The Book of Woe: The DSM and the Unmaking of Psychiatry (5 page)

Raines’s revision offered something for private practice and hospital psychiatrists alike. It also had a different focus from the earlier manual—largely, Raines explained, because the recent establishment of the National Institute of Mental Health meant that statistical analysis, once the “
stepchild of [the] Federal Government
¹⁸
,” would now be handled by public officials. Freed from that drudgery, psychiatrists could pay closer attention to diagnosis, and the new revision stood ready to aid them with eighty-seven diagnoses to choose from, each with a paragraph describing a prototypical patient. If, for instance, a patient was complaining of “diffuse” anxiety, “not restricted to situations or objects . . . not controlled by any specific psychological defense mechanism . . . characterized by anxious expectation and . . . associated with somatic symptomatology,” then the doctor could diagnose
Anxiety Reaction
¹⁹
. On the other hand, if “the anxiety . . . is allayed, and hence partially relieved, by depression and self-depreciation . . . precipitated by a current situation . . . associated with a feeling of guilt for past failures or deeds . . . [and] dependent on the intensity of the patient’s ambivalent feeling toward his loss,” then the patient had
Depressive Reaction
²⁰
.
Because of this new focus, the manual had a new name:
The Diagnostic and Statistical Manual: Mental Disorders
.

When it was released in 1952, the DSM’s nomenclature imposed some order on the professional landscape. As insurance payments came to play an increasing role in the medical marketplace, those new diagnoses proved useful, especially to private-practice doctors. But these successes came at a cost: by delineating a realm of “
disorders of psychogenic origin
²¹
or without clearly defined physical cause or structural change in the brain,” the DSM represented a partial abandonment of Kraepelin’s promise that mental disorder could be understood like physical disease, and eventually would be explained as the manifestation of brain pathologies. And by incorporating Freudian concepts like
defense mechanism
and
ambivalence toward loss
, the DSM glossed over a question that had been looming since the New York Psychoanalytic Society claimed psychoanalysis for medicine. Were those psychogenic disorders really medical problems? Should psychiatrists continue to try to carve up the landscape of mental suffering in the way that the rest of medicine was carving up the afflictions of the body?

By 1963, leading psychiatrists such as Karl Menninger were beginning to think the answer was no. “
Instead of putting so much emphasis
²²
on different kinds . . . of illness,” he wrote, “we propose to think of all forms of mental illness as being essentially the same in quality and differing quantitatively.” Menninger didn’t think the search for “what was behind the symptom” should be abandoned. Rather, he believed, like Edward Jarvis, that psychiatrists should focus their attention not on hypothetical brain disturbances or quasi-medical psychogenic diseases, but on “
Man in transaction with his universe
²³
”—the economic, political, and social world in which psychological life was lived.

Many of his colleagues shared Menninger’s dour view of diagnosis, and, glad as they were to use the book to get insurance payments, they otherwise ignored not only the DSM, but nosology in general. By the late 1960s,
it had become a professional backwater
²⁴
; discussions of disease classification were relegated to the last session of the last day of professional conferences. But even if the DSM had managed to put Kraepelin’s promissory note into abeyance, if not to abandon it entirely in favor of Menninger’s transactional view, still a market based on confidence cannot tolerate outstanding debt forever. After the repeated blows to psychiatry’s credibility in the late 1960s and early 1970s—the reliability fiascos, the Rosenhan caper, the homosexuality debacle—the note was finally called in. In 1975, a Blue Cross executive told the
Psychiatric News
,
the APA’s house organ, that his industry was reducing mental health treatment benefits because “
compared to other types of services
²⁵
, there is less clarity and uniformity of terminology concerning mental diagnoses.” And in 1978, a presidential commission, convened, among other reasons, to set priorities for federal funding, concluded that “documenting the total number of people who have mental health problems . . . is difficult not only because opinions vary on how mental health and mental illness should be defined, but also because the available data are often inadequate or misleading.”

