The Book of Woe: The DSM and the Unmaking of Psychiatry (36 page)

Before O’Brien got down to the business at hand—his committee’s proposals—he turned to the business of business. “People should understand that when they read things in the newspaper about Pharma influence, I don’t believe it,” he said, as he made the conflict-of-interest disclosure required of every speaker. “We stopped that a long time ago, even though in the past we might have had some consultancies.” O’Brien didn’t say exactly what they had stopped, but it clearly wasn’t the consultancies. Indeed, he was still working for three drug companies. “Only two of them are actually producing drugs that you can prescribe or buy,” he explained, and this work “is really socially important, because there are very few medications available and not many companies are working on this.” The public fails to understand this, and psychiatry (or at least psychiatrists’ income) is the victim of its ignorance.

This was a riff that could not help but ingratiate O’Brien with his audience. And he needed all the help he could get. He had to explain to his colleagues, many of them skeptical, why his group had eliminated the categories of
substance abuse
and
substance dependence
, which the DSM-IV had used to sort out the people who merely get in trouble with drugs from those who get addicted to them. In their place, the committee proposed the supercategory of
substance use disorders
, which, it said, occurred whenever there was a “problematic pattern” of substance use that led to “clinically significant impairment and distress.” O’Brien’s group, perhaps remembering that no one had yet defined clinical significance, had listed eleven further criteria. If an impaired patient met two of them, he or she had the disorder. So, for instance, if in a twelve-month period you “often” drink “larger amounts or over a longer period than intended,” and experience “craving or strong desire or urge to use alcohol,” you qualified for Alcohol Use Disorder. The few studies that had been done using the new diagnoses indicated that many people looked forward intensely to their next party and, when they got there, took that third martini or extra toke—enough, in fact, to cause some Australian researchers to forecast
a DSM-5-related 60 percent increase
¹
in the prevalence of drug-related diagnoses.

O’Brien thought these warnings were balderdash, but he also thought the DSM-IV was balderdash. “I feel free to criticize DSM-IV,” he said, because he’d been part of that revision, which he now characterized as “a bunch of wise men sitting around a table and asking what happens when people start using drugs.”

“Although we thought we were wise, we were wrong,” he said. “There is no evidence to support this idea of drug abuse.”

Not that people don’t use drugs to their own or others’ detriment. But the problem isn’t that sometimes the use causes collateral damage (abuse) or becomes habitual (dependence). The problem is “compulsive, out-of-control drug seeking.” O’Brien would have preferred to call the reformulated disorder
addiction
, but “some people have a kind of allergy to the word,” believing that it carries too much stigma. Avoiding the a-word is “useless,” O’Brien said. “When you have the president talking about addiction to oil, the word has lost its pejorative tone,” and besides, even if the president did mean it pejoratively, addiction is “what the average doctor is going to call it.” But the chair was evidently outvoted, and the anodyne new name won the day.

Whatever its name, O’Brien had no doubt about the nature of the problem. “Addiction is a brain disease,” he said. Of course, this was the tacit assumption of the DSM, not to mention of psychiatric nosology for the last hundred years: that what psychiatrists were treating were illnesses that originated in the brain, and that someday they would find out exactly where and how. That promise, O’Brien reminded the crowd, had gone unfulfilled. “Let’s take depression or anger or any of the other things we diagnose,” he said. “They’re all subjective. You have to get hints from what the patient says and how they say it, but you have no test for it.”

On the other hand, “we do have tests for craving,” he said. “I think craving could become the first biomarker in psychiatry. I can show you where it is in the brain.” And so he did, flashing a photo on the screen. “If you’re an addict,” he said, “you’re noticing this person is booting right now.” Actually, you didn’t have to be an addict; the picture featured a tied-off arm, a blood-filled syringe stuck into a tracked-up vein. What would be different if you were an addict—at least it would if you had just been given a shot of carbon-11 raclopride, a radioactive marker, and a PET scanner had just detected its emissions—is the way your brain would light up upon beholding this image. “This is the caudate, this is the putamen,” O’Brien said, pointing to the next slide, a chart of an addict’s neural activity. “There’s a complete correlation here between the subjective feeling of craving and the degree of inhibition of the binding of raclopride.” Similarly, said O’Brien, show an alcoholic an image related to drinking, and you will notice “increased blood flow to the cingulate gyrus, the anterior cingulate, the insula, and the nucleus accumbens down here.” In both cases, you’re seeing disturbances in dopamine metabolism, “the reward system,” as O’Brien put it. You’re seeing addiction—not the experience, which can only be described in words and assayed subjectively, but the thing itself—caught when it thought no one was looking, naked and unmistakable.

