The Book of Woe: The DSM and the Unmaking of Psychiatry (39 page)

But then again, popes and dictators and philosopher kings have never had so many drugs at their disposal or a huge scientific-looking book claiming to list the natural varieties of our suffering. Nor have they been able to hold out the tantalizing possibility of elucidating the brain’s role in consciousness, of finding us in its hundred billion or so neurons, its five hundred trillion synapses, its ten-to-the-millionth-power possible connections. Neither have they presided over a populace quite so eager to turn over their (and their children’s) troubles to their brains and to the doctors who claim to know how to understand them, or quite so willing to gobble down mind-altering medications whose mechanisms of action and long-term effects are as unknown as their capacity to blunt feeling is known. So conditions might be ripe for a neuroscience-inflected psychiatry to usher in a new understanding of ourselves as the people of the brain and for us, with the help and encouragement of our doctors and the drug companies, to become the kind of selves who believe in and benefit from that understanding, and for whom the RDoC’s matrix is the troubleshooting manual.

Not that an assault on human agency is what psychiatrists like Insel are after. Despite the creepy
Minority Report
overtones of his idea that we can be mentally ill (and ready for treatment)
before
we actually do anything, it’s impossible to spend an hour or so with him and Cuthbert or, for that matter, with any of the doctors with whom I have spent so much time over the last couple of years and think that they are motivated by anything other than a wish to relieve suffering. Their purpose in cataloging our troubles is surely not to turn us into Shrink McNuggets. But they are in the grips of forces bigger than they are, bigger than any of us. It’s not their fault that medicine is a service industry, that diseases are market opportunities, and that a book of them is worth its weight in gold.

•   •   •

After my visit with Frances in Boston, I e-mailed to ask him to name a diagnostic category that in his view made the strongest case for psychiatric diagnosis.

“
Why do you hate psychiatrists
¹²
so much? Is it because I pinched your cheek?” he wrote back.

I persisted. I wanted to hear about a slam dunk, the psychiatric equivalent of strep or diabetes, a single diagnosis that indicated a single pathology and a single treatment. But I would have settled for less, just one solid example of the value of a diagnostic system.

“Really silly questions,” he replied. “Your bias is showing.”

Frances did offer a defense. Not for the first time, he told me that “psychiatry done badly can be very harmful, psychiatry done well within its proper competence can be noble. The trick is to develop a healing relationship, to care for the person not just the disorder, to diagnose and treat cautiously, and to see the healthy part of the person not just the sick.” All of which is inarguable, if a little hazy, but it doesn’t really answer the question of why pulling off that trick requires a thousand-page catalog of disorders that are not real—other than to inspire confidence among bureaucrats, and among people who are comforted when a doctor names their suffering. Nor does it explain how exactly that book can keep psychiatry within its “proper competence.” Neither does it acknowledge Freud’s warning that medical education is the worst possible training for people who take on the troubles of the psyche, a warning issued long before the medical-industrial complex turned suffering into a commodity and psychiatry into a profession in which clinician communication must be efficient and the “healing relationship” must be established in ten-minute medication management visits.

“It isn’t bias to be skeptical,” I wrote. “And it’s not antipsychiatry to question psychiatry. And it’s not silly, in the context of a book about diagnosis, to ask how nosology relates to the practice of psychiatry.” I gave Frances a hypothetical case, a psychotic person he has diagnosed with Bipolar Disorder. “How does that diagnosis help him to proceed?” I asked. It was the question former APA president Paul Fink once answered by saying, “I got paid.”

“Like to help,” Frances answered. “But the question makes no sense to me. Suggest you read a textbook of psychiatry.”

At $80.99,
Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry
seems like a real bargain, compared with the $410.99
Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry
. At 700 pages, it isn’t exactly concise, but it is a lot shorter than the 4,884-page full-size version, not to mention 200 pages shorter than the DSM-IV. So maybe Benjamin and Virginia Sadock, authors of the
Concise Textbook
, are just trying to save space, but when they tell students that “
DSM-IV-TR attempts to describe
¹³
the manifestations of the mental disorders,” they don’t mention that there’s no reality to those mental disorders or warn students of the dangers of reification.

