The Book of Woe: The DSM and the Unmaking of Psychiatry (28 page)

Okay, it’s not Melville. It’s not even
Fifty Shades of Grey
. But the researchers weren’t asking the men for their critical opinion of the stories. Actually, they weren’t asking the men anything at all, at least not in the usual meaning of that word. They were asking their penises. Sex offenders, especially convicted sex offenders (who were Blanchard’s subjects) lie. But penises do not—mostly, however, because they do not talk. But Blanchard had a solution to this problem: the volumetric plethysmograph, or, as I like to call it, the Penis Whisperer.

The way it works is that the subject sits down in an easy chair. He slips a glass cylinder over his penis. After he pulls a sheet over himself “
to minimize his embarrassment
²³
,” a rubber cuff at the open end of the tube is inflated until it seals against the shaft of his penis. A hose attached to the bottle leads to a pressure transducer, which registers the slightest change in air pressure in the sealed cylinder—like, say, the kind that would be caused by a swelling penis. By mapping the behavior of the bottled-up penis onto the pictures and stories provided to its owner, researchers could chart the true course of a man’s desires.

But before they could say much about whether the readings meant the men were hebephiles, the scientists had to know which phallometric stimulus category
the objects of desire belonged in. To do this, they relied on the Tanner scale, an instrument that uses criteria like breast size, scrotum color, and pubic hair texture to rate the development of each photographic subject on a five-point scale. Having split the pubic hairs, Blanchard and his team were able to use the plethysmograph readings to prove that some men indeed show a strong preference for pubescent kids as defined by Tanner (breasts: 2.67; pubic hair growth: 2.33 [girls] 3.33 [boys]; genital development 3.83), most of whom were between eleven and fourteen years old. From this consistent response, they concluded that “
hebephilia exists
²⁴
and . . . that it is relatively common compared with other forms of erotic interests in children.” Which meant that the DSM-5 should either expand Pedophilia to include “erotic attraction to pubescent . . . children, or, alternatively, add a separate diagnosis of Hebephilia.”

But wait a minute!
you’re probably saying to yourself—that is, if you weren’t so creeped out by this research that you stopped reading. Did it really take doctors poring over pictures of naked kids, showing them to men while whispering erotica into their ears, and charting their penises’ responses to prove that men can be attracted to kids in the bloom of youth? Have they not heard of Humbert Humbert? Or read
Death in Venice
or Plato’s
Symposium
? Or maybe just grazed the ads of the most recent issue of
Vogue
or the celeb photo spreads in
People
? Have they been to a shopping mall recently? Did they really just crash through an open door and claim to have arrived where no one had gone before?

Well, yes. And that’s not all, nor is it the part that Melville might most appreciate. Having infallibly determined the longitude of men’s penises, Blanchard and his team went on to make what Melville called “a revelation of human nature on fixed principles”—that the attraction, when it is to kids at a certain Tanner stage, is an illness.

But for all his charts correlating penile response to stimulus category and his charts of
mean ipsatized penile response and his tables of Z-score transformations of the extremum of the curve of blood volume change, Blanchard never says which fixed principle allows him to conclude that what most states consider statutory rape, and most people consider flat-out wrong, is a mental illness. He doesn’t even bother talking about clinical significance, let alone philosophical notions (and, if he did, he’d have to explain how it goes against natural selection for men to be attracted to girls whose bodies are advertising fertility in nature’s neon lights). He seems to think that the charts and tables speak for themselves, that because he has figured out a way to measure it, a doctor’s pronouncement that hebephilia exists, coupled with our belief that it is repellent, ought to be enough to convince us that if this feeling is in a human heart, then it can only be the symptom of a disease.

Not that it is such a hard sell, this idea that a person who commits a heinous act is sick, at least not to a public confident that doctors know what is and isn’t a disease. Diagnoses are explanations of the otherwise incomprehensible, and to judge from the rates of Bipolar Disorder among children and antidepressant use among adults, from the relief that diagnosis brings to people like Michael Carley and Nomi Kaim, from the speed with which Jared Loughner and Anders Breivik were deemed schizophrenic, and from the opinion, at least in some quarters, that a better mental health system would somehow prevent mass shootings in schools and movie theaters, the market for representing our troubles in psychiatry’s clear light is strong.

