The Book of Woe: The DSM and the Unmaking of Psychiatry (14 page)

The APA didn’t waste any time firing back. “
Setting the Record Straight
¹³
” appeared in the next week’s issue of the
Psychiatric Times
under the byline of the organization’s new president, Alan Schatzberg (the Stanford psychiatrist whose drug company ties had raised Grassley’s dander), along with Scully, Regier, and Kupfer. They accused Frances, as they had Spitzer before him, of launching his salvo with “disregard for the facts”; taken together, these were “unjustified ad hominem attacks” to which the APA now reluctantly had to respond.

“The process for developing the DSM-V has been the most inclusive ever,” they wrote. More than 400 scientists and 200 advisers had bolstered the 150 experts from sixteen countries who constituted the task force and work groups. Their discussions had not been inhibited by the confidentiality agreements, nor had any of them been stopped from presenting at professional meetings, in journals, and even “in countless interviews to the mainstream press.” Indeed, if the proceedings were really secret, they asked, then how could Frances have gotten hold of enough information to fashion his litany in the first place? It wasn’t their fault that he had mistaken their drafts as “final decisions, rather than as statements of work in progress.” Far from being secretive, the DSM leaders were really the victims of their own transparency.

Frances had gotten one thing right: “The DSM-V work groups were freed from the constraints inherent in DSM-IV’s conservative process.” The task force had not, however, simply emancipated them from Frances’s shackles. They had given the committees marching orders: to optimize clinical utility, to use research evidence to guide their recommendations, and to maintain continuity with previous editions. “We are setting up a process that will allow the new DSM to change with new developments, rather than being reified for a decade or more,” they wrote. The authors didn’t add “like some DSMs we know.”

Neither did they name Spitzer or Frances when they complained that the “DSM-III categorical diagnoses are now holding us back,” or that the “DSM-IV system poorly reflects the clinical realities of [our] patients,” or that “researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations.” And they left out Frances’s name when they suggested that what some might see as a revision in disarray and up against time constraints was really only the rapid process made possible “thanks to new publishing technologies, not even imagined in the early 1990s.” The DSM could be nimble, not the lumbering beast Frances had created and with which they were now stuck.

In case the point wasn’t clear, and speaking of ad hominem attacks, the APA signed off by reminding readers that Frances had promised them a “full disclosure” at the outset of his screed, allowing that “it is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby.”

“It is unfortunate,” the APA leaders wrote, “that Dr. Frances failed to take this [promise] to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.” As a matter of fact, they went on, he had been informed—at the very same APA meeting at which he had suddenly become galvanized—that his royalties would end upon publication of the new revision. This coincidence, the APA suggested to readers, was something that “should be considered when evaluating his critique and its timing.”

Allen Frances had made his way onto the APA’s enemies list. Of course, that wasn’t how Schatzberg was going to put it. Nor would Will Carpenter, when he ended his own
Psychiatric Times
rebuttal by responding to Frances’s charge that the task force was overly ambitious. “
Soaring ambition is another matter
¹⁴
,” he wrote. “Here my empathy is with Allen. If I had directed DSM-IV, I imagine that I would think that anyone trying to improve on my work must be very ambitious indeed.” Nor would Renato Alarcon, a work group member, when he suggested, also in the
Psychiatric Times
, that Frances was “
letting nostalgia and passion
¹⁵
obstruct clarity of vision.” Instead of talking about enemies and taking the risk of sounding even more paranoid, they did what their training told them to do when confronted with disturbing behavior. They offered empathy, even pity, and, of course, a diagnosis.

•   •   •

Not that you need special training to approach enmity in this fashion, although psychiatrists may be better at turning supposed insight into a person’s character into a weapon. Passive aggression may be particularly unseemly when it comes from the people in charge of our mental health, but claiming that a person who disagrees is ill motivated, that his objections are really the result of malfeasance or dishonesty, that if he weren’t deluded by ideology or greed or ignorance, if he weren’t somehow pathological, then he’d come to see things the right way—this is a ubiquitous feature of American political life.

And here is a place where science, at least the psychiatric form of it, and politics really come together. Whether among senators or psychiatrists, the exchange of diagnoses generates more heat than light, and the smoke it gives off obscures the trouble that gave rise to the disturbing behavior in the first place. But there was one vulnerability that no one, defender or critic, was discussing, at least not in public. Even Frances muted this concern in the blogs he was thumbing out with regularity, which now appeared in
Psychology Today
as well as the
Psychiatric Times
. He did, however, address it in a letter to the APA trustees that was also signed by Spitzer. “
You must understand
¹⁶
,” they wrote, “that the APA has never held a guarantee on the DSM franchise. There have been serious objections in the past that it is inappropriate for one professional ‘guild’ to control a document with such wide usage and great public health importance.” Frances knew that psychiatrists had been lucky enough to be in the right place—asylums—at a time when the Census Bureau took a sudden interest in counting the insane. History had bestowed the franchise on the APA, and history could take it away—and with it the riches it had brought the guild.

When Frances and Spitzer warned the trustees that to ignore this was to “bet the house,” they meant that literally.
The APA’s financial picture
¹⁷
was bleak, the organization battered by hard economic times and the partial purge of Pharma. Income from the drug industry, which amounted to more than $19 million in 2006, had shrunk to $11 million by 2009, and was projected to fall even more. Membership was dropping, off by nearly 15 percent from its highs, and with it income from dues and attendance fees. Journal advertising was off by 50 percent from its 2006 high of $10 million. Only the DSM-IV had remained steady, reliably bringing in between $5 and $6 million annually, nearly 10 percent of the APA’s income and just enough to keep the APA in the black. Losing that money could be fatal. The credibility problem first noticed by Thomas Salmon now had a price tag on it.

