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

by Gary Greenberg

  Blanchard wanted to overcome this resistance, at least when it comes to hebephilia, because he thought it was a “discriminable erotic age-preference21.” Some men, in other words, have that underlying pattern of arousal necessary to making a diagnosis. They are turned on by kids on the threshold of adulthood more than by anyone else. He can say this with some authority because he and his colleagues examined 2,591 men, most of them convicted sex offenders, in order to determine what aroused them.

  This is where the storytelling comes in. The scientists provided the men with audiovisual aids—large pictures of naked young people, ranging in age from five to twenty-six, displayed on a triptych in front of them, and, piped in through headphones, fictional narratives of sexual situations involving people whose ages roughly corresponded to the pictures on display. The men sat in easy chairs, looked at the pictures, and listened to the tales, one of which started this way:

  Your neighbors’ 7-year-old girl22 is staying overnight at your place. You tell her it is time to get ready for bed. She asks if you will come and tuck her in. When you go to her room, she is already between the covers. You bend over to kiss her on the forehead, but she wraps her arms around your neck and pushes her mouth against yours. Giggling, she throws back the covers to show you she is naked. You sink to the bed, tenderly pressing your lips against the little groove between her legs.

  Okay, it’s not Melville. It’s not even Fifty Shades of Grey. But the researchers weren’t asking the men for their critical opinion of the stories. Actually, they weren’t asking the men anything at all, at least not in the usual meaning of that word. They were asking their penises. Sex offenders, especially convicted sex offenders (who were Blanchard’s subjects) lie. But penises do not—mostly, however, because they do not talk. But Blanchard had a solution to this problem: the volumetric plethysmograph, or, as I like to call it, the Penis Whisperer.

  The way it works is that the subject sits down in an easy chair. He slips a glass cylinder over his penis. After he pulls a sheet over himself “to minimize his embarrassment23,” a rubber cuff at the open end of the tube is inflated until it seals against the shaft of his penis. A hose attached to the bottle leads to a pressure transducer, which registers the slightest change in air pressure in the sealed cylinder—like, say, the kind that would be caused by a swelling penis. By mapping the behavior of the bottled-up penis onto the pictures and stories provided to its owner, researchers could chart the true course of a man’s desires.

  But before they could say much about whether the readings meant the men were hebephiles, the scientists had to know which phallometric stimulus category the objects of desire belonged in. To do this, they relied on the Tanner scale, an instrument that uses criteria like breast size, scrotum color, and pubic hair texture to rate the development of each photographic subject on a five-point scale. Having split the pubic hairs, Blanchard and his team were able to use the plethysmograph readings to prove that some men indeed show a strong preference for pubescent kids as defined by Tanner (breasts: 2.67; pubic hair growth: 2.33 [girls] 3.33 [boys]; genital development 3.83), most of whom were between eleven and fourteen years old. From this consistent response, they concluded that “hebephilia exists24 and . . . that it is relatively common compared with other forms of erotic interests in children.” Which meant that the DSM-5 should either expand Pedophilia to include “erotic attraction to pubescent . . . children, or, alternatively, add a separate diagnosis of Hebephilia.”

  But wait a minute! you’re probably saying to yourself—that is, if you weren’t so creeped out by this research that you stopped reading. Did it really take doctors poring over pictures of naked kids, showing them to men while whispering erotica into their ears, and charting their penises’ responses to prove that men can be attracted to kids in the bloom of youth? Have they not heard of Humbert Humbert? Or read Death in Venice or Plato’s Symposium? Or maybe just grazed the ads of the most recent issue of Vogue or the celeb photo spreads in People? Have they been to a shopping mall recently? Did they really just crash through an open door and claim to have arrived where no one had gone before?

  Well, yes. And that’s not all, nor is it the part that Melville might most appreciate. Having infallibly determined the longitude of men’s penises, Blanchard and his team went on to make what Melville called “a revelation of human nature on fixed principles”—that the attraction, when it is to kids at a certain Tanner stage, is an illness.

  But for all his charts correlating penile response to stimulus category and his charts of mean ipsatized penile response and his tables of Z-score transformations of the extremum of the curve of blood volume change, Blanchard never says which fixed principle allows him to conclude that what most states consider statutory rape, and most people consider flat-out wrong, is a mental illness. He doesn’t even bother talking about clinical significance, let alone philosophical notions (and, if he did, he’d have to explain how it goes against natural selection for men to be attracted to girls whose bodies are advertising fertility in nature’s neon lights). He seems to think that the charts and tables speak for themselves, that because he has figured out a way to measure it, a doctor’s pronouncement that hebephilia exists, coupled with our belief that it is repellent, ought to be enough to convince us that if this feeling is in a human heart, then it can only be the symptom of a disease.

