The Book of Woe: The DSM and the Unmaking of Psychiatry (31 page)

Skodol also ventured an explanation for not simply choosing one of the established personality theories, with its validated concepts and measures, and instead cobbling together a model that, as the APA work group noted on the website, was still “pending empirical validation.” “
We knew we couldn’t incorporate
³⁰
anybody’s model in toto,” he told me, “because the APA wasn’t going to pay royalties” to any copyright holder.

Whatever the rationale, the proposal left Widiger hopping mad. “The empirical support is a farce,” he wrote in an e-mail to his colleagues, the section “
embarrassingly bad
³¹
.” It would become “the laughingstock of the DSM and psychiatry,” he predicted. “It’s a monumental mistake.”

Widiger wasn’t alone in being appalled. John Livesley went public with his charge that the proposal was “a disaster.” He withdrew his name from the work group’s journal article describing the changes and published his own dissenting opinion in March 2010, lamenting the proposal as a “
lost opportunity” that “negates years of progress
³²
toward a scientific-based classification system.” In April, Frances called the proposal a “
cumbersome hodgepodge
³³
” whose dimensions were “the favorites of the few members of the work group who have personal research experience in this area.” The comments submitted to the website during the spring ran strongly against the proposals. In September, a group of eight psychiatrists and psychologists, some of the biggest names in the business, ranging from the ancient psychoanalyst Otto Kernberg to the even more ancient father of cognitive-behavioral therapy, Aaron Beck, to the upstart political psychologist Drew Westen, put aside their differences to tell readers of the
American Journal of Psychiatry
that the proposal was “
an unwieldy conglomeration
³⁴
” whose traits and facets “have not been investigated empirically,” which meant that the model “no longer rests on the decades of research” that had been “the chief rationale” for making the change to a dimensional model in the first place.

In the fall of 2010, the task force staged what Skodol called an “intervention.” “They hated the prototypes”—the descriptions of personality disorders that had replaced the criteria. “They reminded them of DSM-II,” he explained, and they weren’t crazy about the rest of it, either. “You guys look like outliers,” they told him, as they ordered the group back to the drawing board—this time with two “consultants” (“minders,” one committee member called them) to assist in reformulating the proposals. In a series of weekly phone conferences, chaired not by Skodol but by one of the consultants, a new proposal was hammered out and a “simplified and streamlined” proposal was posted on the website in late June. Now there were five trait domains instead of six, and thirty-one facets instead of thirty-seven, and six types instead of five. The criteria for those types were back, reflecting the task force’s mandate to, as Skodol put it, “make the section look more like the rest of them.”

Skodol took his very public rebuke in stride. He understood his colleagues’ protests. “I mean, if you had spent your career studying Dependent Personality Disorder”—one of the five slated for elimination—“then I can see why you would be upset.” Entire data sets accumulated over years would have to be mapped onto new categories. In at least one case—Narcissistic Personality Disorder—the vehemence and volume of the public comments prevailed over the lack of empirical support, leading the committee to rescue it, against Skodol’s wishes, from nosological oblivion. But, he told me, even if this was the “most political” of the decisions, “if you’re going to welcome comments, it doesn’t make sense not to respond to the comments.”

Skodol seemed stung about just one aspect of the “politics.” His group had taken seriously the mandate to switch to a dimensional system, but “the rest of the work groups didn’t get it, and Darrel and David were never able to convince them that dimensionality was the way to go,” he told me. “I don’t think they had quite the clarity of vision that Bob Spitzer had when he did DSM-III. He had this vision, and he sold it until it was bought, and I don’t know that Darrel and David ever did that.”

Kupfer and Regier, in other words, had failed to do in DSM-5 what Frances (at least according to Widiger) had failed to do in DSM-IV: to ram through the changes that would decouple psychiatry from the categories that most of its leaders knew were fictional, that had once worked to restore the profession’s reputation, but now threatened it. Maybe the problem was that Kupfer and Regier’s “bottoms-up” approach registered with their foot soldiers as a lack of leadership, or perhaps the leap from categories to dimensions was so long, the stakes of missing so high, that Spitzer himself couldn’t have sold it. Or maybe Freud was right. Maybe the trouble that surfaced in the personality disorders, the section of the DSM most indebted to the past, was only the latest symptom of a neurosis, of a dream that can’t be fulfilled: to make psychiatry into just another specialized branch of medicine.