They do, however, tell the young doctors that it is a “major challenge” to separate the bipolars from the depressives, and they discuss the “
difficulty of distinguishing a manic episode
¹⁴
from schizophrenia.” They explain that “
depressive symptoms are present
¹⁵
in almost all psychiatric disorders,” that “
every sign or symptom seen in schizophrenia
¹⁶
occurs in other psychiatric and neurological disorders,” and that “the distinction between generalized anxiety disorder and normal anxiety is emphasized by the use of the words ‘excessive’ and ‘difficult to control.’” But, the book reassures the students, these difficulties can be overcome through careful clinical observation. Even if the categories don’t exist, in other words, people can nonetheless be sorted into them.

“
Once a diagnosis has been established
¹⁷
,” Sadock and Sadock write, “a pharmacological treatment strategy can be formulated.” That may involve psychosocial treatment, but as just about any psychiatrist will tell you, the days in which psychiatrists underwent psychoanalysis as part of their training are long gone, as are the days in which psychiatrists routinely practiced talk therapy, so that treatment is most likely not going to be provided by them. When it comes to the technique that remains their sole bailiwick—pharmacotherapy—“
no one drug is predictably effective
¹⁸
.” For bipolar patients, the doctor has at her disposal lithium, anticonvulsants such as Depakote, tranquilizers such as Ativan, and antipsychotics such as Haldol and Zyprexa. “
Often,” advise Sadock and Sadock, “it is necessary
¹⁹
to try several so-called ‘mood stabilizers’ before an optimal treatment is found.”

Even when the diagnosis is established, the treatment is still uncertain. And there is a good reason for this. According to Sadock and Sadock, “
the objective of pharmacologic treatment
²⁰
is symptom remission.” Bipolar isn’t the only case. There is no specific treatment for any of the disorders Sadock and Sadock present, and many drugs are used for many conditions: antidepressants to treat obsessions, antipsychotics to treat depression, mood stabilizers to treat anxiety, and so on. Psychiatrists, in other words, are not treating the disorders they diagnose. The categories, after all, aren’t natural formations; symptoms, the scattered particulars, are all they have to go on and all they can treat.

Which doesn’t mean they shouldn’t treat them. “
Not everyone needs to see
²¹
a psychiatrist for the treatment of a mental disorder,” Frances told me. “But if the problem is moderate to severe, persistent, and impairing, medication is likely to be needed. In my view, this should mostly be provided by psychiatrists, not primary care doctors who are usually out of their depth.” He is surely right about this. Psychiatrists do indeed have a wealth of experience in treating people’s distress with drugs. No clinician can deny the value of that knowledge, the way that people in the throes of a manic episode or a psychotic break or a disabling depression can be helped by drug therapy. Nor can anyone deny that this uncertainty about diagnosis and treatment is exactly what makes the expertise of the psychiatrist essential.

But you don’t have to hate psychiatrists to point out that their expertise is mostly empirical and their treatments potentiated at least as much by hope as by chemistry. Or, to put it another way, that psychiatry, much more than other medical specialties, is still deeply in the debt of ancient medicine. The Platonic ideal of a world of suffering carved up into its natural formations remains exactly that—an ideal, one that psychiatric nosology can’t yet approach. And you also don’t have to hate psychiatrists to think that this gap, the distance between what the profession claims and what it actually knows, between its opportunity and its knowledge, is vast, and that even as the jury remains out on the legitimacy of psychiatry’s claim to understand mental suffering, more and more people are taking daily doses of drugs whose mechanisms are poorly understood and whose long-term consequences, on the body and on the body politic, are uncertain. You don’t have to hate psychiatrists to think that the ever-expanding DSM is not a book that can help psychiatrists stay within their competence, that indeed it encourages them to do the opposite. You don’t have to hate psychiatrists to think that a book that dresses up symptoms as diseases that are not real and then claims to have named and described the true varieties of our suffering is all clothes and no emperor. And you don’t have to hate psychiatrists to think we—patients, doctors, therapists, all of us—might be better off without it.