Of course, there was a catch. “The clinician would have to have a brain-imaging machine,” said O’Brien. “But these are getting to be very common,” he added. He didn’t have to explain to this crowd what that really meant: that devices like brain scanners could be huge profit centers, a way to go outside their comfort zone and get well paid for it, as Lawson Wulsin would put it, to win at the game by delivering the measurement-based care that insurers crave.

It’s too bad the doctors’ brains weren’t being scanned as they gazed upon the evidence that their most fevered cravings were on the verge of fulfillment, that after a century of wandering in the biomedical desert, one psychiatrist was ready to lead them home.

O’Brien ended his talk by pointing out that it’s not just boozers and cokeheads whose addiction (and, presumably, recovery) can be verified by the magic machines. “We’ve listed gambling with the use disorders and we’ve put Internet Use Disorder in the Appendix,” O’Brien said. He’d saved it to the end, but this news was hardly an afterthought. By poaching what the DSM-IV had called Pathological Gambling from the disorders of impulse control work group, his committee had pulled off a coup. It had made official what once was only folk wisdom: that we could be addicted to behaviors as well as to drugs. We could be workaholics and shopaholics, sex addicts and love addicts, hooked on cyberporn and jonesing for carbs. (Indeed, the first question O’Brien fielded was from the head of the Food Addiction Institute, who demanded to know why food addiction
hadn’t been included.) Any strong desire could be put under surveillance and diagnosed with dead certainty, and any behavior with the telltale signs, anything that set that circuitry in motion, could be called a disease.

The brain scanner, O’Brien said, “tells us directly what’s going on.” And that’s the beauty part: no need to take your hints from what junkies or boozers say or how they say it. Indeed, there’s no need to talk (or listen) to them at all. Neither is there any reason to pay attention to those English professors and other amateurs who, emboldened by the DSM’s simple language, might kvetch that it might not be such a good idea to pathologize desire in a country where people line up at midnight to buy the newest iPhone, where greed is a virtue and the pursuit of wealth a spectator sport, where an entire economy depends on an endless cycle of craving and not-quite-satisfaction. When the DSM is finally full of words like
nucleus accumbens
and
putamen
, these critics will be out of business.

And so will the rest of us. Because if the brain scanners fulfill their promise, psychiatrists will finally be able to cut out the middleman entirely, and with him the subjectivity that was once psychiatry’s bread and butter, but which, especially when it comes to diagnosis, has become its bane. After all, who needs dimensional assessment forms, let alone the stunted conversations that allow clinicians to fill them in, when you have raclopride?

•   •   •

While Regier was presenting the results of the field trials, the 159 voting members of the APA Assembly were taking up a question of great importance to him. Roger Peele, the assembly’s representative to the DSM-5 task force, had proposed an action paper that called for all the dimensional measures Regier had proposed—the cross-cutting assessments, the severity scales, and the personality disorder ratings—to be placed in Section 3, the task force’s new name for the Appendix, where they would await “further study.”

“
I wanted to avoid a repeat of Axis V
²
,” Peele told me, referring to the DSM-IV scale that asks a clinician to rate a patient’s overall functioning from 1 to 100. Once that measure had been instituted, Peele remembered, “insurance companies used it as a basis to deny service.” The result was predictable—“One of the first things you were told when you joined a hospital staff was, ‘Doctor, all Axis V’s on this ward are a forty or less’”—and regrettable.

“It makes a farce of psychiatry,” he said.