This confidence—the belief that doctors know all about our suffering—is precious to the APA. It’s what they lost forty years ago, and what Spitzer worked so hard to restore with a book that looked scientific. It’s what the organization is really selling when it sells the DSM. Without this confidence, who will buy the book? And without the book, who will believe the psychiatrists? And without belief, how will their treatments work?

That’s why it’s one thing for Steve Mirin and Steve Hyman to acknowledge the book’s shortcomings to each other or for Kupfer and Regier to insist that its categories aren’t really real, and quite another for the complaint and criticism to come from Frances or Caplan or the British Psychological Society. Criticism from the inside can be tolerated and sanitized and turned into a marketing campaign about the living document. But criticism from the outside must be repelled with all necessary force, for it threatens to let the rest of us in on what psychiatrists already know: that there is no fixed principle for their revelations.

So you really have to wonder why, in the course of revising the DSM, the APA put that confidence at such great risk. Why would they suggest turning statutory rape into a mental disorder, or bereavement into depression, or adolescent eccentricity into psychosis? For that matter, why would they propose, in a country where a third of the population is morbidly obese and where food has become the latest preoccupation of the affluent, to turn “eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances,” and “eating until feeling uncomfortably full” or “when not physically hungry,” and “feeling guilty after overeating” into Binge Eating Disorder? Why would they propose, in a political and economic climate that offers no end of worries and occasions for despair, that people who are anxious and blue, but whose symptoms do not rise to the level of either Major Depression or Generalized Anxiety Disorder, should not be deprived of a diagnosis but instead should be said to suffer from Mixed Anxiety-Depression (which is a pretty clunky name until you consider its acronym)? Why would they propose with a straight face to a society of iSlaves that there is such a thing as Internet Use Disorder? Don’t they grasp just how fragile confidence is?

I can’t really answer that question. But I will point out that the APA wouldn’t be the first American corporation to overplay its hand. It’s happened to the best of them—General Motors, Kodak, Xerox, and all those other companies that suffered disruption and failure when they failed to remember what the confidence man must never forget: that confidence is always built on air, and that when it becomes known that what you are offering isn’t what you’ve cracked it up to be, your brand might lose its allure, and your company might lose its franchise.

E
arly in August 2011, an “Important Notice” appeared on the DSM-5 website. It was from the DSM-5 field trials team and addressed to DSM-5 field trials participants. “Have our e-mails been reaching you?” it asked.

As it happened, I hadn’t heard from the team since the end of February, when I got a note from Regier and Kupfer professing their “delight” at my acceptance as a clinician in the field trials and promising more details soon. In the meantime, however, I’d heard (from Bill Narrow) that my
Wired
article about the revision hadn’t played any better at the APA than it had with Frances. So when no news had come by July, I figured that maybe the delight had worn off and that the DSM leadership had come to the same conclusion as Donna Manning had—that allowing me into the field trials was like “letting the plague rat onto the ship.” (I think she meant this in a good way.)

But the silence turned out not to be about me at all. “
We are . . . test piloting
¹
the training materials,” the team explained after I e-mailed in July asking for an update. They added that they hoped to have them out “in a few weeks.”

A few weeks later, however, the only thing the APA had out was the Important Notice, which offered a new explanation for having been incommunicado. This time the problem was about me, sort of.

The most common reason
²
for this is because our emails are being blocked by your email server’s Spam filter. If you have not received any recent (i.e., within the past 2 months) email communications from the APA regarding field trial participation, please be sure to check your Spam or junk mail folder and look for any communications from us.

I wondered if the team had capitalized “Spam” out of deference to Hormel Foods, one copyright holder to another. I also wondered why they didn’t just put the information that we had supposedly missed right into the notice. I can’t say with certainty that the team was resorting to the excuse that all of us have used at one time or another to explain our dilatory e-mail habits, but I was sure of one thing: there were no messages from the APA trapped in my spam filter. Neither had any e-mails made their way to Michael First or Dayle Jones, both of whom had also signed up—or, according to Jones, to any of the would-be volunteers she knew.