Whatever their patients were suffering from, the doctors’ problem was obvious. The DSM did a lousy job of helping them figure out and agree on which disease belonged to which patient, and even in the cases where it succeeded (after all, how hard is it to diagnose homosexuality?), the DSM didn’t help doctors prove that patients were suffering from medical diseases rather than the human condition. Turning away from Kraepelin and toward Freud had been a boon, but it had now become an embarrassment. Unless something was done, it was going to be increasingly difficult for psychiatrists to make a living.

•   •   •

The war over the homosexuality diagnosis
²⁶
finally came to an end in 1973, when a Columbia psychiatrist, Robert Spitzer, sat down with both sides and hammered out a compromise. The DSM would no longer list homosexuality as a disease, but it would still provide a diagnosis for people who were gay and didn’t want to be:
Ego-Dystonic Homosexuality
²⁷
, a condition, clinicians were advised, that was the result, at least in part, of “negative social attitudes [that] have been internalized.” It was a win-win: gay people would no longer be subject to bizarre and pointless therapies (or to psychiatrist-assisted discrimination), the APA would stop getting humiliated by protests, and therapists everywhere would continue to get insurance dollars to treat gay patients.

Like most compromises, this one left some bad feelings. “
If groups of people march
²⁸
and raise hell, they can change anything in time. Will schizophrenia be next?” one psychiatrist fulminated. “
Referenda on matters of science
²⁹
[make] no sense,” said another. But the compromise at least kept the profession from splitting at its seams even as it began to regain its dignity and the confidence of its patrons in government and industry. And it showed that Spitzer had a great command of both the political and the scientific issues at stake.

When I met with him, Spitzer, nearing eighty and hobbled by Parkinson’s disease, was barely able to walk from the easy chair in his sunny living room to the kitchen table, where sandwiches whipped up by his full-time aide awaited, but his mind seemed undiminished. He certainly remembered what his profession was up against after the homosexuality crisis, and he was not mincing words about it.

“
Psychiatry was regarded as bogus
³⁰
,” he said. “I knew it would be better off if it was accepted as a medical discipline.”

Like Salmon before him, he believed that a nosology that met the scientific demands of the day was the key to restoring credibility to his profession. He also knew that if he managed to fashion that solution, “my colleagues would think I had done something very worthwhile.” So he volunteered for the job of revising the DSM, and, given his successful nosological diplomacy on the homosexuality front, the APA was delighted to have him.

Spitzer also knew that even if his job was to carve nature at its joints with the scalpel of scientific knowledge, he was stuck with the same dull instruments that Salmon and Kraepelin used—which were not all that different from what ancient doctors like Hippocrates had at their disposal: their senses, and the empirical world they could apprehend. And while ancient doctors could taste a patient’s urine or smell his sweat or peer into body cavities for information the patient couldn’t provide directly, psychiatrists were limited to the symptoms a patient could describe and the signs embedded in his behavior and comportment.

Still, as Kraepelin had demonstrated, it was possible to make observations carefully and group them systematically. Spitzer’s attraction to this method wasn’t so much a matter of conviction as predilection. “Ever since I was a child, I liked to sort things,” he said, recalling that at summer camp he graphed his attractions to different female campers. Of course, to sort out the girls successfully, you have to know which categories to put them in, and what makes them belong in one or the other. You have to believe that beauty and intellect and sense of humor are real properties, and that your way of discerning them is accurate and consistent. Like Kraepelin, Spitzer was certain that if he was careful enough in observing them, the outward manifestations would reveal the underlying mental condition.

To Spitzer, it wasn’t the unfulfilled promise of Kraepelin and Salmon, but rather psychoanalysis—with its claims that psychopathology was the human condition, that same-sex love was the result of damage inflicted in childhood by absent fathers and overbearing mothers, and that, in general, mental suffering was the result of the eternal war among ego, id, and superego—that had led psychiatry to near shipwreck. It was psychoanalysis that had led psychiatrists like Menninger to abandon the idea of sorting suffering into medical categories. It was psychoanalysis that had persuaded doctors to sort mental disorders according to the inner turmoil that had allegedly caused them—the Oedipal conflict, say, or a fixation on the anal stage of infantile sexual development. And it was psychoanalysis that claimed that when it came to our psychological lives, the line between illness and health could be drawn by determining if the problem was the result of intrapsychic conflict, of the lies we tell ourselves about ourselves, of the truths we dance around or repress and transmute into symptoms.

