The Book of Woe: The DSM and the Unmaking of Psychiatry (4 page)

Frances is seventy years old, a big, swarthy man with a prominent brow set off by a shock of white hair. I once heard a bartender tell him he looked like a cross between Cary Grant and Spencer Tracy. The bartender may have been flirting or fishing for a bigger tip, but he had one thing right: Frances, like those stars, exudes charm and authority in equal measure. He’s soft-spoken, his voice high and reedy, and his patter is compulsively self-effacing, but like certain dangerous animals, he’s unpredictable, and always ready to spring.

I hadn’t known Frances for very long before he said something to me that he came to regret. It was just before dawn on a morning in August 2010. He’d finished his workout and cracked open his first Diet Coke of the day in the kitchen of the California home he shares with his psychiatrist wife, Donna Manning. The jihad Frances had launched against his former colleagues had made him appealing to magazines like
Wired
, which had sent me to get the skinny on this loyalist denouncing the new regime. Since I’d arrived the day before, he’d been giving it to me, volubly and forcefully; and now we returned to one of the recurring themes of yesterday’s conversation: the way the DSM seemed to grant psychiatrists dominion over the entire landscape of mental suffering, a perch from which they could proclaim as a mental disorder any aberration they could describe systematically. I asked him whether he thought a good definition of mental disorder would establish the bright boundary that would sort the sick from the unusual, and thus keep psychiatry in its proper place.

“
Here’s the problem
³⁶
,” Frances said. “There is no definition of a mental disorder.”

I mentioned that that hadn’t stopped him from putting one into the DSM-IV, or the people who were then making the DSM-5 from fiddling with it.

“And it’s bullshit,” he said. “I mean you can’t define it.”

This was the comment that Frances would come to regret—or at least, when it appeared in
the lead of the
Wired
article
³⁷
, to regret having said to me. He soon found himself explaining it—to other writers, to his mildly titillated grandchildren, to attorneys who used it to discredit his testimony as a forensic expert, and, worst of all from his point of view, to Scientologists and other opponents of psychiatry who used it to draft Frances into their cause. Frances never quite blamed me for having turned his words into aid and comfort to the enemy. But even so, he was pretty sore about it, especially, he said, because my use of his words might encourage mentally ill people to go off their medications. I had turned him into my Charlie McCarthy, he complained—not by putting words in his mouth, but by throwing my tone into his voice.

I’m sure Frances would have used a different phrase if he’d thought about it. He didn’t intend to dismiss the diagnostic enterprise, let alone all of psychiatry, but rather to say only that it is impossible to find that bright line and probably not worth the bother, that a good clinician can be trusted to determine significance and then, with the help of a decent diagnostic manual, figure out which disorder to diagnose and get on with the treatment. He was shooting from the hip, and even though I don’t regret reporting his comment, I can see why he wishes I hadn’t.

On the other hand, metaphors often have significance beyond their author’s intent, although, as Freud pointed out, sometimes analysis is required to ferret it out. Fortunately for us, there is a philosopher of bullshit. His name is Harry Frankfurt, and he’s taught at Yale and Princeton, and in 2005 he published a tiny gem of a book called
On Bullshit.
“
Bullshit is unavoidable
³⁸
whenever circumstances require someone to talk without knowing what he is talking about,” writes Frankfurt. “Thus the production of bullshit is stimulated whenever a person’s obligations or opportunities to speak about some topic exceed his knowledge of the facts relevant to that topic.” Filling in the gap between opportunity and knowledge requires the bullshitter to stand “
neither on the side of the true
³⁹
nor on the side of the false,” he adds. “His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says.”

For the last fifteen years, some of the smartest psychiatrists in the world, people who have studied diagnosis for their entire careers, people motivated, at least in part, by the desire to relieve suffering, have worked longer and harder, and taken more fire, than they ever expected as they revised the DSM-IV. But if you ask any one of them (and I have asked many) about the DSM’s diagnoses and criteria—new and old—he or she will tell you they are only “fictive placeholders” or “useful constructs,” the best the profession can do with the knowledge and tools at hand. They are fully aware, in other words, that their opportunity (although they may call it an obligation) to name and describe our psychological suffering far exceeds their knowledge. They have intentionally, if unhappily, stood on the side of neither the true nor the false, and for the sixty years since the first DSM was published, they have gotten away with it.