I
n September 2011, David Kupfer traveled across his home state to kick off “Categories and Controversies: The Ethical Dimensions of the DSM-5,” a program at the Center for Bioethics at the University of Pennsylvania. He told the audience of about seventy-five how glad he was to be at the university that two of his children had attended and that housed many of his research partners. In these friendly confines, he seemed confident. “You don’t have to pay attention,” he said, “because I’m assured you have the slides, so if you wanted to wander around or take a nap . . .” He was casual and personal as he told us about his experience working on DSM-IV (which, he said, had left him with “no interest and no desire” to work on DSM-5, but he’d nonetheless been talked into taking the reins) and about the importance of innovating while still maintaining continuity with the past. In a nod to the day’s topic, he gave assurances about the importance of public input and displayed the statistics from the public comments, which now totaled 10,751. He explained that DSM-5 would be a living document, although he still wasn’t sure how or when or under what circumstances DSM-5.1 and further updates would be issued. And he ended with an announcement, delivered with mock seriousness. “We’ve decided on the color of the cover,” he said. The slide showed the familiar DSM cover, only in purple instead of the DSM-IV-TR’s gray. “It was a huge debate, but that’s been settled,” Kupfer said with a smile.

Kupfer acknowledged the DSM-5 troubles only obliquely, noting almost in passing that there were “individuals who will say from the outset that it’s ridiculous to revise DSM-IV,” a charge he breezed past with a brief reminder of the current book’s shortcomings. But just as I was contemplating that nap, he turned to a subject that was, at least to me, new and startling.

“I want to tell you a little about the competition,” he said, a group at Columbia, led by a “young psychiatrist” named Helena Hansen. “They’re not a group that has anything to do with DSM-5,” he continued. They had invited Kupfer to one of their meetings. “I didn’t have to wear a vest to protect me,” he joked, “and it was a great experience.” Kupfer reported that Hansen and her team were proposing a “DSM receptor,” a group “outside the usual suspects” that would “periodically convene” to monitor “the implications of DSM-5 on society” and “collaborate closely with the DSM task force” to reckon with the findings, and that Kupfer was planning to take them up on their offer.

“I call them my friendly gadflies,” he said. He didn’t add “as opposed to some other gadflies I know,” but anyone who had been following the developments would get the point: the APA was taking concerns like Frances’s seriously enough to appoint a committee of ombudsmen.

When I tracked her down, Helena Hansen wasn’t at Columbia, but rather at New York University, where she was a professor of anthropology and psychiatry. She told me she was indeed part of a group looking into the social dimensions of psychiatric nosology. They had responded to the APA’s call for public comment, had gotten some money from the Robert Wood Johnson Foundation to hold a meeting on the subject—the session Kupfer had attended—and sent out an article for review.

“
There has been a continual struggle
¹
to recognize and incorporate socio-cultural considerations into the DSMs,” she told me in an e-mail. “This has not been seen as mainstream to the project, which is focused on buying credibility for psychiatry through biological formulations.”

She sure sounded as if she had the chops for the gadfly position. But there was a problem: my e-mail was the first she’d heard of Kupfer’s plan.

“I am not sure what Kupfer meant by gadfly,” she wrote.

I sent her my transcription of his talk.

“
This is amazing
²
!” she wrote. “Wow. Well, I am tickled that we are now a ‘committee of experts.’”

Hansen seemed willing to do the job. But she wasn’t exactly waiting by the phone for Kupfer to call and offer it to her. “We are just hoping the piece gets published,” she told me.

•   •   •

Back in California, the unfriendly gadfly sent me a staccato message in mid-November that seemed more fit for a telegram than an e-mail. “
Approaching endgame
³
. This is turning out to be much worse than I anticipated. A truly shitty way to end a career.”

Frances’s dour dispatch contrasted sharply with the ebullient one he had sent just a few weeks before. “
A random and geographically diverse
⁴
pick-up team of previously unknown idealists joins forces to create a grassroots movement that saves DSM-5 from itself and spares the world an orgy of diagnosis and a worsening epidemic of prescription drug use.” And that was just the subject line.

