The Book of Woe: The DSM and the Unmaking of Psychiatry (38 page)

But an ambiguous research record hadn’t stopped the work group from gerrymandering the bereavement exclusion out of MDD, nor was it stopping other work groups from considering destabilizing changes like the removal of Asperger’s or the introduction of entirely new diagnoses like DMDD. On the other hand, those diagnoses had one advantage over melancholia: they didn’t threaten to introduce a biological measure into the DSM and make the rest of the book look bad in the bargain. Offered a key to one of the cells of its epistemic prison, the APA had decided that the cost of freedom was too high.

•   •   •

In June 2012, the APA posted a change to the permissions policy on its DSM-5 website. “
The APA owns all products
⁶
generated by the Work Groups developing DSM-5,” it declared. This included, they asserted, not only proposed criteria, but also the discussions that led to the work groups’ decisions. To those who wondered how this squared with the insistence that this was the most transparent DSM ever, the APA issued a reassurance: “Requests will be considered for permission to describe the criteria and development process in narrative form.” The organization wasn’t trying to erase history, only to control it.

There was no explanation of this change. It was hard not to think that it had something to do with my having shown up at the annual meeting and peppered the presenters with questions, from which the APA’s communications experts could only conclude that their embargo had not stopped me from writing my book.

On the other hand, the new policy also came shortly after Allen Frances put his scathing description of the development process on the op-ed page of
The New York Times
. The APA, he charged, was guilty of “
arrogance, secretiveness
⁷
, passive governance and administrative disorganization.” It had failed to rein in its experts, who had in turn (and predictably) manufactured new disorders, heedless of the fact that “new diagnoses in psychiatry can be far more dangerous than new drugs.” And now he had come to a reluctant conclusion—that the APA “is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy,” and that it should be stripped of the diagnostic franchise.

Frances acknowledged that there was no obvious immediate successor, but he suggested the Department of Health and Human Services, the Institute of Medicine (a section of the National Academy of Sciences), or even the World Health Organization. He mentioned one obvious contender, the National Institute of Mental Health, only to dismiss it as “too research-oriented and insensitive to the vicissitudes of clinical practice.” Since sponsoring the planning conferences at the beginning of the DSM-5 effort, the NIMH had indeed remained on the sidelines—not because nosology was out of its bailiwick, but because the institute had lost faith in the DSM. “
Our resources are more likely
⁸
to be invested in a program to transform diagnosis by 2020,” NIMH director Thomas Insel told me, “rather than modifying the current paradigm.”

The NIMH is placing its bets for a new paradigm on a program it calls the Research Domain Criteria (RDoC), a name that recalls the Research Diagnostic Criteria, the Washington University initiative that led to the transformation of diagnosis in the DSM-III. Just as Spitzer and his colleagues had been confronted with widespread dissatisfaction with the diagnostic system among psychiatrists, so too had Insel heard the discontent among his peers on his frequent trips to hospitals and universities around the country.

What Insel heard “over and over again
⁹
” on his tour was that psychiatrists were tired of being trapped by the DSM. “We are so embedded in this structure,” he told me. He and his colleagues had spent so much time diagnosing mental disorders that “we actually believe they are real. But there’s no reality. These are just constructs. There’s no reality to schizophrenia or depression.” Indeed, Insel said, “we might have to stop using terms like
depression
and
schizophrenia
, because they are getting in our way, confusing things.” Thirty years after Spitzer burned down the DSM-II and built the DSM-III in its ashes, psychiatry might once again have to “just sort of start over.”

Spitzer’s error, at least according to Bruce Cuthbert, the NIMH psychologist in charge of RDoC, was not that he tried to cram psychological suffering into faux medical categories, but that he continued to think of suffering as a function of the mind. “
So many of our disorders
¹⁰
historically have been conceived of as disorders of mind,” Cuthbert says. This leaves scientists in an impossible position. “As scientists we have to measure things,” he says. “What else can we do?”

