This Is Running for Your Life (23 page)

Midway through some oppressive ADHD statistics, I realized that staying upright while riding the Olympian half-pipe of learning curves in extremely windy conditions would be the secondary challenge of the next five days. The first would be dodging a diagnosis myself. It's a not-uncommon fear where
DSM-5
revisions are concerned: instead of locking down existing diagnoses, the APA is extending their bounds by adding disorders, making the criteria for existing ones less specific, and furthering the idea that mental illnesses are defined on a spectrum. Introducing shades of gray has created a future scenario in which half of us will be diagnosed with an anxiety disorder by age thirty-two. Although the spectrum helped give shape to broad diagnoses for depression, autism, and bipolar disorder, it also opened up a stretch of bad road in the thinking about such things as schizophrenia, compulsive disorders, and our atomized attention spans. The resulting diagnostic creep, some say and studies suggest, will ultimately land on one spectrum or another anyone who has ever gone on a bender, had a bad month, or drifted through the day transfixed by cat videos.

By way of introducing his talk on removing the so-called bereavement exclusion from the diagnosis for major depression, Dr. Sidney Zisook asked the room to diagnose a patient reporting a persistent lack of “get-up-and-go” and an inability to think straight. The room played along and was soon prepared to confirm that this imaginary fellow was majorly, clinically depressed. What if, Zisook then ventured, we learned that the patient had just been diagnosed with cancer? Would that change things? After some concessionary points about medicalizing a “normal” person, Zisook's conclusion was: not really.

Dr. Zisook then cited his own experience with grief as an example of healthy bereavement. “I don't think I was ever funnier than I was at my mother's funeral,” he mused, adding that he had missed his deceased parents “for about two minutes” at a recent event honoring his child. This, it was implied, was a normal response to the loss of a loved one. You make the best of a tough situation, spend a couple of minutes with your memories on major occasions, and get on with your life. It sounded clean and hygienic and a little unhinged. It must be odd, anyway, observing and managing your own mental health, ensuring your civilian counterpart makes good time transitioning from acute to integrated grief. I imagined Dr. Zisook reflecting on his own emotional journey through his daughter's birthday—on the drive home or maybe in the shower the next morning—and feeling soothed by the results.

The data suggests removing the bereavement exclusion so we can call depression depression, Zisook said, and get on with it. He also noted that patients are generally relied upon to decide for themselves whether they are bereaved or clinically depressed. This makes sense for a number of reasons, but chiefly because once you wind up in a doctor's office, the diagnostic process—in this case by making a clear rejection of causality—will sink you every time. If you have been feeling lower than a flea on a sewer rat for more than two weeks (the current time frame for a diagnosis of major depression), it doesn't really matter what's happening in your life, or if the natural course of grief or other stressors have adaptive benefits. You may as well have caught pinkeye and will walk out with a prescription. I drifted into a daydream about Dr. Zisook killing at his mom's funeral that was interrupted by his offhand but memorably phrased observation that everybody knows “being female is a validator for depression.”

A few minutes into the Q&A, a psychiatrist in the far reaches of the auditorium stood up to tell us that he has been suffering from what he called “complicated grief” since the day his wife died, seven years ago. His mother's recent passing had triggered a relapse, and he was terrified to feel himself slipping away. The room grew more cavernous somehow; there was shouting for him to speak up. As his monologue continued, the audience began grappling with a secondary concern—whether to obey the impulse to turn their eyes onto this poor creature. A middle-aged Indian man, he appeared exactly as distraught as he said he was. The misery began at day one, he insisted. It turned on like a switch and now he can't get past it. How is that depression? Who will help me?

