The Book of Woe: The DSM and the Unmaking of Psychiatry (3 page)

All of these work; I favor the last one, but then again, I’m hardly unprejudiced, and even I have to admit that the DSM barely qualifies as literature. It’s lacking in plot, and it bears all the traces of having been written by committee; it is, as Henry James said of the nineteenth-century novel, a “
loose, baggy monster
²⁴
.” But then again, unlike the works of Tolstoy and Thackeray, the DSM belongs to a genre that is forgiving of poor writing, that ends up inviting and rewarding it. The book avoids the Latinate jargon that physicians tend to favor, but it is written by doctors and designed to be used in medical offices and hospitals around the world; it is a medical text. Which, nowadays anyway, means it is a scientific text, one that casts its subjects into dry, data-driven stories, freed from the vagaries of hope and desire, of prejudice and ignorance and fear, and anchored instead in the laws of nature.

•   •   •

I’m not sure that this is the right genre for understanding us, and I’m not alone in my doubts. Psychiatry didn’t always have dominion over the landscape of mental suffering, at least not the kind that shows up in everyday life. Psychiatrists, once known as “alienists,” originally presided over asylums housing people too crazy to function outside them. The treatments the doctors doled out, if they doled out any at all, varied from hospital to hospital and took place largely out of the view of polite society. Psychiatrists did not appear on television to give relationship advice. They did not suggest ways to beat the winter blues. They did not prescribe cocktails of psychoactive drugs to accountants and schoolteachers while telling them what they suffered from.

Not that there weren’t doctors doing those things or their equivalents. But most of them were neurologists like George Beard, who suggested, toward the end of the nineteenth century, that symptoms ranging from “
insomnia, flushing, drowsiness
²⁵
, bad dreams” through “ticklishness, vague pains and flying neuralgias” to “exhaustion after defecation” added up to a disease that, in his bestselling
American Nervousness
, he christened
neurasthenia.
Or Silas Weir Mitchell, author of the bestselling
Fat and Blood
, his account of how to treat neurasthenia and hysteria (the details of which I won’t go into; just use your imagination on the title and you’ll get the idea), who was the inspiration for “The Yellow Wallpaper,” Charlotte Perkins Gilman’s famous fictionalized account of the rest cure
she took at his hands. Or John Harvey Kellogg, who teamed up with his industrialist brother, Will, to introduce America’s fatigued brain workers to the wonders of flaked cereals, electric light baths, and pelvic massage. Or Sigmund Freud, whose ideas about intrapsychic conflict as the source of psychological turmoil, which he called neurosis, landed on American soil (along with Freud himself) in 1909.

Whatever the merits of their particular theories, these doctors had one thing in common. People flocked to them, to the spas where nurses swaddled them for their naps, to the offices where they were shocked or steamed or vibrated, and to the analysts’ couches where they disburdened themselves of their family secrets and lurid fantasies. The everyday psychopathology of the masses was a burgeoning and protean market, especially among the swelling ranks of the affluent; and doctors, armed with the authority of the microscope and the pharmacy, had seized it.

The enormous opportunity created by the democratizing of mental illness, and exploited by neurologists, was not lost on psychiatrists. In the first third of the twentieth century, they began to escape the asylum, setting out mostly for private offices, where they, too, began to minister to the walking wounded, mostly by practicing psychoanalysis. Their colleagues/competitors included neurologists, but they also included anthropologists and art historians and social workers—nonmedical people who had been trained in psychoanalysis and had hung out their shingles. Given the ascendant power of medicine, these lay analysts might well have failed to capture much of the market from doctors, but the New York Psychoanalytic Society, dominated by psychiatrists, was not content to wait for the invisible hand to lift them to dominance. In 1926, for reasons it didn’t spell out explicitly, it declared that only physicians could practice psychoanalysis.