The APA already had a competitor for its franchise: the World Health Organization. Its International Classification of Diseases had an entire section devoted to psychiatric disorders. In fact, the diagnosis codes found in the DSM are really taken from the ICD. As Michael First, who now works on the ICD, pointed out, “
In reality, clinicians in the United States
¹⁸
, all of us, don’t ever have to buy a copy of the DSM.” Most practitioners don’t know this, he added—at least not yet. But “the franchise depends on the quality of the book. If they put out a crappy product, people could just say, ‘This is so bad, I don’t need to use it anymore. I’ll just go use the ICD.’” And when we therapists go to do that, we will discover something else that most of us don’t know:
the ICD, created by a public agency, is available for download
¹⁹
from the WHO’s website. It won’t take up any space on our bookshelves, and, perhaps its best selling point, anyone can browse it for free.

That fact is likely to impress many clinicians who think they have to shell out two hundred bucks when the new book comes out, especially when they discover that the ICD is quick and to the point—no checklists to go down, no long pages about prevalence or family characteristics or recording procedures, which are of much less interest than, say, reimbursement rates, to the average clinician. The APA leaders had to know that all the spin control, all the denunciations, all the confidentiality agreements in the world might not be enough to counter the fact that stalwarts like Frances and First were doubting the soundness of the new book. If a crappy product unleashed a public battle, then the rest of us might discover that the DSM was nowhere near as necessary as it had been cracked up to be. That wouldn’t be good for the APA’s bottom line.

And here is another way in which the politics of DSM resembles the politics of the larger world. For who can doubt that what politicians are really arguing about is money?

•   •   •

Even when they weren’t arguing so openly about dollars—back in the 1970s, before anyone knew that the DSM-III would be a bestseller—the writers of the DSM understood that turning diagnosis into a bureaucratic function left them with only an aspirational relationship to modern medicine. Spitzer may have wrested psychiatry from Freud’s grasp and dipped it into the stream of scientific rhetoric, but where he held it most firmly was where it was the weakest. He had left the profession unable to stave off the next drapetomania, except perhaps on the grounds of decency and common sense—important considerations, but not scientific or immune to local mores.

Having eliminated theories about the nature and causes of mental illness, Spitzer had also taken away his colleagues’ ability to draw a line between illness and health. A man may be feeling as fit as a fiddle, but a radiologist who spots a mass in his lung or a cardiologist looking at the results of an echocardiogram might have a better idea about his state of health. A woman may be missing her period, suffering nausea in the morning, and feeling lousy all day, but an obstetrician who can read a blood test can reassure her that she is not sick, only pregnant. But no psychiatrist, listening to a patient’s woes, can listen to his complaints and offer similarly certain appraisals.

This was not merely an abstract problem for Spitzer. For he was well aware there was at least one group of people who met all the criteria for a mental illness but who, on the other hand, could only be considered sick at the risk of psychiatry’s always fragile credibility. Their existence was confirmed not by an enemy of psychiatry playing gotcha, but by one of the DSM-III’s own—a Washington University psychiatrist and task force member named Paula Clayton. She was part of the team that had perfected the Research Diagnostic Criteria, the prototype of the DSM-III approach, and she had made
an unsettling if unsurprising discovery
²⁰
: people who had recently suffered the death of a loved one often had at least five of the nine symptoms of depression, which meant that if you went strictly by the book, they were mentally ill.

The grief over grief was a scientific and political disaster waiting to happen. How would it look when clinicians began to diagnose mourners with mental illness and declared for themselves a territory that was among the last bastions of religion? And yet if a clinician, suffering from a sudden attack of common sense, was free to decide that the patient wasn’t really sick even if he met the criteria, then wouldn’t that return psychiatry to the days when clinicians’ assumptions determined the line between illness and health, and psychiatry was reviled for its unreliability?

Spitzer’s solution was characteristically wily. He carved out an exception to the depression diagnosis and deftly inserted it at the back of the DSM-III. In a section called “Conditions Not Attributable to a Mental Disorder That Are a Focus of Treatment or Attention,” a clinician could learn that the recently bereaved may well have all the symptoms of depression, but because “
a full depressive syndrome
²¹
frequently is a normal reaction to the death of a loved one,” the patient’s condition was better understood as Uncomplicated Bereavement. Clinicians confronted with the absurdities of the descriptive approach were thus given cover to ignore it even as their prerogative to treat the recently bereaved was preserved (although insurers rarely if ever pay for treatment of those non-mental-disorder conditions).

The
bereavement exclusion
²²
, as it came to be known, became part of the diagnostic criteria in the DSM-III-R, where it acquired a time limit: after two months of meeting five of the nine criteria, the bereaved became mentally ill. But certain thorny matters—notably, whether or not a clinician should distinguish among the death of a parent or child, the death of a celebrity, and the death of the family dog—remained up to the individual clinician to decide. Even so, it was a win-win, which may be why no one seemed to notice that the loophole amounted to saying that people who had all the symptoms of a disorder had the disorder—
unless they didn’t
. The criteria didn’t really add up to a mental illness until a doctor determined that a disorder was present and by this judgment transformed suffering into the symptoms of a disease.

This is, in part, as it should be. Isn’t this what we go to doctors for—to learn, from someone who
knows
, the true nature of our suffering, to find out whether that nagging pain is the leading edge of something horrible or just a random twinge, to find out if our persistent malaise is grief or depression or maybe even a malfunctioning thyroid? Even before we ask for remedy, this is what we ask of our doctors: to lay bare the beginnings of our suffering, to elicit our present crisis, to tell us what is going to happen in the end. Without that story, we might not take their pills, and—since so much of our response to medication is the result of placebo effects, and placebo effects in turn depend on the patient’s belief in his or her doctor—the pills might not work.