The Book of Woe: The DSM and the Unmaking of Psychiatry (7 page)

Mirin was prepared for this inquisition. His press office had briefed him about the ways of reporters, and his staff had subjected him to a mock grilling. Nor did he have to face it alone. He’d brought with him an expert on diagnostic questions: Darrel Regier, whom he had recently hired to head up the APA’s research arm, the American Psychiatric Institute for Research and Education. Mirin had recruited Regier from the National Institute of Mental Health, where he had risen to the rank of vice admiral in the Public Health Service. Regier was attractive to Mirin in part because of his familiarity with the ways of government bureaucracies, but at least as important was the fact that Regier, an epidemiologist as well as a psychiatrist, had been measuring the levels of mental illness in the population since the earliest days of DSM-III.

What Regier had seen didn’t inspire confidence. As the head of the NIMH’s Epidemiological Catchment Area (ECA) team, he had overseen a group of researchers who, starting in 1980, fanned out across five U.S. cities armed with a questionnaire keyed to the diagnostic criteria in DSM-III.
They’d asked twenty thousand people
¹²
, selected to reflect the general population, about their worries and their sadness, about whether they heard voices, about how they slept and ate. They tabulated the results and, in 1984, began to release them in a series of journal articles.

The ECA’s findings
¹³
were stunning. In any given year, more than 20 percent of Americans qualified for a DSM-III diagnosis. Nearly one-third of us—eighty million people, according to the 1990 census—would have a mental illness in our lifetimes.
And the sick among us were really sick
¹⁴
. Sixty percent of those diagnosed with a mental illness had a
comorbid disorder
, meaning they qualified for at least two diagnoses. Ninety-one percent of people with schizophrenia had at least one other diagnosis, as did 75 percent of people with a depressive disorder. Fifteen percent had three or more diseases. More than half of the people with a drug-related diagnosis, such as Cannabis Abuse, also had a second (or third) diagnosis. Even more alarming,
only 19 percent
¹⁵
of the afflicted had sought help for their troubles, a number that dropped to 13 percent in the cases where only one diagnosis was warranted. It seemed that America had an enormous but unacknowledged and untreated public health problem whose effects on productivity, on family life, and on the body politic were unfathomable.

This potential fivefold increase in the size of the market for psychiatry wasn’t so much an embarrassment of riches as a plain embarrassment. Even accounting for the fact that epidemiological studies, in which researchers go out looking for trouble, almost always yield bigger numbers than studies that rely on numbers gleaned from doctors’ offices and hospitals, the results beggared imagination. They also cast doubt on the DSM. The questions at least had to be asked: Was the problem in the minds of the people or in the methods of the doctors? Did the DSM-III make it too easy to turn people’s everyday troubles into disease? Was the book that saved the profession going to lead it to another downfall?

Two decades later, Regier thinks the answers are all too clear. I interviewed him in 2010, in his spacious office on a high floor of APA headquarters in Arlington, Virginia. At sixty-seven, he has a smooth, unlined face. His tie is tightly knotted, his shirt as crisp and neat as his office. He gives off a quiet confidence, the certainty of a man who has crunched the numbers and seen the results, and concluded that “we just don’t have good thresholds for identifying what we would consider mental disorders.” Having eliminated any account of the origin or nature of mental illness in favor of pure observation, the DSM-III had also eliminated the thresholds, vague as they might be, provided by Freud’s insistence that mental illness was distinguished by its origins in intrapsychic conflict. The resulting symptom-based diagnosis is binary; if you have five of the nine symptoms of depression, you have the same disorder as a person with all nine, just as if you have a small stage 1 tumor in your lung, you have the same disease as someone with the same kind of tumor who is about to die. With those five symptoms, as with the first appearance of the tumor, you have crossed the line from health to illness, and the rest is only a question of severity.