But the attempt to measure the mind has led to nothing but dead ends like the old, now discredited theories about depression and serotonin. “There was going to be a one-to-one map between our putative mind diseases and biology,” says Cuthbert. “Whoops! It wasn’t that simple.”

The way to start over, according to Cuthbert and Insel, is to forget about the mind and look directly to the brain for understanding our suffering. We shouldn’t take the fact that people have been describing disorders of the mind such as melancholia for more than two thousand years or schizophrenia for more than a century as evidence that those diseases exist and then try to find them in the brain, Cuthbert said. Instead we should ask, “What does the brain do? What did it evolve to do? And we know that now.”

What we know now, Cuthbert explained, is that “there are very specific circuits in the brain that perform somewhat specific things.” Previous attempts to map the brain onto disorders of the mind failed not only because they were looking for mind disorders, but also because they had the brain’s role in psychopathology wrong. The trouble didn’t originate in individual brain structures like the hippocampus or frontal cortex. Neither was it in droughts and floods of neurotransmitters. Rather, it was to be found in circuits of neurons, the pulsating networks that experience builds in the brain, each their own little ecosystem in the vast electrochemical jungle between our ears. Understanding circuits, or even knowing that they existed, wasn’t even possible a generation ago, but now, thanks to MRI, PET, and other brain-scanning technologies, “we know there are circuits for fear,” Cuthbert said. “We know there are circuits that guide us to approach things that are desirable and to go get them, like the food that we need for nourishment. We know there are circuits for memory. So we know something about the organization of these circuits now, and we have an idea that these circuits are involved in lots of different disorders.”

Cuthbert doesn’t expect neural circuits to map onto the DSM disorders any better than neurotransmitter metabolism has. But then again, this may not matter. If, for instance, researchers can trace the neurocircuitry of the startle response, figure out all the electrochemical events that make an animal blink and hunch and shrink away from a sudden noise, then they will be on their way to understanding the anxiety found in many DSM disorders. The arousal itself having been elucidated, it will no longer be merely a scattered particular waiting to be gathered under the correct diagnosis. Indeed, fictive placeholders will no longer be necessary. They will be replaced by the natural formations that the brain scanners have detected as the sources of this particular kind of suffering.

Cuthbert pointed to a chart titled “Draft Research Domain Criteria Matrix.” Its rows list the five natural formations the NIMH is interested in: negative valence systems, including threat, fear of loss, and frustration; positive valence systems, including motivation, learning, and habit; cognitive systems (attention, perception, and memory); systems for social processes (facial expression identification, imitation, attachment/separation fear); and arousal/regulatory processes (stress regulation). Its columns are eight units of analysis—such as genes, molecules, and cells—which the NIMH would like researchers to use to investigate the domains. So, for instance, a scientist interested in working memory (a cognitive system) might want to look into the dorsolateral prefrontal cortex, while a researcher in the negative valence domain could propose a study about the
hypothalamic-pituitary axis
or the
bed nucleus of the stria terminalis
or
corticotrophin-releasing factor
. Ultimately, so Cuthbert and Insel hope, the matrix will be filled in with knowledge about these domains, and the neural substrates of the distress of people with attachment/separation fear or difficulties in regulating stress will be elucidated, pinpointed, and presumably targeted for treatment, without any need for recourse to putative mind diseases.

Cuthbert was not clear about whether it is the mind that is putative or only its diseases, although the fact that most of this research is going to take place on animals is a clue to the relative place of the human mind in this scheme. And, indeed, it is hard to see how the idea that human consciousness is something more than the sum of its parts—an idea that, however muted, still lingers in the notion that a state of mind such as depression can be something real, something that surpasses and unites its scattered particulars—can survive an effort such as RDoC. Not that the program signals the death knell of the self (and not that psychiatry, for all its influence, could slay the idea of human agency that has developed over the last five thousand years or so), but it does seem to signal the profession’s intent to complete its abandonment of the mind as the location and source of our suffering, an effort that began in earnest when Spitzer kicked psychoanalysis out of the DSM and that might end as it turns to circuits and systems whose primary virtue is that they can be measured. It seems to signal a future in which diagnosticians will let the brain talk in its own language of inputs and outputs, of ganglia and dendrites, of myelin sheaths and afferents; tell its owner what it is saying; and then provide treatments that are no longer targeted at mythical chemical imbalances or fictive disorders but at the faulty circuits that are causing distress.