•   •   •

Or maybe the APA
was
trying to erase history. In early November 2012, the draft of the DSM-5 disappeared from the DSM-5 website, removed, according to a note on the home page, “to avoid confusion or use of outdated categories and definitions.” It wasn’t enough to threaten legal action against people who might want to use the draft criteria as part of a research project or, I don’t know, a book about the development of the DSM-5. It is, of course, possible that the APA really feared that a paper using outdated criteria would slip by a peer reviewer or that a doctor would render a diagnosis based on discarded definitions. But it is also possible that the APA hit the delete button for the same reason Soviet apparatchiks airbrushed old photos: to prevent embarrassment.

The move was so arrogant, and so unnecessary, and so heedless of the public trust the APA holds—in short, it was so incompetent that it made me wonder if Frances had been right all along: that the trouble with the DSM-5 was purely bureaucratic, that if it turns into the disaster he has predicted, it will not be because the APA has found itself perfectly situated to exploit the capitalist imperative to turn all need into markets and thus to manufacture need by the carload. Neither will it be because a diagnostic empire built on air must at some point come crashing down, as if some tragic principle were at work, ensuring that hubris inevitably meets justice. Nor will it be because the attempt to catalog our suffering is doomed to be a fool’s errand, that our troubles will always outdistance our attempts to take their measure. It will be because the Keystone Kops bungled the job. Only naiveté or animus toward psychiatry or a writer’s fervent wish for drama could make someone read more into the unfolding events than incompetence, to see the DSM-5 as anything other than one more step in the long, random walk of human folly.

But there is a reason insiders trot out the one-bad-apple defense when disasters occur. It distracts from the more disturbing truth—in this case, that a profession that has been struggling to establish its credentials for more than a century, that has lurched from crisis to crisis, always for the same reason, always because it cannot make good on its claim to be treating diseases as other doctors do—that such a profession has something rotten at its foundation: its have-it-both-ways, real-until-it-isn’t diagnostic manual.

You don’t have to be a hater to think that the DSM, no matter how often it is revised or how competently, will never manage to pour the old wine of human suffering into the new skin of scientific medicine. And you don’t have to resort to biblical analogies to show that the Bible of psychiatry is failing to do what it is presumably intended to do, and what would bolster the argument for bringing our mental suffering under the medical gaze: to improve psychiatric treatment. You don’t even have to be an upside-down Jesuit or a Leibowitz unwittingly sowing the seeds of destruction. You could be Tom Insel, who is neither an antipsychiatrist nor a Jesuit of any spatial orientation, who is, in fact, America’s psychiatrist in chief.

“
Whatever we’ve been doing for five decades
²²
,” he told me, “it ain’t working. And when I look at the numbers—the number of suicides, number of disabilities, mortality data—it’s abysmal, and it’s not getting any better. All of the ways in which we’ve approached these illnesses, and with a lot of people working very hard, the outcomes we’ve got to point to are pretty bleak”—especially, he added, compared with the “extraordinary” progress in other fields, such as the 70 percent drop in mortality from cardiovascular disease since he went to medical school or the steep reductions in deaths from auto accidents and homicides. “There are some people for whom some of what we do is enormously helpful,” he said. But even so, “we don’t know which treatments are working for which people.” And this litany of failure, he said, “gets us back to your interest in nosology. Maybe we just need to rethink this whole approach.”

That’s what Pliny Earle said in 1886, and what Thomas Salmon said in 1917, and George Raines in 1951, and Robert Spitzer in 1978, and Steve Hyman in 2000: that without a working nosology, psychiatry is a failure, that the current nosology (whatever it is) is sadly lacking, that the profession needs a new paradigm. You don’t have to be an antipsychiatrist to wonder if incompetence can possibly explain all that futility, or if a profession that, despite its repeated failures, continues to “cherish expectations with regard to some mode of infallibly discovering the heart of man,” as Melville once put it, deserves our confidence. You only have to know what Tom Insel knows and is honest enough to say out loud.