  Not that it is such a hard sell, this idea that a person who commits a heinous act is sick, at least not to a public confident that doctors know what is and isn’t a disease. Diagnoses are explanations of the otherwise incomprehensible, and to judge from the rates of Bipolar Disorder among children and antidepressant use among adults, from the relief that diagnosis brings to people like Michael Carley and Nomi Kaim, from the speed with which Jared Loughner and Anders Breivik were deemed schizophrenic, and from the opinion, at least in some quarters, that a better mental health system would somehow prevent mass shootings in schools and movie theaters, the market for representing our troubles in psychiatry’s clear light is strong.

  This confidence—the belief that doctors know all about our suffering—is precious to the APA. It’s what they lost forty years ago, and what Spitzer worked so hard to restore with a book that looked scientific. It’s what the organization is really selling when it sells the DSM. Without this confidence, who will buy the book? And without the book, who will believe the psychiatrists? And without belief, how will their treatments work?

  That’s why it’s one thing for Steve Mirin and Steve Hyman to acknowledge the book’s shortcomings to each other or for Kupfer and Regier to insist that its categories aren’t really real, and quite another for the complaint and criticism to come from Frances or Caplan or the British Psychological Society. Criticism from the inside can be tolerated and sanitized and turned into a marketing campaign about the living document. But criticism from the outside must be repelled with all necessary force, for it threatens to let the rest of us in on what psychiatrists already know: that there is no fixed principle for their revelations.

  So you really have to wonder why, in the course of revising the DSM, the APA put that confidence at such great risk. Why would they suggest turning statutory rape into a mental disorder, or bereavement into depression, or adolescent eccentricity into psychosis? For that matter, why would they propose, in a country where a third of the population is morbidly obese and where food has become the latest preoccupation of the affluent, to turn “eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances,” and “eating until feeling uncomfortably full” or “when not physically hungry,” and “feeling guilty after overeating” into Binge Eating Disorder? Why would they propose, in a political and economic climate that offers no end of worries and occasions for despair, that people who are anxious and blue, but whose symptoms do not rise to the level of either Major Depression or Generalized Anxiety Disorder, should n
ot be deprived of a diagnosis but instead should be said to suffer from Mixed Anxiety-Depression (which is a pretty clunky name until you consider its acronym)? Why would they propose with a straight face to a society of iSlaves that there is such a thing as Internet Use Disorder? Don’t they grasp just how fragile confidence is?

  I can’t really answer that question. But I will point out that the APA wouldn’t be the first American corporation to overplay its hand. It’s happened to the best of them—General Motors, Kodak, Xerox, and all those other companies that suffered disruption and failure when they failed to remember what the confidence man must never forget: that confidence is always built on air, and that when it becomes known that what you are offering isn’t what you’ve cracked it up to be, your brand might lose its allure, and your company might lose its franchise.

  Chapter 16

  Early in August 2011, an “Important Notice” appeared on the DSM-5 website. It was from the DSM-5 field trials team and addressed to DSM-5 field trials participants. “Have our e-mails been reaching you?” it asked.

  As it happened, I hadn’t heard from the team since the end of February, when I got a note from Regier and Kupfer professing their “delight” at my acceptance as a clinician in the field trials and promising more details soon. In the meantime, however, I’d heard (from Bill Narrow) that my Wired article about the revision hadn’t played any better at the APA than it had with Frances. So when no news had come by July, I figured that maybe the delight had worn off and that the DSM leadership had come to the same conclusion as Donna Manning had—that allowing me into the field trials was like “letting the plague rat onto the ship.” (I think she meant this in a good way.)

  But the silence turned out not to be about me at all. “We are . . . test piloting1 the training materials,” the team explained after I e-mailed in July asking for an update. They added that they hoped to have them out “in a few weeks.”

  A few weeks later, however, the only thing the APA had out was the Important Notice, which offered a new explanation for having been incommunicado. This time the problem was about me, sort of.

  The most common reason2 for this is because our emails are being blocked by your email server’s Spam filter. If you have not received any recent (i.e., within the past 2 months) email communications from the APA regarding field trial participation, please be sure to check your Spam or junk mail folder and look for any communications from us.