At the APA meeting in Honolulu, Insel laid out his vision of that future. He showed an animation illustrating the differences in brain development between children with ADHD and normal kids, differences that he said originated very early in life. “
We call this attention deficit/hyperactivity disorder
¹¹
,” he said, but “think about it for a moment. Attention, that’s cognition; hyperactivity, that’s behavior; so this is a cognitive-behavioral disorder. That’s the way we define it, the way we characterize it, the way we study it, the way we treat it.” He looked over at the PowerPoint screen, where the two kinds of brains were still projected. “This to me looks like a disorder of cortical maturation. Imagine if we took everyone with myocardial infarction and said they had a chest-pain problem. Yes, these kids do have attention deficit, they do have hyperactivity, that is part of it, but if you don’t begin to think about ADHD as a disorder of cortical maturation, you’ll never ask the key questions . . . Maybe we could use this as the target to develop treatments instead of always thinking about the observable symptoms.”

The same is true of schizophrenia, Insel continued, and presumably of other psychiatric disorders. “Behavior is a late manifestation of brain disorders, so if mental disorders are brain disorders and we’ve only allowed ourselves to define them based on manifest symptoms and signs, we’re talking about getting into this game in the ninth inning. And in medicine we don’t do so well when we get into the game very late.” Psychiatrists, not to mention their patients, can’t afford to wait until people actually suffer to intervene—and, if RDoC is successful at laying bare the neural and genetic substrates of our suffering, they won’t have to. They will be able to render a diagnosis before there is even trouble, based on what they can see in the brain.

And since the brain is nothing but electricity and meat, since, that is, it is real, brain-based diagnosis will also be real, not reified real but really real, and psychiatric nosology will finally put paid to the century-old promissory note—not by finally connecting signs and symptoms to biology and chemistry, but by getting out of the mind business and placing all the money on the brain. In the system the RDoC envisions, there will be no more reminders to clinicians not to think of diagnoses as actual diseases, no more worries that the DSM is taken too seriously, no more whining about epistemic prisons, no more fights over symptom counts or disorder names, no more exclusion criteria, no more doomed attempts to ride the royal road of descriptive psychiatry to the kingdom of anatomical pathology, no more unworkable definitions of mental illness, and, above all, no more bullshit.

•   •   •

On the other hand, maybe not. In 2020, or whenever RDoC comes to fruition, after the animals have been startled or frustrated or taught a new maze and had their brains duly mashed and assayed, after the matrix has been filled in, Insel and Cuthbert or their successors will still have to name those circuits and then define all those words. They will have to say exactly what those measurements of neurons in the stria terminalis or cortisol in the spinal fluid are measuring. And then they will have to do what Kraepelin and Salmon and Spitzer and Frances and First and Regier and every other would-be psychiatric nosologist has had to do: figure out what
fear of loss
is and where it leaves off and
attachment/separation fear
sets in, and how much of each is pathological and when and whether to say that the measured symptoms add up to an illness. They will once again be faced with the fact that there is very little that is important about us that can be defined in such a way as to measure it, and that numbers and words may be incommensurable vocabularies, two irreconcilable languages in which to understand us.

The mind may well be an illusion, something the brain does to entertain us while it goes on about its business, whatever that business is, but it’s a gorgeous illusion and very convincing. I’ll bet you think you are in there reading this, just as I am sure I am in here writing it, and when you are doing that, or when you are anxious or depressed, I’ll bet you are pretty sure it’s because of something other than some crossed-up brain circuits. The mind is also a resilient illusion. The idea that we are agents, that our brains serve us just as our other organs do—in this case providing us with the means to author our lives—and that this is in some sense what it means to be human, has survived all sorts of assaults, and it may survive this one as well.