In early September, when I still hadn’t gotten the errant messages, or anything at all, I e-mailed Eve Moscicki, the APA researcher in charge of the clinician field trials, asking when I might hear from her team and when the trial might begin. The next day her office sent an apology and the password I needed to log in to the REDCap website. I also received a separate apology directly from Moscicki. She explained, “
We have learned
³
that some security settings automatically delete our e-mails and the recipient never sees them.” She didn’t say why the APA couldn’t figure out how to do what every Viagra dealer and Nigerian scamster seemed to know how to do. (I did pass along my skepticism to Moscicki, pointing out that no one seemed to have received anything and suggesting that the problem might be at her end. “
Thanks for your candid note
⁴
,” she wrote back. “Much appreciated.”)

I went to the Vanderbilt site. My password and login didn’t work. Ten days, and many e-mails later, I was finally able to sign in. Just a day after that, the APA finally figured how to get an e-mail blast past all those spam filters. It was
another note from Kupfer and Regier
⁵
, congratulating me, once again, on being accepted into the program. They didn’t acknowledge that it had been five months since they first did that, and a full year since the APA announced the start of field trials. They did, however, give me my official title—Collaborating Investigator—and assigned a new significance to this “unique opportunity”: it would be, they promised, “one of the most important psychiatric research studies of this decade.” And if that wasn’t reward enough, they were also offering fifteen continuing education credits, my name in the DSM-5, and a free copy of the book, whenever it came out.

•   •   •

One part of my training had already begun. As Bill Narrow had explained at the APA meeting, and as the team reminded us, we Collaborating Investigators were supposed to “familiarize” ourselves with the revisions by poring over the website, paying attention to the diagnoses we were most likely to render.

This was a tough assignment. The changes were many and complex. Here, for instance, is the
DSM-5 proposal for Generalized Anxiety Disorder
⁶
(GAD), a diagnosis most of us collaborators were likely to use, as it stood in June 2011.

A. Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (e.g., family, health, finances, and school/work difficulties).

B. The excessive anxiety and worry occurs on more days than not, for 3 months or more.

C. The anxiety and worry are associated with one or more of the following symptoms:

1. restlessness or feeling keyed up or on edge

2. muscle tension

D. The anxiety and worry are associated with one (or more) of the following behaviors:

1. marked avoidance of activities or events with possible negative outcomes

2. marked time and effort preparing for activities or events with possible negative outcomes

3. marked procrastination in behavior or decision-making due to worries

4. repeatedly seeking reassurance due to worries

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

G. The disturbance is not better accounted for by another mental disorder (e.g., anxiety about Panic Attacks in Panic Disorder, negative evaluation in Social Anxiety Disorder, contamination or other obsessions in Obsessive-Compulsive Disorder, separation from attachment figures in Separation Anxiety Disorder, reminders of traumatic events in Posttraumatic Stress Disorder, gaining weight in Anorexia Nervosa, physical complaints in Somatic Symptom Disorder, perceived appearance flaws in Body Dysmorphic Disorder, or having a serious illness in Illness Anxiety Disorder).

And here is
the old one
⁷
:

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

The APA didn’t make it easy for us to see the differences by placing the diagnoses side by side or creating a chart or, for that matter, just using their word processor’s Track Changes command as Michael First had in Honolulu. And there were many changes. Six months of worry had become three. Fatigue, difficulty concentrating, irritability, and sleep troubles were out, while avoidance, procrastination, reassurance seeking, and “marked time and effort preparing for activities or events with possible negative outcomes” (think Mrs. Dalloway) were in. The threshold had been changed from three out of six Criterion C symptoms to one out of two Criterion C and one out of four Criterion D symptoms. “A number of events” that are the subject of worry has become “two or more domains of activities or events.” And so on.

The good news was that I hadn’t ever committed the old criteria to memory, so at least I wouldn’t have to unlearn them. I was, however, going to have to get accustomed to using criteria to make the diagnosis in the first place. That’s not something anyone I know in this business actually does. Mostly we’re content to find a label that matches people in some vague way and then get on with the business of helping them figure out what’s going on in their lives that landed them in our offices.