The man who had once portrayed himself as “
pretty Spockean
⁵
(as in
Star Trek
, not Benjamin)—too rational, old, and indifferent to take things personally”—was evidently having some mood swings.

Among the idealists who had buoyed him was psychologist David Elkins, head of one of the American Psychological Association’s divisions. He had written
an open letter to the APA
⁶
, complaining about the DSM-5’s lowered diagnostic thresholds, shaky evidence, carelessness with the public health, and, of particular concern to psychologists, its “reconceptualizations of mental disorder as primarily medical phenomena.” Elkins posted the letter on a petitions website on October 25, and it had attracted nearly five thousand signatures by November 8. That was the day that the president of the American Counseling Association sent
a letter on behalf of his 115,000
⁷
DSM-buying members to the president of the APA. It reiterated the petition’s objections about the quality of the science behind DSM-5. It called for the book to acknowledge that “mental disorders may not have a biological component” (although it did not explain just how it would be possible to have a mental disorder that did not somehow involve the brain). And it urged the APA to make public the work of the scientific review committee it had appointed to review the proposed changes, as well as to allow an evaluation of “all evidence and data by an external, independent group of experts.”

This was a “tipping point,” Frances wrote me. It wasn’t the first time he’d thought that. In February 2010, the tipping point was going to be his open letter to the APA board. At the end of that year, it was going to be my
Wired
article, which would “
bring Darrel to see DSM-5
⁸
through the eyes of the world that lives outside the bunkers.” In the summer of 2011, he thought it would be his blog detailing the scientific shortcomings of DSM-5. But this time, he thought, the APA—its trustees if not its DSM bureaucrats—would have to see how bad things were. It was one thing to dismiss his protests as the raving of a jealous ex-chairman clinging to his passing glory (and royalties) and quite another to ignore these two powerful groups of professionals—and customers—not to mention the two or three hundred people from around the world signing the petition every day.

Of course, the APA was still hearing from Frances. His fingerprints were all over the letters from the psychologists and counselors, and he continued to chide them in his blogs—BlackBerryed in from San Diego and Carmel, as well as from Italy and Israel and Turkey and wherever else he happened to be traveling (often presenting his PowerPoint on the impending disaster)—and in the interviews he was granting to journalists all over the world. And he was now, he told me, “rattling some cages” on a back channel to the APA trustees and officers, with whom he was “
trying to negotiate
⁹
a face-saving compromise.” (I think he meant their faces.) Even as he repeated his claim about the unimportance of bosses (“The most useless person on the battlefield is Napoleon,” he wrote), he was in the thick of the battle, more godfather than general, perhaps, but directing the war just the same.

And he was trying to direct me more than ever.

“
Cast of fascinating and colorful characters
¹⁰
who deserve recognition and will greatly enrich human interest in your story,” read the subject line of a note introducing me to a former television news producer (“bright, active, and great contacts”), a “somewhat eccentric and fascinating British lady who knows all there is to know about social networking,” and a “seasoned mental health consumer advocate.” And these weren’t even the same previously unknown idealists who, just a few weeks earlier, he had nominated as the “unsung heroes” of my book.

“
This will likely be the most important
¹¹
interview you do for the book,” he wrote, when I told him about an interview I’d scheduled with an APA trustee. He gave me some advice on how to “get him comfortable” with me and warned me that I shouldn’t “spook him” by letting him know just how much contact he and I had had.

“
Don’t waste your best brains
¹²
,” he advised me, when he heard about another interview, whose subject, Frances thought, “was a nice enough guy but peripheral.”

He was trying to help someone he believed to be an ally, I think. But as allies go, I was problematic. I had sent him a peace offering for the bullshit quote—a copy of
On Bullshit
—but it continued to rankle. “
I was in Dubuque
¹³
, Iowa, in the courtroom testifying . . . before a jury of upstanding cornfed godfearing people who got to discover [via] Greenberg just how foul mouthed was this defender of the constitution,” he wrote. “Thanks again, Gary.”