But, as those prevalence numbers made clear, doctors using DSM checklists were all too likely to find disease everywhere. There was no governor, no way to say this person was sick and that one was simply unhappy, nothing like the CT scan that confirms that the patient with the persistent cough and fatigue has a tumor in his lung. A doctor who diagnosed strep entirely on the basis of symptoms was practicing bad medicine, while a doctor who diagnosed depression only on the basis of symptoms was practicing standard psychiatry. It seemed that in his attempt to make psychiatry look more like the rest of medicine, Spitzer had actually fashioned a book that only highlighted the differences.

The comorbidity rates—the frequency with which people qualified for more than one diagnosis—were another embarrassment. Here again, Regier said, the ECA studies pointed not so much to a sick population as to a flawed manual. Spitzer had anticipated the possibility of multiple diagnoses, and in the introduction to DSM-III he suggested that there was a hierarchy of mental illness, that some disorders only had a narrow range of symptoms while others contained multitudes. Schizophrenia, for instance, was far more encompassing than major depression, so clinicians confronted with a patient presenting symptoms of both were advised to render only a schizophrenia diagnosis on the assumption that the low mood was part of the more comprehensive disorder. Regier pointed out that this amounts to a claim that the depression itself is “just noise,” of no inherent interest or value in understanding the patient or their disorders. But the ECA team found that people with symptoms of both schizophrenia and depression were different from people with only schizophrenia in many ways. Ignoring their depression meant failing to get a complete diagnostic picture and losing “an enormous amount of data” about mental health. “The ECA blew the hierarchy out of the water,” Regier said proudly. “It just didn’t make any sense when we started looking at the data.”

Concerns like this led the APA to abandon the hierarchy in the DSM-III-R, but the real problem, Regier told me, was not the approach but something much more basic: the idea that DSM disorders are discrete diseases that exist in nature in the same way as cancer and diabetes. This, to Regier, is the fundamental flaw of the DSM, the one that accounts for the high rates of both prevalence and comorbidity. “It makes it seem like an anxiety disorder doesn’t have any mood symptoms and a mood disorder doesn’t have any anxiety symptoms. But it isn’t that simple. It’s just not the way people present.”

But it is the way the DSM presents mental illness; indeed, that neat separation is the signal innovation of the DSM-III. Fortunately for Mirin and Regier, by the time of their fateful meeting with the
Post
editors, they’d turned their skepticism into a strategy. “We walked them through how we understood mental illness, and what our thoughts were about diagnosis and the DSM,” Mirin recalled. Not, of course, their thoughts about the book’s failure to correspond to clinical reality or about the way the categorical approach trapped diagnosticians in a tautological loop (which, after all, were highly technical matters, known and understood only by experts), but rather their thoughts about the troubles reported in the daily paper that might make the average editor skeptical: the shifting sands of psychiatric diagnosis, the prevalence rates, the frequent and repeated revisions of the nosology, the disorders that came and went with dismaying regularity. These they readily acknowledged, but then they turned them to advantage. The problem wasn’t that psychiatry was inexact when compared with the rest of medicine, but rather that the rest of medicine was nowhere near as certain as it was cracked up to be. The glucose levels that constitute diabetes, the cholesterol counts that call for treatment, the blood pressure that qualifies as hypertension—these numbers had all changed over time, and after no small amount of wrangling. To hold psychiatry to a more stringent standard was unfair and would make victims of doctor and patient alike.

This approach was exactly the right one for his audience. “They were smart people,” Mirin said. “They were sophisticated enough to understand that what their doctor told them about hypertension was not carved in stone, either.” If the
Post
’s editors noticed the intellectual sleight-of-hand at work here, the way that these leading psychiatrists were distancing themselves from the same claims to certainty that had allowed the DSM to rescue psychiatry from the pseudoscience precipice (or, for that matter, if they wondered whether or not they should keep taking their diuretics), they didn’t say, at least not in print. Perhaps they were afraid they’d seem unsophisticated or just plain dumb. Either way, six days after the meeting,
the paper came out in favor of parity
¹⁶
, Congress passed a limited version of the bill, and mental health professionals everywhere rejoiced. Six years and many editorials later, parity became the law of the land. Mirin and Regier’s strategy succeeded. They had spun the dross of diagnostic uncertainty into gold.