Back in Vienna, Freud, who had long loathed America as a land of the shallow and unsophisticated, was livid. “
As long as I live
²⁶
,” he thundered, “I shall balk at having psychoanalysis swallowed by medicine.” He spelled out the reasons for his objections in
The Question of Lay Analysis
. Medical education, he wrote, was exactly the wrong training for the therapist’s job. “
It burdens [a doctor
²⁷
] with too much . . . of which he can never make use, and there is a danger of its diverting his interest and his whole mode of thought from the understanding of psychical phenomena.” Instead of learning from “
the mental sciences
²⁸
, from psychology, the history of civilization and sociology,” Freud wrote, would-be physician analysts would learn only “anatomy, biology and the study of evolution.” They would thus be subject to “the temptation to flirt with endocrinology and the autonomous nervous system,” and to turn psychoanalysis into just another “specialized branch of medicine, like radiology.”

Steeped in the wrong genre, Freud worried, doctors would not provide the densely layered readings of their patients’ suffering that he had offered in his essays on subjects like melancholia and narcissism, in case studies about delusional characters like the Wolf Man and the Rat Man, and in books declaring the significance of the seemingly insignificant, of dreams and jokes and slips of the tongue. They would not try, as analysts surely would, to understand the reason Sandy thought someone had sucked out his bones, as opposed to the infinity of other delusions he could have had. Instead, they would offer the kind of cure suggested in their medical texts, the kind that doesn’t care what, if anything, the delusion itself might actually mean.

Freud might not have minded that first DSM, which was issued in 1952, thirteen years after his death. He might have recognized his legacy in the names of the sections—“Disorders of Psychogenic Origin” and “Psychoneurotic Disorders”—and of diagnoses such as anxiety reaction and sexual deviation
.
He might have been pleased by the literary descriptions, steeped in psychoanalysis, which turned up, for instance, in the definition of
depressive reaction
as the result of “
the patient’s ambivalent feeling
²⁹
toward his loss.” Buoyed by the continued presence in the book’s 132 pages of his notion that the mind was a host of inchoate and often contradictory feelings, Freud might have been willing to acknowledge that his forecast of a hostile takeover of psychoanalysis by medicine had been wrong. He might even have admired his descendants for their cleverness in avoiding that fate and yet still claiming the perquisites of the doctor, for having figured out how to have it both ways.

But Freud might also have predicted that it was only a matter of time before the strain between the reductive impulse of medicine and the expansive nature of psychoanalysis raised internal havoc. The problems began in 1949, before the first DSM was published, when
a psychologist showed
³⁰
that psychiatrists presented with the same information about the same patient agreed on a diagnosis only about 20 percent of the time.
By 1962, despite various attempts
³¹
to solve this problem, clinicians still were agreeing less often than they disagreed, at least according to a major study. In 1968, at just around the time the second edition of the DSM came out, research showed that for any given psychotic patient,
doctors in Great Britain
³²
were more likely to render a diagnosis of manic depression than schizophrenia, while doctors in the United States tended to do the opposite—a difference that was obviously more about the doctors than the patients.

In the meantime, one of psychiatry’s own had turned against it. Thomas Szasz, an upstate New York doctor with a libertarian bent, argued in
The Myth of Mental Illness
(1961) that psychiatrists had mistaken “problems of living”—the age-old complaints that characterize our inner lives—for medical illnesses, and the result was a loss of personal responsibility (and a sweetening of the pot for doctors). Also in the early 1960s,
Erving Goffman and Michel Foucault
³³
, among other academics, chimed in with their view that mental illness was more sociological than medical, and that psychiatrists were pathologizing deviancy rather than turning up genuine illness—which they (along with Szasz) believed existed only in cases where physiological pathology could be identified as the source of the trouble.

The arguments about diagnostic agreement and the nature of mental illness might have remained arcane academic topics had it not been for a Stanford sociologist, David Rosenhan, who, in 1972, sent a cadre of healthy graduate students to various emergency rooms with the same vague complaint: that they were hearing a voice in their heads that said “Thud.” All the students were admitted with a diagnosis of schizophrenia, and although they acted normally once they were hospitalized (or normally for graduate students; they spent much of their time making notes, behavior that was duly jotted down in their charts as indicative of their illness), the diagnosis was never recanted. Some were released by doctors, and others had to be rescued from the hospital by their colleagues, but all were discharged with a diagnosis of Schizophrenia, in Remission
.