And it wasn’t just the insurance companies whose demands turned psychiatry into a game of Diagnosing for Dollars. A public sector psychiatrist, Peele knew that bureaucracies like his were number-crazy. If the DSM offered measures, then clinicians were sure to be compelled to use them, and their workload would increase—a problem obscured by the Facebook approach to evaluating the measures. “The ‘liking’ of severity scales . . . by clinicians volunteering to be part of the DSM-5 field trials is not necessarily representative of the vast majority of American clinicians who did not volunteer to be part of such trials despite many opportunities to do so,” he wrote in the resolution.

Perhaps the burden of the dimensions would have been worthwhile, and the method of evaluating them unimportant, had they had any scientific integrity. But “most, if not all, are not based on science,” Peele told me—and that was assuming you could even find out what they were. “Some of them are so immature that if you go to the website, they aren’t even shown.” And indeed, even at this late date, a click on the tab for many proposed measures returned the message that “recommendations . . . are forthcoming. We encourage you to check our Web site regularly for updates.”

The day before the assembly meeting, Regier had had a chance to defend himself to a committee with the power to endorse the resolution to the full body. He spoke longer than anyone else at the meeting, but nothing he said swayed the committee, which recommended the passage of the resolution; and the very next day the assembly voted unanimously to send the dimensional measures, which Regier had once promised as the key to springing the APA from its epistemic prison, to the elephant burial ground.

•   •   •

As he had in Hawaii, Michael First spent the beginning days of the meeting hanging out with this year’s gathering of the Association for the Advancement of Philosophy and Psychiatry. It wasn’t quite so captivating this time around. “Too much name-dropping of philosophers whose work I am not familiar with,” he told me, “so the arguments are too hard to follow.”

Still, First knew enough about philosophy and its significance to the DSM to have once put his name on a paper urging the task force to appoint a DSM-5 work group that would take up “conceptual issues” such as the definition of mental disorder. “
Conceptual questions are not minor ‘side issues
³
’ to be dealt with in improvised ways,” the group wrote. “Conceptual clarification is a critical partner to good scientific work . . . [and] advances the scientific rigor of our work.” The paper was published in 2008. The task force never responded.

Four years later, and too late for them to have any impact, the philosophers were given a chance to philosophize at one of the annual meeting’s official symposia—“Philosophical and Pragmatic Problems for DSM-5.” But, as they had in Hawaii, they remained mostly on the fringes, this time at a Crowne Plaza a few blocks from the convention center, where the elevator actually stopped at the floor of the meeting room. Everyone attending had heard David Kupfer assert that the DSM was all but completed, and the panels on ideology and the role of science in medicine and other chewy issues seemed more like pathologists’ probes at a postmortem than clarifications contributed by critical partners.

First was the discussant for the symposium, which the APA had scheduled for the same time slot as the field-trial session. He had asked me to report the results to him. He shook his head as I read them off.

“Point twenty for GAD?” he asked. “Really?”

He ventured an explanation. The new criteria required a clinician to determine if the patient’s anxiety led him or her to avoid activities “with possible negative outcomes” or to procrastinate “due to worries” or to “repeatedly [seek] reassurance.” These, First thought, were vague notions, poorly written and untested; it was no surprise that clinicians could not agree on them.

This much, he acknowledged, was speculation. But that was his point: he had to speculate, and so would the people who had to figure out what to do with the DSM-5, because the field trials had not been designed to find out what had gone wrong, nor was there time for a second round to see if the problem, whatever it was, had been fixed. There was only one possible solution, First said: to go back to the DSM-IV definition.

I thought I might have glimpsed, for the first time, some Firstian schadenfreude, but he sounded more disappointed than gloating, like a professor explaining a concept to hardheaded students for the umpteenth time. He told me he was beginning to give up hope that the APA would listen to him, that indeed he was already looking beyond the publication of DSM-5. As the problems of the new book became clear, he thought the APA might draft him back into service, giving him a chance once again to do what he’d been born to do. After the conference, I suggested that if the DSM-5 turned out as he feared it might, he was likely to have his work cut out for him. “
Yes,” he said, “but I do like a challenge
⁴
.”