This Is Running for Your Life (22 page)

That few of us have taken a good look at it might explain how the manual became a load-bearing pillar of the pharmaceutical industry.
DSM-IV
marked a new era in our understanding and treatment of mental illness, one that rewarded psychiatry's desire to be recognized as a medical science and Big Pharma's dream of filling the Aral Sea basin with cash. Although we have adopted the language of war to describe the nature of modern well-being—how we fight and struggle and battle with ourselves, win and lose, face demons, destruct and rebuild—the
DSM
's military origins, along with their vested interest in causality, have been buried deep under half a century of proselytizing for mental health as a biomedical concern and its treatment a medical transaction.

This new framework for understanding how we feel had rational lines but plenty of interpretive room, and a renovated psychiatric infrastructure was inlaid with its first prescription. Not even the interested parties predicted what happened next. Depression, especially, proved to be a pandemic gold mine. Since Prozac was patented in 1988, antidepressants have become the fourth-biggest-selling drug in the country. Alone in the market in the early days, Prozac sales jumped 20 percent in 1993. At its peak, Prozac outdid Eli Lilly's projections forty-five times over, bringing in three billion dollars in a single year. Last year Americans consumed over ten billion dollars' worth of antidepressants.

Like every other late-twentieth-century capitalist enterprise, the mental health industry was soon in cancerous thrall to perpetual growth. Soon pharma-sponsored studies were indicating antidepressants as an effective treatment for “generalized anxiety,” “social phobia,” and all manner of compulsive disorders and substance addictions. The search for new disorders was consolidated, so that scientific studies, the illnesses they identify, and the drugs designed (or retrofitted, as the case may be; the why and how of the way antidepressants work are that rare
unknown known
) to treat them might debut together. After “pre-menstrual dysphoric disorder” was introduced in
DSM-IV
, Prozac was quickly rebranded as Sarafem and marketed to women whose severe menstrual cycles now fell under the rubric of mental illness. Billions of dollars were funneled into advertising campaigns after the Food and Drug Administration let out its already generous direct-to-consumer advertising legislation in 1997, and doctors were the targets of separate but equally extravagant marketing blitzes. Outside of New Zealand, the United States is the only country in the world that allows such advertising, and millions of Americans were diagnosed by their television sets during the evening news or an episode of
Road Rules
. Just ask your doctor.

The fifth version of the
DSM
, in the works for over a decade, is at least a year behind its original publication schedule. After a series of delays, the APA has committed to a drop-dead of spring 2013. The psychiatric community is bitterly divided over revisions that will shape both the culture and a multibillion-dollar business. The problem is the APA claims its first allegiance is to scientific research; whatever comes of that research cannot be their concern. They shouldn't be punished for relaying the story of who we are and what we have; is it their fault that story now serves as both a holy text and a guide to surviving the world we've created?

From a narrative standpoint, it's tough to argue with that. The APA is subject to the insanity it documents—if anything, its confusions are highly symptomatic. The story and the storyteller have merged into one big book of crazy, and now we're all mixed up in this thing together. The writers of
DSM-5
have claimed that the switch from Roman to Arabic numerals reflects its status as “a living document” subject to frequent updates, like software, to five-point-one and so on. In the name of transparency, the APA opened up a comments section on its
DSM-5
site, and throughout the conference the eight thousand comments logged thus far are frequently cited as valuable to a process that is described in terms of consensus and yet defined by the convolutions of soft, commercial science.

The plight of the
DSM
reflects that of psychiatry's bedeviled identity: driven toward scientific validation despite essentially humanistic aims and means, the field has come to embody the modern refusal of art and science to meet for anything but a fight to the death. If War is the only winner when two great nations seek to destroy each other, Business appears poised for victory in the battle between psychiatry's polar interests. That they were supposed to be fighting for us seems easily forgotten.