But it wasn’t the prosecutors and juries he was most worried about. It was the real enemy, the antipsychiatrists, to whom “
your brilliant opening
¹⁴
” had given ammunition. He allowed that maybe I hadn’t meant this outcome, but that just made matters worse. “It was my lips that sank this ship,” he wrote, “but you know sin on this one too . . . You are not concerned enough to avoid giving them aid and comfort.” Heedless of the consequences of my own words, I was encouraging patients to discontinue treatment.

“I am pretty light about most things in life, but this is not a joke and you still don’t get it,” he scolded. It was an unusually excoriating performance for someone who, true to his word, had previously favored teasing me—for instance, calling me “
Paula Caplan in drag
¹⁵
”—over yelling at me.

Of course, it’s not as if Caplan or any other antipsychiatrists needed my help, not when Frances himself was delivering one blistering blog after another. The Citizens Commission on Human Rights, the agitprop wing of Scientology, was hanging on his every word and gleefully reprinting news articles about this “
one-time pillar of the psychiatric establishment
¹⁶
,” as one report put it. Even the real Paula Caplan had reached out to congratulate him for his courage in an e-mail he forwarded to me under the subject line “
Fate has an ironic sense of humor
¹⁷
.”

“
Everything I say
¹⁸
,” he lamented, “is seized by the antipsychiatry fanatics and misused for their own unfortunate purposes.”

The more his criticisms of DSM-5 were turned against his profession, the more he protested that he was Panza, not Quixote. Neither was he Saul, suddenly truth-struck on his way to Damascus and testifying to the new revelation, nor was he an apparatchik-turned-dissident denouncing his former comrades for their ideological excesses, nor was he a deposed emperor confessing to his own nakedness even as he exposed the new boss’s. He was a loyal opponent, not an enemy of the state, and he wanted to make sure I understood that.

“
Where you see intelligent conspiracy
¹⁹
, I see dopey incompetence,” he wrote. “In movie terms, you see APA and DSM-5 as
The
Parallax View
meets
The
Stepford Wives.
I see it as the Keystone Kops
meets
The Gang That Couldn’t Shoot Straight
.”

“
Dereification is just as dumb
²⁰
as reification,” he told me. “A construct is just a construct—not to be worshiped and not to be denigrated.” Psychiatry, he was saying, has to live in the tension between the desire for certainty about the nature of our suffering and the impossibility of understanding it (or ourselves) completely. A DSM that tries to end this tension by turning itself into a living document was bound to collapse into chaos; that was the cardinal error of the incompetent DSM-5 regime. But to criticize the nosological enterprise, and with it psychiatry itself because it can’t achieve certainty was to erect a straw man and then burn it—and to endanger the good the profession could do. This, Frances told me, was the greater mistake. And he was sure I was making it.

“
I like to think the best of you
²¹
,” he wrote. He wanted to think I was not so much against psychiatry in principle as “angrily disillusioned [that] there is no Santa Claus”—offended that it can’t be as scientific as, say, physics. I was, he said, referring to James Joyce’s
Ulysses
,
an “upside-down Jesuit,” demanding an explanation that religion never claimed to offer and then enthusiastically denouncing it for its failure to provide it.

If this was the case, then, like Kupfer and Regier, I was guilty only of incompetence. But there was another possibility. “The less charitable interpretation of your blind spot is that it fits your Caplanesque worldview”—that I was prejudiced against psychiatry, suspicious of its claim to dominion over our inner lives, and that its failure to live up to a trumped-up scientific standard, so baldly on display in the unfolding debacle, was only a convenient excuse for me to denounce it.

Which I suppose is true. Not that I am somehow determined to see psychiatry ridden out of the medical kingdom. Nor do I think all psychiatrists are drug-pushing Pharma dupes. But it hadn’t been my idea to turn psychoanalysis into a branch of medicine in 1926. Neither had I had anything to do with the decision, made four decades ago, after the attempt to render the psyche as just another organ in the body had led to disaster, to save psychiatry by creating a DSM ripe for the reifying and then, when the categories became cumbersome or inadequate or just plain embarrassing, to blame others for taking them too seriously. Nor was it I who kept insisting, against all evidence, that the mind could be understood as the output of neurotransmitters, its suffering as chemical imbalances, and psychiatry as a Santa Claus doling out drugs from an ever-growing bag.