The Book of Woe: The DSM and the Unmaking of Psychiatry (40 page)

Insel may be right that a deeper foray into the thickets of the brain will yield what psychiatry has long sought: a taxonomy of disorders validated by biochemical findings. And Frances may also be correct that in the meantime mythical disorders are better than no disorders at all, that without them patients won’t listen to their doctors or get the benefits of having a name for their pain. But no one knows what would happen if psychiatrists simply let themselves out of their epistemic prison by no longer pretending to know what they can’t know. No one knows what would happen if they simply told you that they don’t know what illness (if any) is causing your anxiety or depression or agitation, and then, if they thought it was warranted, told you there are drugs that might help (although they don’t really know why or at what cost to the brain, or whether you will be able to stop taking them if you want to; nor can they guarantee that you—or your child—won’t become obese or diabetic or die early), and offer you a prescription.

There are undoubtedly patients who would balk. Depressed people might be less willing to surrender their orgasms to Prozac if they don’t think they are correcting a biochemical imbalance called Major Depressive Disorder. Psychotic patients might object to a lifetime of taking drugs that blunt their emotions, cloud their cognition, make them gain weight, and shorten their life span if they don’t think they are being treated for Schizophrenia. Parents might hesitate to ply their kids with stimulants and antipsychotics if they believe that they are merely calming them down rather than treating their ADHD or BD (or, once the DSM-5 goes into effect, their DMDD). After all, this is a country whose pharmacological Calvinism has led to a four-decade-long war on drugs used merely to change the way we feel, and that harbors disdain—especially when it comes to our mental lives—for treating symptoms rather than underlying causes.

But other people would surely be willing to take the gamble. Indeed, they already are.
Seventy-two percent
²³
of the prescriptions for antidepressants in the United States are written for patients who are not given a psychiatric diagnosis of any kind, who suffer from troubles ranging from tiredness and headaches to “
abnormal sensations” and “nonspecific pain
²⁴
.” It’s impossible to know exactly how the prescribing doctors sold their patients on the idea of using the drugs, and while it’s likely that at least some doctors told patients they had depression but then didn’t write that down in the chart, it’s also easy to imagine a conversation in which the doctor confesses her uncertainty about diagnosis, but suggests that other patients with similar symptoms have benefited from the drug and encourages the patient to give it a try.

Of course, this is exactly the kind of problem that Frances thinks arises when nonpsychiatric physicians (family doctors and other primary care providers account for 80 percent of those prescriptions) go beyond their proper competence. He may be right about this, but that doesn’t necessarily mean specialists are more restrained in their prescribing habits, nor is whatever advantage they might have over their nonpsychiatrist colleagues the result of being better at figuring out which of the nonreal mental disorders listed in the DSM their patients have. Rather, it is more likely to come from their greater experience in treating symptoms, in making the artful judgment of which potion is likely to help which patient. If this—the ability to match symptom with drug—were the only claim that psychiatry made, if psychiatrists stopped pretending that they know the proper names for our suffering, then perhaps the profession could finally free itself from the prison it has built.

Of course, a psychiatry that gave up a common scientific language, and the perquisites it garners, might also not have a DSM, or at least not one that looks anything like the DSM we have now. But by no longer insisting that it is just like the rest of medicine, and by renouncing its noble lies about the scientific status of psychiatric diagnosis, the profession might become a more honest one than it is now. Given that psychiatrists demand honesty from their patients, honesty is perhaps the least we should ask of them. It might even build our confidence. (And theirs: with less to defend itself about, psychiatry, or at least the APA, might have less need for secrecy and paranoia, and less need to diagnose all its opponents with Antipsychiatry Disorder.)

But there is no doubt that an honest psychiatry would be a smaller profession. It would have fewer patients, more modest claims about what it treats, less clout with insurers, and reduced authority to turn our troubles into medical problems simply by adding the word
disorder
to their description. It would, in other words, be more likely to stay within its proper competence. Its restraint would depend not on the modesty of aristocrats, who have proven themselves to be unreliable in that respect, and not on government regulation, which, even if it were possible, has recently fallen into disrepute, and not on the discovery of the boundary between mental health and mental illness, which will always prove elusive, but on that much more modern and effective arbiter, the one master to whom we all seem to submit: the marketplace.

•   •   •

Speaking of marketplaces, an honest psychiatry would not be such a good thing for my profession, at least not if it meant the end of the DSM as we know it. We talk therapists have arguably been the book’s prime beneficiaries. While psychiatrists are treating the floridly psychotic, the raving manic, the suicidal and the catatonic and the delirious, we, by and large, get to minister to the walking wounded. Thanks to Bob Spitzer’s expansive approach to the DSM, we can casually jot down “Generalized Anxiety Disorder” or “Adjustment Disorder” and talk (on the insurance tab) with our patients about the meaning of life, while right down the hall psychiatrists are making momentous decisions about whether a man who thinks his bones have been sucked out of him is bipolar or schizophrenic and which drugs to prescribe. While they have to take the DSM at least a little seriously, we can pretend it doesn’t exist, give it the cynical bureaucrat’s shrug, denounce it even as we cash those insurance company checks. And when it comes time to revise it or explain it or defend it, and its flaws are once again open to scrutiny, it’s the psychiatrists who take the heat.