Technically that was his question. As a keen approximation of the kinds of crises presented in psychiatry offices thousands of times a day, it couldn't have felt more out of place. You could sense the hostility that prickles through a room when someone has shown bad form, in this case bringing his own, impossible problems into a tidy discussion about data and outcomes. In reply Dr. Zisook mentioned the study groups looking into the possibility of including “prolonged grief disorder” as a new diagnosis in
DSM-5
. I would soon learn that the suggestion of study groups is the APA version of a brush-off. And yet this news was more important to the widower than it might first have seemed: putting a name to his suffering had become its own imperative. It was at least a point of order in the chaos.

*   *   *

Although David Kupfer, the chair of
DSM-5
, had congratulated the presenters for hitting all the major controversies, “Mood Disorders Across the Lifespan: Implications for
DSM-5
” was a pretty sleepy affair. When mildly challenged by questioners from Brazil, Finland, and Canada during their Q&A sessions, the presenters had been quick to defer to an absence of full knowledge about everything up to and including the topic they were discussing. By contrast, the next day's personality-disorders symposium was a straight-up riot, where practicing psychiatrists bared hind molars over
DSM-5
's plan to wipe half the PD diagnoses from the books.

Tougher to understand and more comprehensive as diagnoses, personality disorders as they are defined perhaps get closest to Freud's psychic schema of id, ego, and superego—a trio that threatens a kind of moral chaos when out of balance. Like psychoanalytic conflicts, personality disorders emphasize a patient's inability to exist peacefully in the world, as opposed to her own skin. The names—antisocial, avoidant, borderline, histrionic, narcissistic—suggest a failure to engage and consequent crisis of identity. Freudians claimed successful psychoanalysis as a safe passage into adulthood; Carl Jung believed the personality only reaches perfection in death. It's classically rich terrain, but as psychiatry continues to narrow its focus on the individual and his scientific profile, the whole concept of having a personality—a way of being formed symbiotically, over time and in relation to others—is politely being ushered to the land of the obsolete, where it will rest between chivalry and laser-disc players.

Five out of the ten personality disorders are currently on the cutting block: narcissistic, paranoid, schizoid, histrionic, and dependent. The proposed changes and consolidations left angry clinicians like Thomas Widiger, the head of research for
DSM-IV
, trying to illustrate major ideological points with frustrated micro-critiques of the newly proposed dimensions, traits, and criteria. What, for instance, does a weird, self-canceling criterion like “(lack of) rigid perfectionism” have to do with the diagnosis of schizotypal personality disorder? With fewer disorders and blurry criteria, all personality disorders will blend together—which, in a system built around the appearance of discrete classifications, amounts to a form of sabotage. But giving up on the category, Widiger told us, means giving up on a branch of psychiatry that has devised successful treatments for patients with strong suicidal tendencies. If anything, why not get rid of “personality disorder not otherwise specified”—a junky diagnosis used to capture those who don't fit cleanly into an APA mold. Most disorders, including depression and bipolar, have NOS contingencies that ultimately negate all the tortured wordsmithing that goes on at conferences like this one.

NOS can also be used as a weapon. In the last decade, thirty-one thousand troops have been discharged from the U.S. military on the grounds of a personality-disorder-NOS diagnosis.
The New York Times
reported in early 2012 that military commanders have specifically requested a PD-NOS diagnosis in order to purge unwanted individuals from their ranks. It's also a money-saver: because personality disorders are treated as preexisting conditions (if anything can be said to have an early onset, it's probably your personality), veterans' benefits are waived and the military is no longer responsible for the treatment of service-related injuries, including the costly and pervasive post-traumatic stress disorder. With its clear delineation of cause and effect, PTSD is the most prominent vestige of the
DSM
's roots. Treating it the modern way—including powerful opiate and psychotropic prescriptions—has been a conspicuous, catastrophic failure. A couple of months after the Honolulu conference, the army reported a record high of active-duty and reserve suicides. A 2009 study found that an American veteran commits suicide every eighty minutes, doubling the combined total of Iraq and Afghanistan casualties each year.