*   *   *

Something about the Aqua Waikiki Wave, my hotel on the strip, did not agree with me. Every morning in Honolulu I woke up with marbled, swollen eyes and a body that appeared to have been baked in ruby sprinkles overnight. If this was paradise's idea of a rejection slip, I had to admire its gothic flair. I would begin to recover human form by late afternoon, around the time I was expelled from the convention center's great glass facade, with nowhere to go but back to my mysterious allergen chamber, and no way to get there but through Waikiki's gauntlet of high-end stores.

In general these stores sold prohibitively expensive versions of what could be had on the cheap two blocks away, on Kuhio. Long, floral dresses and thin, sequined tops, mostly, themselves selling the ineffable stink of quality and the ersatz rewards of retail piety. Every evening, as I made my doleful way down Kalakaua Avenue, I considered whether I had acquired the need for its wares since passing them by the previous day. Every evening the answer was:
Possibly. Let's see.

Along with Sephora and Prada and Bottega Veneta, there is a Macy's department store. Straddling the sidewalk in front of Macy's, a sandwich board flanked by two whiskery men advertises the Hawaii Gun Club. Their sign says
SHOOT REAL GUNS.
Their sketchy, lupine look says, “I shoot real guns.” From a block's distance they're a Hells Angels mirage in the midst of a flip-floppy tourist frenzy. An olfactory berth had formed around them despite the heavy flow of shoppers. Upon first sighting, I cut in close in the hopes of a hard sell, or at least the handoff of some literature. But the one was absorbed by the other's private ranting as I passed. This is all I could make out: “Five, six years old—and in
fucking therapy
!”

That morning, my first at the conference, I had decided to attend a three-hour session called “Mood Disorders Across the Lifespan: Implications for
DSM-5
.” A ballroom designed to hold hundreds of people was tipping toward capacity when I shuffled in a few minutes late. The conference's program was packed with workshops and lectures with names like “Cluster B Personality Disorders and the Neo-Noir Femme Fatale,” “Spies and Lies: Cold War Psychiatry and the CIA,” “Faith and Resilience: Carl Dreyer's
The Passion of Joan of Arc
,” and, perhaps most beguiling, “Children of Psychiatrists.”

Those and several military PTSD research sessions were taking place that morning alone. The choice was an object lesson in the modern difficulty of making even the most trivial commitments. All through the afternoon's discourse on the difference between bereavement and depression (there will be no difference, according to
DSM-5
), dismantling the connection between self-cutting and suicide (the former will no longer be a criterion for a borderline-personality diagnosis and may graduate to becoming its own disorder), a new mood disorder called late-life depression (they have little data about the unique presentation of major depression later in life, but will try to do better in coming years), and a danger to clinical practitioners called “the fallacy of misplaced empathy” (i.e., relating to a grieving patient instead of diagnosing her with depression), I felt the conference-goer's remorse flowing strong. Are they having a better time over in “Adult Sexual Love and Infidelity”?

The
DSM-5
task force—a group of about two dozen psychiatrists, academics, neuroscientists, and researchers—chose early on to define their work against
DSM-IV
, which meant that those associated with its writing were relegated to the sidelines of the conference and often to another site entirely, where a shadow conference made up of
DSM-5
rejects was taking shape. The new guard was in full effect for the mood-disorders session, which began at the beginning: a psychologist named Ellen Frank's discussion of “stressors in early life.”

Each presentation opened with the same PowerPoint slides identifying the speaker and his or her conflict-of-interest disclosures. No one had current drug company ties, if only because they were required to sever them in anticipation of moments like this. Frank focused on the changes being proposed to the criteria for bipolar disorder in children. In thirty years, she said, she has never treated a patient who met all of the diagnostic criteria for bipolar disorder. And yet Frank felt the
DSM-IV
criteria were not too broad but too restrictive; with more mixed specifiers it would be easier to identify the kids at risk of moving from a unipolar to a bipolar disorder. She made what was essentially a usage argument for the descriptive value of
energy
over
mood
when diagnosing young people with bipolar disorder. She cited one bit in particular—patients must report “a distinct period of abnormally and persistently elevated, expansive, or irritable mood”—as an insufficiently objective variable. An objective variable, it would seem, is just a turn of phrase that patients will cop to more readily. The words
elevated, expansive, or irritable mood
felt imprecise to Frank, maybe a little judgy. Why not “a distinct period of abnormally and persistently increased activity or energy”? The appearance of excessive but benign futzing is the most deadly aspect of these semantic shell games; what look and sound like glazed distinctions can have consequences as enormous as they are elusive. My heart might have gone out to Ms. Frank were it not sack-weighted with envy.

