The Book of Woe: The DSM and the Unmaking of Psychiatry
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Even when the diagnosis is established, the treatment is still uncertain. And there is a good reason for this. According to Sadock and Sadock, “the objective of pharmacologic treatment20 is symptom remission.” Bipolar isn’t the only case. There is no specific treatment for any of the disorders Sadock and Sadock present, and many drugs are used for many conditions: antidepressants to treat obsessions, antipsychotics to treat depression, mood stabilizers to treat anxiety, and so on. Psychiatrists, in other words, are not treating the disorders they diagnose. The categories, after all, aren’t natural formations; symptoms, the scattered particulars, are all they have to go on and all they can treat.
Which doesn’t mean they shouldn’t treat them. “Not everyone needs to see21 a psychiatrist for the treatment of a mental disorder,” Frances told me. “But if the problem is moderate to severe, persistent, and impairing, medication is likely to be needed. In my view, this should mostly be provided by psychiatrists, not primary care doctors who are usually out of their depth.” He is surely right about this. Psychiatrists do indeed have a wealth of experience in treating people’s distress with drugs. No clinician can deny the value of that knowledge, the way that people in the throes of a manic episode or a psychotic break or a disabling depression can be helped by drug therapy. Nor can anyone deny that this uncertainty about diagnosis and treatment is exactly what makes the expertise of the psychiatrist essential.
But you don’t have to hate psychiatrists to point out that their expertise is mostly empirical and their treatments potentiated at least as much by hope as by chemistry. Or, to put it another way, that psychiatry, much more than other medical specialties, is still deeply in the debt of ancient medicine. The Platonic ideal of a world of suffering carved up into its natural formations remains exactly that—an ideal, one that psychiatric nosology can’t yet approach. And you also don’t have to hate psychiatrists to think that this gap, the distance between what the profession claims and what it actually knows, between its opportunity and its knowledge, is vast, and that even as the jury remains out on the legitimacy of psychiatry’s claim to understand mental suffering, more and more people are taking daily doses of drugs whose mechanisms are poorly understood and whose long-term consequences, on the body and on the body politic, are uncertain. You don’t have to hate psychiatrists to think that the ever-expanding DSM is not a book that can help psychiatrists stay within their competence, that indeed it encourages them to do the opposite. You don’t have to hate psychiatrists to think that a book that dresses up symptoms as diseases that are not real and then claims to have named and described the true varieties of our suffering is all clothes and no emperor. And you don’t have to hate psychiatrists to think we—patients, doctors, therapists, all of us—might be better off without it.
• • •
Or maybe the APA was trying to erase history. In early November 2012, the draft of the DSM-5 disappeared from the DSM-5 website, removed, according to a note on the home page, “to avoid confusion or use of outdated categories and definitions.” It wasn’t enough to threaten legal action against people who might want to use the draft criteria as part of a research project or, I don’t know, a book about the development of the DSM-5. It is, of course, possible that the APA really feared that a paper using outdated criteria would slip by a peer reviewer or that a doctor would render a diagnosis based on discarded definitions. But it is also possible that the APA hit the delete button for the same reason Soviet apparatchiks airbrushed old photos: to prevent embarrassment.
The move was so arrogant, and so unnecessary, and so heedless of the public trust the APA holds—in short, it was so incompetent that it made me wonder if Frances had been right all along: that the trouble with the DSM-5 was purely bureaucratic, that if it turns into the disaster he has predicted, it will not be because the APA has found itself perfectly situated to exploit the capitalist imperative to turn all need into markets and thus to manufacture need by the carload. Neither will it be because a diagnostic empire built on air must at some point come crashing down, as if some tragic principle were at work, ensuring that hubris inevitably meets justice. Nor will it be because the attempt to catalog our suffering is doomed to be a fool’s errand, that our troubles will always outdistance our attempts to take their measure. It will be because the Keystone Kops bungled the job. Only naiveté or animus toward psychiatry or a writer’s fervent wish for drama could make someone read more into the unfolding events than incompetence, to see the DSM-5 as anything other than one more step in the long, random walk of human folly.
But there is a reason insiders trot out the one-bad-apple defense when disasters occur. It distracts from the more disturbing truth—in this case, that a profession that has been struggling to establish its credentials for more than a century, that has lurched from crisis to crisis, always for the same reason, always because it cannot make good on its claim to be treating diseases as other doctors do—that such a profession has something rotten at its foundation: its have-it-both-ways, real-until-it-isn’t diagnostic manual.
You don’t have to be a hater to think that the DSM, no matter how often it is revised or how competently, will never manage to pour the old wine of human suffering into the new skin of scientific medicine. And you don’t have to resort to biblical analogies to show that the Bible of psychiatry is failing to do what it is presumably intended to do, and what would bolster the argument for bringing our mental suffering under the medical gaze: to improve psychiatric treatment. You don’t even have to be an upside-down Jesuit or a Leibowitz unwittingly sowing the seeds of destruction. You could be Tom Insel, who is neither an antipsychiatrist nor a Jesuit of any spatial orientation, who is, in fact, America’s psychiatrist in chief.
