The Book of Woe: The DSM and the Unmaking of Psychiatry

by Gary Greenberg

  In an uneducated community4, 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 survey5,” 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 knowledge6, 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 marginal7 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 anatomy8,” 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 interpretation9 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 approach10, 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 Manual11 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 pages12 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 doctors13. 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 therapy14 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 adapt15, especially now that Freud was dead and couldn’t object. Freud’s insistence that only early c
hildhood 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 cases16 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 nomenclatures17 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.

  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 Government18,” 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 Reaction19. 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 Reaction20. 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 origin21 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 emphasis22 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 universe23”—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 backwater24; 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 services25, 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 diagnosis26 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 Homosexuality27, 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 eve
rywhere would continue to get insurance dollars to treat gay patients.

  Like most compromises, this one left some bad feelings. “If groups of people march28 and raise hell, they can change anything in time. Will schizophrenia be next?” one psychiatrist fulminated. “Referenda on matters of science29 [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 bogus30,” 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.