I don’t mean to say that the DSM is nothing more than bullshit, or that the APA is merely trying to hoodwink us in order to maintain its franchise or make a buck (or a hundred million of them, which is what the DSM-IV has earned it). That would be as glib as tarring the entire diagnostic enterprise with Dr. Cartwright’s brush. And as uninteresting: finding bullshit in a professional guild’s attempt to strengthen its market position would be no more remarkable than discovering gambling in Casablanca. But what are neither glib nor uninteresting are the circumstances that make it necessary and possible for the 150 men and women on the DSM-5 task force and work groups to have it both ways, to manufacture fiction and yet act as if it were fact. If the story of the DSM-5 has any redeeming value, if it is more than a story about parochial disputes and internecine warfare, it is that it can reveal the conditions that motivate the publication of the DSM and the interests that another revision serves.

Some of those circumstances are straightforward enough, and depressingly banal. If fully 10 percent of your guild’s revenue, and an uncountable amount of your authority, depend on a single book, a book that once saved your profession from oblivion and since then has brought it fabulous riches, you don’t give it up easily. But other circumstances are less obvious and more dangerous, and the idea that gives psychiatry the power to name our pain in the first place—that the mind can be treated like the body, that it is no more or less than what the brain does, that it can be carved at its joints like a diseased liver—is perhaps the most important of all. It reflects what is best about us: our desire to understand ourselves and one another, to use knowledge to relieve suffering, even if it results in a kind of reductionism that insults our sense of ourselves as unfathomably complex and even transcendent creatures. It also reflects what is worst—the desire to control, to manipulate, to turn others’ vulnerabilities to our advantage. The first impulse demands a search for truth at all costs. The second makes it imperative to get away with whatever you can in order to exploit a market opportunity. When those impulses collide, commerce—and often bullshit—will prevail.

A
llen Frances is not the first psychiatrist to draw a bead on his profession’s inability to distinguish between illness and health. Neither is he the first to worry about the effects of this uncertainty on public confidence in his profession. The two concerns have gone hand in hand since at least 1917, when Thomas Salmon gave a talk in Buffalo, New York, to the American Medico-Psychological Association (the new name for the Association of Superintendents, which would later be renamed the American Psychiatric Association).

“
The present classification of mental diseases is chaotic
¹
,” Salmon told his colleagues. “This condition of affairs discredits the science of psychiatry and reflects unfavorably upon our association.” He proposed a solution: a classification of twenty different mental diseases “that would meet the scientific demands of the day.”

Although his organization was already seventy years old, Salmon’s list was one of the first proposals for a psychiatric
nosology
,
or classification of diseases. Earlier psychiatrists had kept track of their patients, but their concerns ran much more to the statistical than to the diagnostic. In part, this was because they were making their count at the behest of the Census Bureau, which, starting in 1840, had wanted to know just how many people were “insane,” but not which forms of insanity they had. When those numbers increased dramatically throughout the mid–nineteenth century—especially in neighborhoods where new asylums had been built—their explanations were more sociological than physiological or psychological. “
It cannot be supposed
²
that so many people were suddenly attacked with insanity when these establishments were opened or enlarged,” said Massachusetts doctor Edward Jarvis, head of his state’s Commission on Lunacy. Rather, he explained, “the more the means of healing are provided and made known to the people, the more they are moved to intrust [
sic
] their mentally disordered friends to their care.” Supply, at least when it came to mental hospitals, could create demand.

But what had driven these recently discovered patients insane in the first place? “
Within the last fifty years
³
, there has unquestionably been a very great real increase of the malady [insanity] in the progress of the world from the savage to the civilized state.” Not that “these two great facts, the development of mental disorder and the growth of human culture, stand as cause and effect,” he added quickly. But then again, Jarvis was more than just saying. There were two types of causes of insanity—physical (as in “palsy, epilepsy, fever, and blows on the head”) and moral, “those which first affect the mind and the emotions.” This second type of cause was surely on the increase, a by-product of all that progress and the brave new world it had ushered in.

In an uneducated community
⁴
, or where men are born in castes and die without stepping beyond their native condition; where the child is content with the pursuit and the fortune of his father, and has no hope or expectations of any other, these undue mental excitements and struggles do not happen, and men’s brains are not confused with new plans nor exhausted with the struggle for a higher life, nor overthrown with the disappointment in failure. In such a state of society, these causes of insanity cannot operate.