•   •   •

Maybe you’re not smart or sophisticated enough to understand this argument, either. Maybe you think Mirin and Regier were just trying to have it both ways. You might then suggest that those prevalence numbers were still a little fishy. You might wonder out loud what would happen if 25 or 30 percent of the population exceeded the standard glucose or blood pressure thresholds, but only 19 percent of that group—about 5 percent of the population—ever got sick enough to even show up at their doctor’s office. You might then ask what exactly those numbers added up to, whether they measured disease at all, and if the whole idea of hypertension or type 2 diabetes had been created by an industry too interested in selling treatments to people who were actually healthy. You might point out that regardless of whether or not they are diseases in themselves or only risk factors, blood pressure and glucose levels can at least be measured with a high degree of certainty. And you might raise the question of whether or not it’s really fair to compare conditions such as high glucose and blood pressure to mental illnesses, whether or not telling a patient he has hypertension for which he should take diuretics is really the same kind of intervention as telling him he has a chemical imbalance that antidepressants will correct.

Darrel Regier would have an answer for some of those questions. You think those numbers are high? Well, he would tell you, or at least he told me, you should see
the Midtown Manhattan Study
¹⁷
. Regier started his training with the people who ran that project, which began in 1952, took ten years to complete, and was conducted exactly where you think it was. Researchers canvassed 1,911 Manhattanites and concluded, according to Regier, that 85 percent of the population had a mental illness.

When Regier graduated from Indiana University’s medical school in 1970, the Midtown Manhattan Study still constituted the standard epidemiology of mental illness. “I was just coming out of a residency where I was seeing really sick patients,” he said, “and I’m saying to myself, ‘What are they talking about over here with all of these people who have an occasional symptom but are never going to go into treatment? What is normality if 85 percent have a mental illness?’”

The Midtown Manhattan Study is a talking point for most defenders of the DSM. They cite that 85 percent number as evidence that even if the DSM is an imperfect document, and even if it catches an improbable number of people in its diagnostic net, at least it’s better than what we had in the old days. We in the mental health business call this a
downward comparison
, and we sometimes recommend one to our patients to help them put their problems in perspective. “Yes, it’s true your wife left you for your next-door neighbor,” you might say, “but at least your kids won’t have to commute as far as most children of divorce.” It’s usually a pretty lame intervention, as that example indicates, and to the extent that it’s successful, it’s often because you’re actually bolstering the patient’s self-esteem by pointing out that he’s better off than the next guy. Schadenfreudian therapy, you might call it.

You can’t exactly blame psychiatrists for grasping at this straw. But some straws are flimsier than others. Take that 85 percent number, for instance. The Midtown Manhattan Study team, which was headed by sociologist Leo Srole, never said that 85 percent of its subjects were mentally ill. In fact, Srole and his colleagues hadn’t set out to diagnose New Yorkers at all. Indeed, they wrote, they didn’t want to use the DSM or any other diagnostic system because they were “
designed for classifying full-blown pathology
¹⁸
”—and didn’t do such a good job of defining it in the first place.
So rather than ask
¹⁹
about symptoms of mental illnesses, they asked about childhood fears of thunder and strangers, and current attitudes toward drinking and gambling. They solicited subjects’ worries about the atom bomb and old age. They asked whether they thought people talked behind their backs or if they wondered whether “anything is worthwhile” or if they believed that “most people think a lot about sex.” They paid attention to whether the interviewees were sloppy or neat, nervous or relaxed, if they were facetious, dull, or rambling. They attempted, in other words, to capture the everyday experience of the average citizen and to determine how much psychological suffering it entailed.

To make their assay, Srole’s team devised
a six-point classification
²⁰
of
symptom formation
. People at the “healthy extreme” got a zero. At the next two stages were people who had “emotional disturbance without apparent constriction or disability,” and the last three ratings “span[ned] the morbidity range of the mental health spectrum.” These were the people whose symptoms had “crippling effects on the performance of . . . daily life roles”—as close to a working definition of mental illness as Srole’s team ventured.