“Whatever we’ve been doing for five decades22,” he told me, “it ain’t working. And when I look at the numbers—the number of suicides, number of disabilities, mortality data—it’s abysmal, and it’s not getting any better. All of the ways in which we’ve approached these illnesses, and with a lot of people working very hard, the outcomes we’ve got to point to are pretty bleak”—especially, he added, compared with the “extraordinary” progress in other fields, such as the 70 percent drop in mortality from cardiovascular disease since he went to medical school or the steep reductions in deaths from auto accidents and homicides. “There are some people for whom some of what we do is enormously helpful,” he said. But even so, “we don’t know which treatments are working for which people.” And this litany of failure, he said, “gets us back to your interest in nosology. Maybe we just need to rethink this whole approach.”
That’s what Pliny Earle said in 1886, and what Thomas Salmon said in 1917, and George Raines in 1951, and Robert Spitzer in 1978, and Steve Hyman in 2000: that without a working nosology, psychiatry is a failure, that the current nosology (whatever it is) is sadly lacking, that the profession needs a new paradigm. You don’t have to be an antipsychiatrist to wonder if incompetence can possibly explain all that futility, or if a profession that, despite its repeated failures, continues to “cherish expectations with regard to some mode of infallibly discovering the heart of man,” as Melville once put it, deserves our confidence. You only have to know what Tom Insel knows and is honest enough to say out loud.
Insel may be right that a deeper foray into the thickets of the brain will yield what psychiatry has long sought: a taxonomy of disorders validated by biochemical findings. And Frances may also be correct that in the meantime mythical disorders are better than no disorders at all, that without them patients won’t listen to their doctors or get the benefits of having a name for their pain. But no one knows what would happen if psychiatrists simply let themselves out of their epistemic prison by no longer pretending to know what they can’t know. No one knows what would happen if they simply told you that they don’t know what illness (if any) is causing your anxiety or depression or agitation, and then, if they thought it was warranted, told you there are drugs that mig
ht help (although they don’t really know why or at what cost to the brain, or whether you will be able to stop taking them if you want to; nor can they guarantee that you—or your child—won’t become obese or diabetic or die early), and offer you a prescription.
There are undoubtedly patients who would balk. Depressed people might be less willing to surrender their orgasms to Prozac if they don’t think they are correcting a biochemical imbalance called Major Depressive Disorder. Psychotic patients might object to a lifetime of taking drugs that blunt their emotions, cloud their cognition, make them gain weight, and shorten their life span if they don’t think they are being treated for Schizophrenia. Parents might hesitate to ply their kids with stimulants and antipsychotics if they believe that they are merely calming them down rather than treating their ADHD or BD (or, once the DSM-5 goes into effect, their DMDD). After all, this is a country whose pharmacological Calvinism has led to a four-decade-long war on drugs used merely to change the way we feel, and that harbors disdain—especially when it comes to our mental lives—for treating symptoms rather than underlying causes.
But other people would surely be willing to take the gamble. Indeed, they already are. Seventy-two percent23 of the prescriptions for antidepressants in the United States are written for patients who are not given a psychiatric diagnosis of any kind, who suffer from troubles ranging from tiredness and headaches to “abnormal sensations” and “nonspecific pain24.” It’s impossible to know exactly how the prescribing doctors sold their patients on the idea of using the drugs, and while it’s likely that at least some doctors told patients they had depression but then didn’t write that down in the chart, it’s also easy to imagine a conversation in which the doctor confesses her uncertainty about diagnosis, but suggests that other patients with similar symptoms have benefited from the drug and encourages the patient to give it a try.
Of course, this is exactly the kind of problem that Frances thinks arises when nonpsychiatric physicians (family doctors and other primary care providers account for 80 percent of those prescriptions) go beyond their proper competence. He may be right about this, but that doesn’t necessarily mean specialists are more restrained in their prescribing habits, nor is whatever advantage they might have over their nonpsychiatrist colleagues the result of being better at figuring out which of the nonreal mental disorders listed in the DSM their patients have. Rather, it is more likely to come from their greater experience in treating symptoms, in making the artful judgment of which potion is likely to help which patient. If this—the ability to match symptom with drug—were the only claim that psychiatry made, if psychiatrists stopped pretending that they know the proper names for our suffering, then perhaps the profession could finally free itself from the prison it has built.
Of course, a psychiatry that gave up a common scientific language, and the perquisites it garners, might also not have a DSM, or at least not one that looks anything like the DSM we have now. But by no longer insisting that it is just like the rest of medicine, and by renouncing its noble lies about the scientific status of psychiatric diagnosis, the profession might become a more honest one than it is now. Given that psychiatrists demand honesty from their patients, honesty is perhaps the least we should ask of them. It might even build our confidence. (And theirs: with less to defend itself about, psychiatry, or at least the APA, might have less need for secrecy and paranoia, and less need to diagnose all its opponents with Antipsychiatry Disorder.)