Practically speaking, it may not make much difference to responsible clinicians if personality disorders and their criteria are cut in half. With experience and an engaged heart, psychiatrists develop their own Tao of disorder, what Jung called “a real knowledge of the human soul.” Everything from familiarity with Woody Allen types to first gut impressions were cited as valid litmus tests for neuroticism—or “negative emotionality,” as it's now called—a trait of almost every personality disorder. (“If you give me a pony,” one presenter offered by way of example of a classic Debbie Downer–ism, “that means I'll wind up shoveling horse shit.”) The problems begin, another presenter noted, when you have to put this stuff into a book. But for
DSM-5
to be accepted by insurance companies, general practitioners, and the public, as Widiger ruefully pointed out,
it has to make sense
.

One of the new criteria proposed for borderline personality disorder was singled out for PowerPoint scrutiny. The checklist will now inquire into the patient's “sense of a self that is unique and grounded in personal history.” What's tricky about people who fit the profile for a personality disorder is that they are often—you might even say by definition—not the best judges of their own character. More so than other mental illnesses, to have a personality disorder is to be perceived as having a personality disorder. Alone in her room or with her thoughts, a toxic narcissist gets along just fine. It's when she tries to exist out in the world that things go pear-shaped.

For those still reeling from the reclassification of a category-four dickhead to a sufferer of mental illness, the shifting of a personality disorder's terms away from social dysfunction and toward impaired self-image is further bad news. In the same way that the descriptions of these disorders can also be read as guidelines for how a person should be, to define a personality outside of a social context or a shared reality is to change the definition of what a person
is
. We were told that a focus group of nurse practitioners had revolted against the idea of refocusing personality disorders around a self-directed, self-reported checklist. The nurses called interpersonal function the “bread and butter” of a PD diagnosis. The study also raised the intriguing but rather hopeless question of whether a social worker would define “self” and “identity” differently from, say, a neuropharmacologist, or a psychotherapist, and on and on and on.

“That's not my reality” is already the mantra of the self-involved. Most of us have a hard enough time overthrowing the idea that we are located at the center of the universe—I don't know about you, but everything about my experience of the world would seem to confirm it. Personality and the terms of a social, adult existence are really all that are keeping us from becoming a race of self-reinforcing oligarchs. Must they now become their own privately experienced realities as well?

The next week, on a train from Los Angeles to San Diego, I listened from across the aisle and against my will as a young man described and defended the terms of his personality. He was a kind of public broadcaster, speaking to his seatmate without pause and with the diaphragmatic gusto of someone certain that everyone within his signal radius was interested in whatever he had to say. Had I not been so wrecked by an overnight flight, I would have obeyed my instinct and switched seats. After about fifteen minutes another woman did just that, and it really ticked the young man off.

“I bet you one hundred million dollars she left because of my talking,” he interrupted himself to complain. I hadn't noticed the exit-in-progress before that point. Though he feigned oblivion to putting on the foregoing performance, the young man was closely monitoring its effect, all while eating Maruchan instant lunch out of a cup. The woman with the blond bob's escape was an insult to his personality, and further evidence of the declining state of “social etiquacy.” You got the feeling this had happened before.

“Honestly, this is me,” he sighed, tired of explaining an obvious point to a world too slow or too stupid to grasp it. “And we're in public. This is not like a freaking movie, this is public transportation.” His friend, a young woman, replied softly, “Yeah, but nobody else is talking.”

“It's not just her,” he snapped. “I'm expressing myself about people who are like that.” The way he saw it, Blond Bob would be talking too if she had two friends in the world to rub together. That Blond Bob had relocated with the stealth of a navy SEAL, making the opposite of a scene, wasn't the point. Maruchan felt judged, and that was wrong. He fielded creditor calls throughout the trip. After losing his job during the recession he ran up a sizable debt, mostly on clothes made necessary by a move into California's convoluted weather patterns. The creditors were threatened with lawsuits and bankruptcy, alternately; he had done the research. He couldn't find a job, and whose fault was that?