Rosenhan’s recounting of his exploit, “On Being Sane in Insane Places,” appeared in the January 1973 edition of
Science
. Later that year, gay activists, including some psychiatrists, after years of increasingly public and contentious debate, finally persuaded the APA to remove homosexuality from the DSM—a good move, no doubt, but one that, especially after what had happened to the graduate students, couldn’t help but reveal that even when psychiatrists did agree on a diagnosis, they might have been diagnosing something that wasn’t an illness. Or, to put it another way, psychiatrists didn’t seem to know the difference between sickness and health.

Forty years, two full rewrites, and two interim revisions of the DSM later, they still don’t. Psychiatrists have gotten better at agreeing on which scattered particulars they will gather under a single disease label, but they haven’t gotten any closer to determining whether those labels carve nature at its joints, or even how to answer that question. They have yet to figure out just exactly what a mental illness is, or how to decide if a particular kind of suffering qualifies.
The DSM instructs users
³⁴
to determine not only that a patient has the symptoms listed in the book (or, as psychiatrists like to put it, that they
meet the criteria
), but that the symptoms are “clinically significant.” But the book doesn’t define that term, and most psychiatrists have decided to stop fighting about it in favor of an I-know-it-when-I-see-it definition (or saying that the mere fact that someone makes an appointment is evidence of clinical significance). Instead, they argue over which mental illnesses should be admitted to the DSM and which symptoms define them, as if reconfiguring the map will somehow answer the question of whether the territory is theirs to carve up.

This kind of argument leads to all sorts of interesting drama, much of which you will soon be reading about, but none of it can answer the question I posed about Sandy: Is
disease
really
the best way to understand his craziness? How much of our suffering should we turn over to our doctors—especially our psychiatrists?

I don’t know the answer to that question. But neither do psychiatrists. Even in a case as florid as Sandy’s, they cannot say exactly how they know he has a mental illness, let alone what disorder he has or what treatment it warrants or why the treatment works (if it does), which means that they cannot say why his problem belongs to them. That’s no secret. Any psychiatrist worth his or her salt will freely acknowledge (and frequently bemoan) the absence of blood tests or brain scans or any other technology that can anchor diagnosis in a reality beyond the symptoms. What they are more circumspect about is the disquieting implication of this ignorance: that if a physician wants to claim that drapetomania and homosexuality and, as the DSM-5 has proposed, at one time or another, Hypersexuality
and Internet Use Disorder
and Binge Eating Disorder
are medical illnesses, there is nothing to stop him from doing so and if he is shrewd and lucky and smart enough to persuade his colleagues to follow him, the insurers, the drug companies, the regulators, the lawyers, the judges, and, eventually, the rest of us will have no choice but to go along.

So while the psychiatrists who author the DSM and I share an ignorance about how much of our inner travail should be considered illness, only the psychiatrists have the power to decide, and only the American Psychiatric Association claims those decisions as intellectual property that is theirs to profit from. That’s why I think you should be more disturbed by their ignorance than mine. After all, if the people who write the DSM don’t know which forms of suffering belong in it, and can’t say why, then on what grounds can the next instance in which prejudice and oppression are cloaked in the doctor’s white coat be recognized? Or, to put it more simply, why should we trust them with all the authority they’ve been granted?

•   •   •

That’s a question that psychiatrist Allen Frances has been asking recently. Frances knows a great deal about power and psychiatry. Indeed,
The New York Times
once called him “
perhaps the most powerful psychiatrist in America
³⁵
.” That was in 1994, when Frances, who then headed the psychiatry department at Duke University School of Medicine, was chair of the DSM-IV task force, the APA committee responsible for that revision. He’s retired now, and not as powerful, but he’s a lot more famous, mostly because he has spent the last four years waging a scorched-earth campaign against his successors, largely on the grounds that they are abusing their power. He’s warned anyone who will listen that the DSM-5 will turn even more of our suffering into mental illness and, in turn, into grist for the pharmaceutical mill.