Upward mobility carried risks with it, and so did modern education. Indeed, the “professional insane”—doctors, lawyers, teachers, and the like—were uniquely subject to the demands that “arise from excessive culture and overburden the mental powers.” Which is why, he thought, 3.75 percent of them were on the rolls in Massachusetts.

“
From all this survey
⁵
,” Jarvis concluded in 1872, “we are irresistibly drawn to the conclusion that insanity is a part of the price we are paying for the imperfection of our civilization.”

Jarvis’s conclusion made the particulars of his patients’ afflictions less important than their demographics and geography and economics, and their relief more a matter of social than medical remedy. This may well have reflected some idealism on his part and a sense that psychiatry’s job was to help perfect civilization rather than to cure individuals. But there is a less noble reason for Jarvis’s and his colleagues’ nosological inattention: they simply couldn’t compete with their microscope-armed brethren. As the magnificently named psychiatrist Pliny Earle complained in 1886:

In the present state of our knowledge
⁶
, no classification of insanity can be erected upon a pathological basis, for the simple reason that, with slight exceptions, the pathology of the disease is unknown. Hence, for the best understood foundation for a nosological scheme for insanity, we are forced to fall back upon the symptomatology of the disease—
the apparent mental condition
, as judged from the outward manifestations.

All the statistical analysis in the world, and all the recommendations for the perfection of society, would not make psychiatrists real doctors; real medicine was practiced upon individual patients, upon their errant physiologies and the bugs that had made them go haywire. As if this weren’t trouble enough, the democratization of mental illness had so favored neurologists that by the time World War I broke out, psychiatry, according to historian Edward Shorter, “
had become marginal
⁷
to the mainstream of medicine.” So when Thomas Salmon presented his classification of diseases to his colleagues in Buffalo, it was clear that they risked professional demise if they could not fill in the gap between opportunity and knowledge by meeting those scientific demands.

•   •   •

Salmon’s solution took inspiration from an earlier attempt to solve the same problem. In the late nineteenth century, a German doctor named Emil Kraepelin had noted the nosological chaos in which psychiatrists claimed with certainty that their patients suffered from “masturbatory insanity” or “wedding night psychosis” or “dementia praecox,” but couldn’t say how they knew what these conditions were, or where one started up and another left off, or, most important, whether or not they existed.

Kraepelin would have liked to ground his nosology as his colleagues in other specialties did. “
Pathological anatomy
⁸
,” he wrote, offered “the safest foundation for a classification,” but the brain, where that pathology would most likely be found, was way beyond the reach of the instruments of the time. So he settled for what Pliny Earle had lamented as second best. He proposed that the landscape of mental suffering could be effectively mapped if a doctor observed it carefully and systematically enough, if, that is, he stuck faithfully to the phenomenon as it presented itself in the clinic. Discern how symptoms grouped together in patients, how, for example, delusions of grandeur went together with mania, or how hallucinations dogged the same patients who were paranoid, and then chart the course and outcome of those cases, and you have the basis for an accurate taxonomy of insanity, one that, or so Kraepelin promised, would line up with the pathological anatomy that doctors were sure to discover in the future.

Kraepelin’s method required patience and discipline and, above all else, a steely determination not to indulge in “
poetic interpretation
⁹
of the patient’s mental process, [which] we call empathy.”

“Trying to understand another human being’s emotional life,” he once told his students, “is fraught with potential error . . . It can lead to gross self-deception in research.”

Early in his career, Kraepelin got a job in an Estonian asylum. He didn’t speak the local language, so it was a perfect opportunity to hone his method for discerning the nature of his patients’ illnesses undistracted by empathy. He observed their behaviors, noted them on cards, sorted them according to which ones appeared together, and chronicled what happened to the patients who had those groups of symptoms. In 1893 he published the first in a series of textbooks in which he gave names to the illnesses he claimed to have discerned and provided descriptions of how they could be recognized.

Kraepelin’s taxonomy had to compete with Freud’s rich and riveting accounts, and it languished, especially in the United States. But when Salmon introduced his nosology, he didn’t write about Oedipal complexes or reaction formations. Instead
he took a Kraepelinian approach
¹⁰
, laying out neat categories of mental illness, many of which, including dementia praecox
and manic-depressive insanity and involutional melancholia, were cribbed directly from his German forebear.