But there is no doubt that an honest psychiatry would be a smaller profession. It would have fewer patients, more modest claims about what it treats, less clout with insurers, and reduced authority to turn our troubles into medical problems simply by adding the word disorder to their description. It would, in other words, be more likely to stay within its proper competence. Its restraint would depend not on the modesty of aristocrats, who have proven themselves to be unreliable in that respect, and not on government regulation, which, even if it were possible, has recently fallen into disrepute, and not on the discovery of the boundary between mental health and mental illness, which will always prove elusive, but on that much more modern and effective arbiter, the one master to whom we all seem to submit: the marketplace.
• • •
Speaking of marketplaces, an honest psychiatry would not be such a good thing for my profession, at least not if it meant the end of the DSM as we know it. We talk therapists have arguably been the book’s prime beneficiaries. While psychiatrists are treating the floridly psychotic, the raving manic, the suicidal and the catatonic and the delirious, we, by and large, get to minister to the walking wounded. Thanks to Bob Spitzer’s expansive approach to the DSM, we can casually jot down “Generalized Anxiety Disorder” or “Adjustment Disorder” and talk (on the insurance tab) with our patients about the meaning of life, while right down the hall psychiatrists are making momentous decisions about whether a man who thinks his bones have been sucked out of him is bipolar or schizophrenic and which drugs to prescribe. While they have to take the DSM at least a little seriously, we can pretend it doesn’t exist, give it the cynical bureaucrat’s shrug, denounce it even as we cash those insurance company checks. And when it comes time to revise it or explain it or defend it, and its flaws are once again open to scrutiny, it’s the psychiatrists who take the heat.
Not that I feel particularly sorry for them, but it is clear that for us nonpsychiatrist clinicians, the stakes are purely monetary. Without those codes and the access they give us to insurance companies’ compensation schemes, the unfettered marketplace will decide how much we are worth. Weekly visits with me right now cost the equivalent of a monthly payment on a car. I try to adjust my charges according to what a person can afford to drive. But while for some people that’s a BMW, for others it isn’t even a badly used Kia, and I have no doubt that shorn of their DSM-enabled insurance subsidy, fewer people could pay me anything at all. So I would make less money. In this, I am like workers everywhere in America, although at least for now my job can’t be offshored.
• • •
An honest psychiatry might also lead the way to a new understanding of illness. The idea that disease is suffering caused by an identifiable pathogen that can be targeted and killed by medicine’s magic bullets is a historical accident, one that originated at the height of the Industrial Revolution and that springs as much from commerce as from science. It has been an extraordinarily beneficial idea, but like all inventions, it has its drawbacks—notably that it has encouraged us to think that all our troubles will ultimately yield to the microscope and the pill.
“The future belongs to illness25,” Peter Sedgwick wrote in the early 1970s. “We are just going to get more and more diseases, since our expectations of health are going to become more sophisticated and expansive.” Thanks to a DSM that has kept pace with those expectations, that future is here. It has arrived in a capitalist age, which means that we have placed our well-being in the not-so-invisible hands of a medical-industrial complex whose proprietors have a stake in reducing suffering to biochemistry. It has spawned a psychiatry that can’t help giving us more and more diseases, at least not if it wants to meet the economic, if not the scientific, demands of the day.
Still, the problem with psychiatry may not be that it lags behind the other medical specialties, with their magic bullets and the science by which they identify the targets. Rather, it may be a harbinger of a time when the low-hanging fruit has been picked, when the inadequacies of modern medicine to the complexity of our suffering—physical and mental alike—have become manifest, and when the folly of encouraging us to give up the ghost for the machine is unmistakable.
Because there is one definition of mental disorder that is not bullshit. Mental disorder, like all disease, is suffering that a society devotes resources to relieving. The line between sickness and health, mental and physical, is not biological but social and economic. It is the line between the distress for which we will provide symp
athy and money and access to treatment, and the distress for which we will not. For the past 150 years, we have relied on doctors to decide who gets those resources, and they in turn have furnished us with diseases that, they assure us, are not figments of their imaginations, but real entities that reside in tissues and cells and molecules, that can be observed and measured, and, if all goes well, treated. Psychiatry has tried its best to stake its claim to this bonanza, perhaps nowhere so ardently as in its attempt to fashion its book of woe, but it has not worked. This may be because the psychiatrists in question, or their technologies, have not been up to the job. It may be because that line can’t be drawn without deciding how a human life is supposed to go, how it ought to feel, and what it is for—questions for which science, no matter how robust, is no match. It may be because the arc of history bends toward justice, and biochemistry may not be the fairest basis on which to determine whose suffering deserves recognition. But it may also be because the human mind, even in its troubles, perhaps especially in them, has so far resisted this attempt to turn its discontents into a catalog of suffering. And for this we should be glad.
Afterword
The careful reader will by now have detected the odor of a certain barnyard effluent suffusing this book. My opportunity to publish at the same time as the DSM-5 exceeds my knowledge of what is actually in the new manual. Indeed, it is very likely that you know more about its specifics as you read this than I do as I write in early January 2013. But I do know a little about the final product.