Spitzer hadn’t much liked the psychoanalytic training that had been required of him and most psychiatrists of his era, and he really didn’t like being an analyst. “
I was uncomfortable with not knowing
³¹
what to do with their [patients’] messiness,” he said. “I just didn’t know what the hell to do.” And it was obvious to him that Freud’s theory of mind was a poor substitute for pathological anatomy, and the complexes and resistances and defense mechanisms—the psychoanalyst’s stock-in-trade—were far too ungrounded in any kind of empirical reality to be useful. Proving the existence of ego, id, and superego was like proving the existence of the Holy Trinity. These notions were more metaphysics than physics, psychoanalysis more religion than science, and the crises of the 1960s and 1970s were the result.

Of course, this was exactly the problem: psychoanalysis had thrived in the theoretical vacuum left by the continued ignorance of how the brain works. So it wasn’t like there was a theory waiting in the wings to replace it. But, Spitzer reasoned, if his only options were a theory that couldn’t be proved (and that was leading his profession to disaster after disaster) or no theory at all, then the correct choice was obvious. It was time to abandon Freud’s pretense to understanding the origin and nature of mental illness, and to return to the one thing Kraepelin said psychiatrists could safely claim to know: what they could observe.

Spitzer was already working with a group of researchers at Washington University in St. Louis to resurrect Kraepelin.
By 1972, the group had described
³²
fourteen different diagnostic groupings, established the criteria by which patients could be placed into one or another of them, and conducted research showing that the diagnoses were reliable. Six years later, the Washington University group issued the
Research Diagnostic Criteria
³³
(RDC), twenty-one categories with checklists of the criteria by which each one could be known.

The RDC bore virtually no resemblance to the DSM, then in its second edition. Where the DSM-II listed illnesses like Depressive Neurosis, defined as a “disorder manifested by an excessive reaction of depression due to an internal conflict,” the RDC created Major Depressive Disorder, defined not in a paragraph full of Freudian jargon, but as a list of symptoms:

A. One or more distinct periods
³⁴
with dysphoric mood or pervasive loss of interest or pleasure. The disturbance is characterized by symptoms such as the following: depressed, sad, blue, hopeless, low, down in the dumps, “don’t care anymore,” or irritable . . .

B. At least five of the following symptoms are required to have appeared as part of the episode for definite and four for probable (for past episodes, because of memory difficulty, one less symptom is required).

1. Poor appetite or weight loss or increased appetite or weight gain (change of 0.5 kg a week over several weeks or 4.5 kg a year when dieting)

2. Sleep difficulty or sleeping too much

3. Loss of energy, fatigability [
sic
], or tiredness

4. Psychomotor agitation or retardation (but not mere subjective feeling of restlessness or being slowed down)

5. Loss of interest or pleasure in usual activities, including social contact or sex (do not include if limited to a period when delusional or hallucinating) (The loss may or may not be pervasive.)

6. Feeling of self-reproach or excessive or inappropriate guilt (either may be delusional)

7. Complaints or evidence of diminished ability to think or concentrate, such as slowed thinking, or indecisiveness (do not include if associated with marked formal thought disorder)

8. Recurrent thoughts of death or suicide, or any suicidal behavior

C. Duration of dysphoric features at least one week, beginning with the first noticeable change in the subject’s usual condition (definite if lasted [
sic
] more than two weeks, probable if one to two weeks).

Purged of shaggy concepts and imprecise language, the RDC could tell clinicians exactly what to look for and what they had found if they saw it—a method that would leave much less room for disagreement.