Not that I feel particularly sorry for them, but it is clear that for us nonpsychiatrist clinicians, the stakes are purely monetary. Without those codes and the access they give us to insurance companies’ compensation schemes, the unfettered marketplace will decide how much we are worth. Weekly visits with me right now cost the equivalent of a monthly payment on a car. I try to adjust my charges according to what a person can afford to drive. But while for some people that’s a BMW, for others it isn’t even a badly used Kia, and I have no doubt that shorn of their DSM-enabled insurance subsidy, fewer people could pay me anything at all. So I would make less money. In this, I am like workers everywhere in America, although at least for now my job can’t be offshored.

•   •   •

An honest psychiatry might also lead the way to a new understanding of illness. The idea that disease is suffering caused by an identifiable pathogen that can be targeted and killed by medicine’s magic bullets is a historical accident, one that originated at the height of the Industrial Revolution and that springs as much from commerce as from science. It has been an extraordinarily beneficial idea, but like all inventions, it has its drawbacks—notably that it has encouraged us to think that all our troubles will ultimately yield to the microscope and the pill.

“
The future belongs to illness
²⁵
,” Peter Sedgwick wrote in the early 1970s. “We are just going to get more and more diseases, since our expectations of health are going to become more sophisticated and expansive.” Thanks to a DSM that has kept pace with those expectations, that future is here. It has arrived in a capitalist age, which means that we have placed our well-being in the not-so-invisible hands of a medical-industrial complex whose proprietors have a stake in reducing suffering to biochemistry. It has spawned a psychiatry that can’t help giving us more and more diseases, at least not if it wants to meet the economic, if not the scientific, demands of the day.

Still, the problem with psychiatry may not be that it lags behind the other medical specialties, with their magic bullets and the science by which they identify the targets. Rather, it may be a harbinger of a time when the low-hanging fruit has been picked, when the inadequacies of modern medicine to the complexity of our suffering—physical and mental alike—have become manifest, and when the folly of encouraging us to give up the ghost for the machine is unmistakable.

Because there is one definition of mental disorder that is not bullshit. Mental disorder, like all disease, is suffering that a society devotes resources to relieving. The line between sickness and health, mental and physical, is not biological but social and economic. It is the line between the distress for which we will provide sympathy and money and access to treatment, and the distress for which we will not. For the past 150 years, we have relied on doctors to decide who gets those resources, and they in turn have furnished us with diseases that, they assure us, are not figments of their imaginations, but real entities that reside in tissues and cells and molecules, that can be observed and measured, and, if all goes well, treated. Psychiatry has tried its best to stake its claim to this bonanza, perhaps nowhere so ardently as in its attempt to fashion its book of woe, but it has not worked. This may be because the psychiatrists in question, or their technologies, have not been up to the job. It may be because that line can’t be drawn without deciding how a human life is supposed to go, how it ought to feel, and what it is for—questions for which science, no matter how robust, is no match. It may be because the arc of history bends toward justice, and biochemistry may not be the fairest basis on which to determine whose suffering deserves recognition. But it may also be because the human mind, even in its troubles, perhaps especially in them, has so far resisted this attempt to turn its discontents into a catalog of suffering. And for this we should be glad.

The careful reader will by now have detected the odor of a certain barnyard effluent suffusing this book. My opportunity to publish at the same time as the DSM-5 exceeds my knowledge of what is actually in the new manual. Indeed, it is very likely that you know more about its specifics as you read this than I do as I write in early January 2013. But I do know a little about the final product.

For this, I can thank the APA. Not that they decided to talk directly to me, but they did use the trustees’ rubber-stamping of the final draft at the beginning of December 2012 as
an occasion to release some details
¹
—among them, the price of the new book, $199. As expected, Hoarding Disorder and Disruptive Mood Dysregulation Disorder were in, Asperger’s was out, and Attenuated Psychosis Symptoms Syndrome was in the Appendix, now officially renamed Section 3, where it would be joined by all the dimensional measures and the “trait-specific methodology” proposal for personality disorders. (Those diagnoses would revert largely to their DSM-IV versions.) Section 3 would also include “the names of individuals involved in
DSM-5
’s development.” I’m looking forward to finding out if my name is among them.

The summary left unanswered some important questions. For instance, while it said that Asperger’s would be “integrated” into the autistic spectrum, it did not spell out exactly how, or whether the APA would retain ownership of the name or relinquish it to all those Aspies in search of an identity. Neither did it illuminate a persistent rumor: that currently diagnosed Asperger’s patients would be “grandfathered,” keeping the diagnosis even if the disorder was eliminated. It mentioned that the bereavement exclusion had been replaced by “several notes within the text delineating the differences between grief and depression,” but did not elaborate except to say that the change “reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.” What a clinician, astute or otherwise, was supposed to do with that recognition was not made clear.

