucidate the gene-environmental interactions that triggered the brain pathology that causes it. But to think there could be psychiatric disorders before there were psychiatrists, to think the only way to understand our suffering is as an illness to be cured by doctors, is to ignore the fact that for thousands of years of recorded history, people thought that mania and psychosis and depression and anxiety were the mark of the prophet, or manifestations of sin or witchcraft or devil possession, or just the nature of life in a fallen world. It is also to overlook the failure of psychiatry, at least so far, to prove that it is the proper venue for understanding and treating what we have come to think of as mental illness. And to think, after all the failures of the DSM to develop an accurate taxonomy, that this time it will be different, that only naysayers and dead-enders and other benighted miscreants could possibly believe that recasting sin or possession or witchcraft as illness is anything other than the mark of progress—well, that is the province of people who, as Herman Melville once wrote, despite “
previous failures
¹⁸
, still cherish expectations with regard to some mode of infallibly discovering the heart of man.”

These people, Melville observed, are like the mathematicians who “in spite of seeming discouragement . . . are yet in hopes of hitting upon an exact method of determining the longitude.” But other scientists maintain this optimism, including, Melville wrote, “earnest psychologists.” He probably didn’t mean to slight psychiatrists. It’s just that he wrote the novel in 1857, which is long after the beginning of recorded history, but only a few years past psychiatry’s emergence as a profession, and long before it began to try, despite seeming discouragement, to enshrine its infallible understanding of mental suffering in the pages of a book.

•   •   •

Melville’s observation comes in his last novel,
The Confidence-Man
. In it, a colossal swindler embarks on a riverboat on an April Fool’s Day and proceeds to take advantage of the passengers’ credulity and greed. It’s a novel about trust—the reader’s as well as the passengers’—which Melville advises his readers to place not in psychologists, no matter how earnest, but in novelists, who, he says, can give us the same knowledge of the twists of our nature that a “
stranger entering
¹⁹
, map in hand, Boston town” has of the city’s crooked streets. But Melville, ever the ironist, won’t let us forget that we place confidence in the novelist at our own peril. He is anything but earnest; whatever truth he depicts emerges from the elaborate lie of a fictive world. Even his publisher was in on the joke:
The Confidence-Man
hit the streets on April 1.

The APA has books to sell, too. But it doesn’t have the luxury of calling attention to its own fictions and chalking them up to art. It can’t say with Melville that “he who, in view of its inconsistencies, says of human nature . . . that it is past finding out, thereby evinces a better appreciation of it than he who, by always representing it in a clear light, leaves it to be inferred that he clearly knows all about it.” Neither can it afford Melville’s arch awareness of the fallibility of all claims to knowledge about the human heart, about the dangers of placing our confidence in anyone’s book about us. So don’t look for the DSM to be published on April Fool’s Day. And, despite the fact that it is full of fictive placeholders, don’t expect the APA to suggest that booksellers shelve it with the likes of
The Confidence-Man.

Which doesn’t mean psychiatrists are above the open and intentional use of fiction, at least not when it comes to inventing mental disorders. Indeed, storytelling was central to at least one DSM-5 proposal: to add a diagnosis called Hebephilia to the sexual disorders chapter. Don’t feel bad if you’ve never heard of Hebephilia, which is what Ray Blanchard—the Canadian doctor who incurred the wrath of the transgendered—calls the attraction of grown-ups to kids in early adolescence. According to Blanchard, lead author of a paper calling for including Hebephilia in the DSM, even among professionals there is a “
general resistance or indifference
²⁰
to the adoption of a technical vocabulary for erotic age-preferences.” Clinicians are more likely to have heard of “granny porn” than of
gerontophilia
, Blanchard said, and hardly anyone uses
teleiophilia
to talk about “the erotic preference for people between the ages of physical maturity and physical decline”—this despite the fact that, as Blanchard noted with some apparent bitterness, “the word
normal
has been off-limits for describing erotic interests for decades.”

Blanchard wanted to overcome this resistance, at least when it comes to hebephilia, because he thought it was a “
discriminable erotic age-preference
²¹
.” Some men, in other words, have that underlying pattern of arousal necessary to making a diagnosis. They are turned on by kids on the threshold of adulthood more than by anyone else. He can say this with some authority because he and his colleagues examined 2,591 men, most of them convicted sex offenders, in order to determine what aroused them.

This is where the storytelling comes in. The scientists provided the men with audiovisual aids—large pictures of naked young people, ranging in age from five to twenty-six, displayed on a triptych in front of them, and, piped in through headphones, fictional narratives of sexual situations involving people whose ages roughly corresponded to the pictures on display. The men sat in easy chairs, looked at the pictures, and listened to the tales, one of which started this way:

Your neighbors’ 7-year-old girl
²²
is staying overnight at your place. You tell her it is time to get ready for bed. She asks if you will come and tuck her in. When you go to her room, she is already between the covers. You bend over to kiss her on the forehead, but she wraps her arms around your neck and pushes her mouth against yours. Giggling, she throws back the covers to show you she is naked. You sink to the bed, tenderly pressing your lips against the little groove between her legs.