  I wondered if the team had capitalized “Spam” out of deference to Hormel Foods, one copyright holder to another. I also wondered why they didn’t just put the information that we had supposedly missed right into the notice. I can’t say with certainty that the team was resorting to the excuse that all of us have used at one time or another to explain our dilatory e-mail habits, but I was sure of one thing: there were no messages from the APA trapped in my spam filter. Neither had any e-mails made their way to Michael First or Dayle Jones, both of whom had also signed up—or, according to Jones, to any of the would-be volunteers she knew.

  In early September, when I still hadn’t gotten the errant messages, or anything at all, I e-mailed Eve Moscicki, the APA researcher in charge of the clinician field trials, asking when I might hear from her team and when the trial might begin. The next day her office sent an apology and the password I needed to log in to the REDCap website. I also received a separate apology directly from Moscicki. She explained, “We have learned3 that some security settings automatically delete our e-mails and the recipient never sees them.” She didn’t say why the APA couldn’t figure out how to do what every Viagra dealer and Nigerian scamster seemed to know how to do. (I did pass along my skepticism to Moscicki, pointing out that no one seemed to have received anything and suggesting that the problem might be at her end. “Thanks for your candid note4,” she wrote back. “Much appreciated.”)

  I went to the Vanderbilt site. My password and login didn’t work. Ten days, and many e-mails later, I was finally able to sign in. Just a day after that, the APA finally figured how to get an e-mail blast past all those spam filters. It was another note from Kupfer and Regier5, congratulating me, once again, on being accepted into the program. They didn’t acknowledge that it had been five months since they first did that, and a full year since the APA announced the start of field trials. They did, however, give me my official title—Collaborating Investigator—and assigned a new significance to this “unique opportunity”: it would be, they promised, “one of the most important psychiatric research studies of this decade.” And if that wasn’t reward enough, they were also offering fifteen continuing education credits, my name in the DSM-5, and a free copy of the book, whenever it came out.

  • • •

  One part of my training had already begun. As Bill Narrow had explained at the APA meeting, and as the team reminded us, we Collaborating Investigators were supposed to “familiarize” ourselves with the revisions by poring over the website, paying attention to the diagnoses we were most likely to render.

  This was a tough assignment. The changes were many and complex. Here, for instance, is the DSM-5 proposal for Generalized Anxiety Disorder6 (GAD), a diagnosis most of us collaborators were likely to use, as it stood in June 2011.

  A.Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (e.g., family, health, finances, and school/work difficulties).

  B.The excessive anxiety and worry occurs on more days than not, for 3 months or more.

  C.The anxiety and worry are associated with one or more of the following symptoms:

  1.restlessness or feeling keyed up or on edge

  2.muscle tension

  D.The anxiety and worry are associated with one (or more) of the following behaviors:

  1.marked avoidance of activities or events with possible negative outcomes

  2.marked time and effort preparing for activities or events with possible negative outcomes

  3.marked procrastination in behavior or decision-making due to worries

  4. repeatedly seeking reassurance due to worries

  E.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  F.The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

  G.The disturbance is not better accounted for by another mental disorder (e.g., anxiety about Panic Attacks in Panic Disorder, negative evaluation in Social Anxiety Disorder, contamination or other obsessions in Obsessive-Compulsive Disorder, separation from attachment figures in Separation Anxiety Disorder, reminders of traumatic events in Posttraumatic Stress Disorder, gaining weight in Anorexia Nervosa, physical complaints in Somatic Symptom Disorder, perceived appearance flaws in Body Dysmorphic Disorder, or having a serious illness in Illness Anxiety Disorder).

  And here is the old one7:

  A.Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  B.The person finds it difficult to control the worry.

  C.The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

  1.Restlessness or feeling keyed up or on edge

  2.Being easily fatigued

  3.Difficulty concentrating or mind going blank

  4.Irritability

  5.Muscle tension

  6.Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

  D.The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack
(as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

  E.The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  F.The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

  The APA didn’t make it easy for us to see the differences by placing the diagnoses side by side or creating a chart or, for that matter, just using their word processor’s Track Changes command as Michael First had in Honolulu. And there were many changes. Six months of worry had become three. Fatigue, difficulty concentrating, irritability, and sleep troubles were out, while avoidance, procrastination, reassurance seeking, and “marked time and effort preparing for activities or events with possible negative outcomes” (think Mrs. Dalloway) were in. The threshold had been changed from three out of six Criterion C symptoms to one out of two Criterion C and one out of four Criterion D symptoms. “A number of events” that are the subject of worry has become “two or more domains of activities or events.” And so on.