Salmon shared something else with Kraepelin: ignorance about the biochemical origins of mental illness, coupled with the assumption that when they were finally discovered, as they inevitably would be, they would prove that the diseases existed in the way we expect diseases to exist, and that psychiatrists had known all along what they were talking about.

Salmon had renewed the promissory note issued by Kraepelin, and the market was quick to take on the debt. A year after his talk,
the association issued the
Statistical Manual
¹¹
for the Use of Institutions for the Insane
, based largely on Salmon’s nomenclature. The book pleased the Census Bureau enough that it adopted the categories for its own ongoing attempt to include the mentally ill in its count of Americans. The
Statistical Manual
was revised ten times between 1918 and 1942, but it remained, as the title implied, primarily a guide to data collection, focused mostly on institutionalized patients whose ills were presumably biological in origin. It also remained brief:
its last edition ran to seventy-one pages
¹²
covering, besides Salmon’s original handful of diagnoses, eight “psychoneuroses” added in response to the ascendancy of psychoanalysis.

By 1940, the American Psychiatric Association (the name Salmon’s organization had adopted in 1921) had
a membership of only 2,295 doctors
¹³
. But World War II, with its influx of soldiers suffering war neuroses
(later to be known as Posttraumatic Stress Disorder), had induced the army to increase the ranks of its psychiatrists, and by the end of the war, thanks to some quick on-the-job training, there were 2,400 psychiatrists serving in the army alone. It wasn’t long before the swelling ranks of psychiatrists sought to extend their success to the civilian walking wounded. “
Our experiences with therapy
¹⁴
in war neuroses have left us with an optimistic attitude,” wrote two prominent psychiatrists in 1944. “The lessons we have learned in the combat zone can be well applied . . . at home.”

But neither psychoanalysis, the dominant mode of therapy, nor the
Statistical Manual
was entirely well suited to these new psychiatrists. Psychoanalysis, with its focus on early childhood as the fount of all pathology, couldn’t really explain why so many soldiers, presumably normal before the war, became mentally ill after exposure to its horrors. Neither could the
Statistical Manual
, with its focus on constitutional and presumably incurable illnesses, account for what seemed to be transient and dramatic reactions to the environment.

Psychoanalysis proved easy enough to adapt
¹⁵
, especially now that Freud was dead and couldn’t object. Freud’s insistence that only early childhood trauma caused neurosis could be modified without losing the basic idea that intrapsychic conflict was the culprit. Trauma later in life, such as a war, could also disrupt intrapsychic functioning and leave people unable to adapt to new and difficult circumstances. This failure could be understood as a
psychoneurotic reaction
, and analysts, armed with this notion, recast psychoanalysis as a theory of adaptation to life circumstances, and their practices as a ministry to the walking wounded.

But the
Statistical Manual
presented a different kind of problem. Its basic terms didn’t even come close to describing what psychiatrists were seeing in the clinic. Indeed, they complained,
only 10 percent of their cases
¹⁶
fit into the classification system. So they began to improvise, stretching diagnostic categories to fit their patients, inventing labels when that didn’t work, and borrowing disease names from other medical specialties whenever they could. The armed forces developed their own nosology, as did the Veterans Administration, and these began to compete for primacy with the edition of the
Statistical Manual
that had been issued in 1942. In 1948, George Raines, chair of the APA’s committee on nomenclature, summed up the situation he faced:

At least three nomenclatures
¹⁷
were in general use, and none of them fell into line with the International Statistical Classification . . . One agency found itself in the uncomfortable position of using one nomenclature for clinical use, a different one for disability rating, and the International for statistical work. In addition, practically every teaching center had made modifications of [the
Statistical Manual
] for its own use and assorted modifications of the Armed Forces nomenclature had been introduced into many clinics and hospitals by psychiatrists.

Psychiatry, or at least the APA, was once again mired in the chaos that Salmon had lamented three decades earlier as a threat to the viability of his profession.

Raines decided to put off a revision of the
Statistical Manual
scheduled for 1948 in favor of a total revamping. Drawing on the armed forces’ classification, input from psychiatric teaching hospitals, polls of the APA’s membership, and reviews of the scientific literature, he and his committee assembled a revised manual, which they submitted to the membership in 1950. The proposed book still provided labels and descriptions for conditions presumed to be unresponsive to the environment as either cause or cure. But it also contained definitions of
reactions
, disorders resulting from traumatic life circumstances and accounted for by the updated, adjustment-focused version of psychoanalysis that had emerged since the war.