The press release did offer some reassurances to a skeptical public. “We have sought to be very conservative in our approach to revising DSM-5,” David Kupfer said. “Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry.” And Jay Scully reminded reporters that the process had been “as open and independent as possible. The level of transparency we have strived for is not seen in any other area of medicine.” An e-mail sent by Kupfer and Regier to task force and work group members in advance of the press release elaborated on just how open and independent that was. “
We do ask that you focus
²
your interviews on the disorder and refrain from talking about the criteria or text,” it read. They apparently didn’t want anyone to spoil the surprise.

The trustees’ vote triggered a spate of news coverage, some of it summarizing the APA’s summary, some of it opining for or against, and at least
one article—in
The Washington Post
³
—repeating charges of corruption in the process, this time by reporting on the study that Sid Zisook, architect of the bereavement policy, once ran proving that Wellbutrin was effective in the bereaved. The APA responded with a press release under David Kupfer’s byline, reiterating all that the task force had done to eliminate conflicts of interest and assuring the public that “
DSM-5 includes material
⁴
to make sure that it is understood that sadness, grief, and bereavement are not things that have a time limitation to them or go away within two or three months.” What it meant that psychiatrists had to be told this, or what they would do now that they had been informed, Kupfer did not say.

Two weeks after the vote, psychiatric diagnosis was back on the front pages, this time when a young man armed with a semiautomatic weapon slaughtered twenty children at an elementary school in Connecticut.
Dilip Jeste, the APA president, told Congress
⁵
that the tragedy, which occurred “at the very time [that] federal and state funding for critical mental health services is under siege,” was a reminder that, because mentally ill people in treatment are “considerably less likely to commit violent acts” than those who are untreated, Congress should “act to protect federal funding for mental health . . . research and services.” Three days later, however, after the National Rifle Association’s Wayne LaPierre told the nation that no matter how many rounds they can fire in an instant, guns don’t kill people, “lunatics” kill people, and suggested that the solution to the problem was a registry of mentally ill people whose diagnoses would presumably lose them their Second Amendment rights, Jeste took a different approach.
Not only was LaPierre’s language “offensive
⁶
,” he said in a news release, but “only four to five percent of violent crimes are committed by people with mental illness,” and that “only a small percentage” of the 25 percent of Americans who will come down with a mental disorder in any given year “will ever commit violent crimes.” Gun violence, in other words, was not an indication of mental illness unless there was money to be made.

Al Frances responded to the trustees’ vote with what he promised would be his last blog on the subject. “
The saddest day
⁷
in my 45-year career,” he wrote, and urged clinicians to “ignore its ten worst changes,” which he enumerated. “Apparently they deleted a few irrelevant things and approved all the junk that was left,” he e-mailed.

Ten days later, Frances broke his promise, telling readers that the APA had “
one last act
⁸
to save DSM 5 before the curtain drops,” and warning that unless the organization used the remaining time to fix the outstanding problems (and add a black-box warning about the dangers of overdiagnosis), the new manual would be “a financial as well as a clinical, scientific, and artistic flop.” He repeated this warning in a series of e-mails to the APA’s leaders, in which he promised to shut up if they heeded his advice. They did not take him up on his offer.

The APA wasn’t the only organization ignoring Frances. In the wake of the trustees’ approval, many proposals to boycott the DSM-5 sprang up—a dozen, by his account. He urged comity. “
Any new boycott must unify the diverse opposition
⁹
,” he wrote, “not further fragment what is already a very fragmented field.” But the groups did not coalesce into a single movement, nor did the antipsychiatrists among the dissidents heed his call to stop using his name (“without permission,” he pointed out) to support their cause. Frances was left to explain once again that his attack on his profession’s foundational text was not an attack on the profession itself.

For his part, Michael First was back on the inside. In late November, I asked him about a rumor I’d been hearing all fall: that the APA had called him to duty to help finalize the manual. “
I can confirm
¹⁰
it’s true,” he e-mailed, “but I really cannot say anything else. Sorry.” He wasn’t going to jeopardize his ability to do once again what he’d been born to do. An insider, who also wouldn’t go on the record, made it clear that his role was limited: reviewing criteria for consistency, editing them for clarity, and making sure the book could be used by clinicians.

First was willing to give me his overall appraisal of the outcome. “
The good news
¹¹
about the DSM-5 is also the bad news,” he e-mailed. “While many little things have changed for the better, and clinicians will find the transition relatively easy to make, the fundamental problems with the descriptive approach remain.” It still explains little, offers scant treatment guidelines, and “relies on categories that facilitate clinician communication but have no firm basis in reality. So I think it’s an improvement,” he concluded, “but it’s also an acknowledgment that psychiatry, especially in its understanding of mental illness, is still in its infancy.” Whether the profession can grow up remains to be seen.