Next was David Shaffer, a pediatric psychiatrist at NewYork-Presbyterian and the ex-husband of
Vogue
editor Anna Wintour. Shaffer, a Brit with recessive white hair and a typically awkward take on the “aloha casual” dress code, affected a wry tone while describing the psychiatric community's response, in the 1970s and '80s, to the discovery that depression was rare to obsolete in children. They just shifted the criteria around to make it so, he said, and began calling things like bed-wetting and nail-biting “masked depression.”

With symptoms like disinhibition and irritability, childhood itself is a cause of attention-deficit/hyperactivity disorder, a diagnosis first associated with children and then extended into adulthood as the first wave of patients grew up. The opposite was true of bipolar disorder, which was drawn back from adulthood into childhood after a child psychiatrist named Joseph Biederman proposed that certain ADHD-diagnosed kids were actually suffering from bipolar disorder, the latter generally held to be a lifelong illness. Because those kids could be wedged into a
DSM-IV
diagnosis for bipolar, a mood disorder, rather than ADHD, an anxiety disorder (sidestepping
comorbidity
, which is the medical way of saying you have two disorders at once, and it is impossible to tell which one flows from the other), they could be prescribed the standard complement of antipsychotic and antiseizure meds. Adolescent bipolar diagnoses have increased 400 percent since 1994, Shaffer told us; more youth are now diagnosed than adults. Young adulthood is the prime onset stage, although most of those diagnoses follow a first encounter with drugs or alcohol, further complicating the question of causality.

Of all the overlaps discussed that afternoon, to me the most compelling was the “get 'em young” mentality that the APA shares with every other big-ass brand in the country, including
Vogue
. More and more children, those mysterious miniatures, are being evaluated for their risk of mental illness and medicated according to prophylactic wont. Biederman's pitch hinged on the idea that ADHD kids sometimes develop into bipolar adults.

It was an argument over a new
DSM-5
disorder then called psychosis risk syndrome, since renamed attenuated psychosis symptoms syndrome—the “maybe your kid will be crazy but at the moment he's just unbearable so how about some Depakote” disorder—at the APA's 2009 convention in San Francisco that caused
DSM-IV
chair Allen Frances to light the torch he has since been waving in the general direction of everyone involved with
DSM-5
. Retired for almost a decade, Frances now spends much of his time thumbing off blog posts on his BlackBerry (he claims not to understand computers; his wife handles the back-end labor) and giving interviews about where psychiatry went wrong from his beachside perch on San Diego's Coronado Island. By far the most authoritative, consistent, and specific opponent of
DSM-5
, Frances claims that the current rate of bipolar and autism diagnoses resulted from the exploitation—mainly by drug companies and social programs—of a manual he spent much of his career devising.

Another
DSM-5
proposal, something called disruptive mood dysregulation disorder, is designed to offset the epidemic bipolar numbers. DMDD is an increasingly common example of a symptom of a more serious diagnosis coming into its own, as “hoarding” is being emancipated from OCD to acquire disorder status. Its full name will be misremembered and misrepresented many times throughout the conference, presumably because it was known as temper dysregulation disorder until that name bombed in a parental focus group. (My heart still lies with oppositional defiant disorder, a fabulously butch variation on the theme.) A key part of introducing new classifications is nailing that perfect combination of prosody and mouth feel.