There are exceptions, of course. Take the psychiatrist I will call Dr. Benway. He’s a respected practitioner in my neighborhood to whom I had referred a young woman I’ll call Charlotte. She was thirty-two years old, the daughter of Chinese immigrants, and recently divorced. I’d been seeing her for a little more than a year, and she had just begun to talk about the way her father used to crawl into bed with her and, as the rest of the family slept, force her to have sex with him. She hadn’t told anyone about this before, and she was unraveling in the way people often do when they start to take apart the finely built edifice behind which they’ve hidden their shame and fear and rage. Charlotte was also in the midst of a huge project at work, one that she needed to complete if she was going to keep her job. So it was not a good time for her to be anxious all day and sleepless at night. She had asked me if I could help her get a prescription for Valium from someone other than her family doctor, to whom she did not want to have to explain herself, and that’s where Dr. Benway got involved.

Returning to me after her visit, she told me that he had given her an antidepressant and a mood stabilizer for her depression and suggested that she try a stimulant for her ADHD; he told her they would explore that possibility more when she returned to him the following week. “Do you think I have ADHD?” she asked.

I told her I did not think she met the criteria.

“Then why would he say that?” she asked. “And why did he prescribe Zoloft and Abilify? Do you think I have depression?” She told me about the psychological tests she’d filled out as part of her paperwork for Dr. Benway, the ones that asked her about different thoughts and feelings she’d had over the last weeks or month. Then she asked, “What is my diagnosis anyway?”

I tried the therapist’s usual evasions, asking her why she wanted to know and what it meant to her to have her professional parent figures disagreeing about her and what it was like for her to think her therapist didn’t know what he was talking about. But she wouldn’t be dissuaded. This was the first time Charlotte had ever been demanding in this way—direct and forthright and confident—and even if it was a demand I was poorly equipped to meet, I felt that I had to meet it. So I fessed up.

“You don’t have one,” I said.

“Why not?”

I explained that therapy, not unlike medication, was really targeted at symptoms, not illnesses, and to the extent that we were surely trying to get at what lay underneath the symptoms, the DSM’s labels and criteria were not particularly helpful toward that goal, that they renamed her suffering without explaining it.

I didn’t tell Charlotte I’d stolen that line from William James. I also didn’t tell her the other reason I hadn’t given her a diagnosis. But I did tell Dr. Benway, because when I called him (to pester him on her behalf to prescribe the Valium so she could sleep, and maybe to chide him for the cocktail he’d mixed for her), the first thing he asked was what her diagnosis was.

“She doesn’t use insurance,” I said. “So she doesn’t have one.”

This could have been Dr. Benway’s moment to go Gregory House on me, to reveal the sign I had missed and the diagnosis it led to, to question how I could possibly treat someone in the absence of a diagnosis. He didn’t do any of this, however. I’m not sure why. It may be because our clinician communication—about Charlotte’s current functioning, her anxiety, her insomnia and difficulty concentrating, her mood swings—didn’t seem hampered by the fact that we weren’t using the language scientifically proven to make our conversation reliable. It may be because when he explained the cocktail he’d prescribed—the way the Abilify/Zoloft combo could “put a floor under her” without agitating her and how adding Ritalin to the mix might just get her neurotransmitters all nicely balanced—I didn’t point out to him that his opportunity to medicate Charlotte exceeded anyone’s knowledge about any of that. Truce, standoff, going along to get along: Dr. Benway’s silence about my diagnostic negligence and mine about his diagnostic exuberance could have been any of those. But somehow I think it might be something else entirely—that we both knew the truth of what I had said: In the absence of an incentive, who would bother with a diagnosis?

•   •   •

But now that I am a Collaborating Investigator, perhaps I should consider giving Charlotte a diagnosis. The DSM-5 with which I am supposed to familiarize myself offers all sorts of possibilities. GAD, for example, with its
marked
s and
excessive
s providing all kinds of wiggle room for the insurance-dependent, is, despite its many changes, an obvious choice. Major Depressive Disorder has been left mostly alone (other than the absence of the bereavement exclusion, and, no matter what the new criteria said, if presented with a grieving patient, I’m going to pretend to be astute and not add the insult of a diagnosis to the injury of a bereavement), and if Charlotte doesn’t reach its five-of-nine threshold, there is always what has been called Dysthymia in DSM-IV and what the DSM-5 proposes to call Chronic Depression, a two-of-six offering. Adjustment Disorder with Mixed Anxiety and Depressed Mood calls for no more than six months to elapse between the psychosocial stressor to which the patient is adjusting poorly and the onset of symptoms, but if I decide that the stressor is Charlotte’s disclosure of the incest and not the incest itself, then that diagnosis would work just fine.