Bitwise

by David Auerbach

This did not fit any conception I had of what a disease was, nor did it fit psychiatry as my parents had described it to me. More importantly, it did not even fit any conception I had of what a taxonomy was.*6 My father was quite a taxonomizer himself—of television, coins, comic books, and science fiction—and those taxonomies made far more intuitive sense to me than the DSM. These checklists didn’t function well as overall rubrics; some of them, at least to my preadolescent self, seemed random. I was hardly a good judge of personality at that point, and the way symptoms and behaviors were arranged and listed seemed puzzling, if not entirely arbitrary. I presumed that there was some expert logic that explained why it was these diseases that people had or did not have.

  When I started hearing people employing terms like “OCD” and “manic depressive” in daily life, they were invoked with little regard to the bloodless lists of criteria given in the DSM. The DSM categories became prescriptive: they generated matching experiences and symptoms as often as they diagnosed them. Freudian psychoanalysis had yielded symbolically sexualized dream imagery, a psychodynamic model of the unconscious at war with itself, and a powerful account of neurosis based in childhood, adolescent, and adult sexuality, usually in some deformed or defective state. We carry so many of these early psychoanalytic concepts with us unwittingly today—the superego, repression, Freudian slips, the unconscious itself—that they have become inextricable from our culture, even if Freud’s all-consuming vision of sexual neurosis has faded. The legacy of the DSM is harder to gauge. Where psychoanalysis aestheticized and dramatized mental illness for the general public, the DSM classified and quantified it. This is, loosely, the shift from qualification to quantification. We moved from describing one’s mishigas to labeling it.*7

  Sometimes I would look up a disorder and wonder how close I was to it, since many disorders possessed at least one sufficiently innocuous criterion that I matched. One of schizophrenia’s criteria was “disorganized speech.” Did that mean I might be schizophrenic because I rambled on with incoherent sentences sometimes? “Lack of enjoyment of experiences” was listed on many disorders! How close was I to madness? Not very, according to my parents. They explained that clinical assessments were not made by such criteria, but by the reasonable judgment of adults like themselves who wouldn’t diagnose people as crazy just because they ticked off the right number of boxes under a DSM category. So what, I asked, was the purpose of these categories? Getting paid, they told me.

  Years later I had my own perverse clinical encounter with the DSM. When I was twenty-six years old and on vacation by myself in New York City, I had a panic attack—maybe. I had spent the evening first at an Evan Parker concert uptown, then at a Keith Rowe and Toshimaru Nakamura concert downtown. In between was a breakneck car ride down the streets of Manhattan by a very high-octane friend, Pei-Yi, while I and my other friend Chris held on to the armrests. After the second show, Chris and I had some very bad chicken—undercooked and sickly pink—at a Chinese restaurant near Tonic, the much-missed club where Rowe and Nakamura had played. Chris headed uptown to his apartment, and I went back to my hotel. Happy and exhausted, I lay down on the bed to unwind, and then my body went mad.

  Time slows down in unfamiliar and frightening situations: just before a car accident, the couple seconds of seeing a car heading far too close to me in the rearview mirror stretched out to feel like minutes. What happened on that night unfolded over what seemed like hours. An unfamiliar wave of discomfort and numbness passed through my body. In my arms and legs and particularly in my head, I felt a terrifying and physical sense of dislocation, as though I were losing all sensation, except that instead of numbness, it was a new kind of pain that I had never experienced before. It was not a sharp pain or a dull pain, not a throbbing pain or a stabbing pain, not tension or heat or cold. I was still very much in my body, but my body had become a far more hostile place. It was pain without being pain, a sensation that didn’t feel comparable to anything I had known but that was incredibly unpleasant and persistent. My head swirled. I could not understand what was going on, and I was all alone in New York City. I called 911.

  I remember being in an ambulance, telling the attendant that I felt like I was going to pass out. He told me that people who say they’re going to pass out never pass out, which was somewhat reassuring but didn’t stop me from thinking that I was dying. I called Chris on the phone and told him that there might have been something wrong with the chicken and that I was going to the hospital. I left messages with my wife and my mother. The feeling continued to roil me without subsiding or worsening. I stayed alert, wondering what was coming next. I was panicked, but not irrational. I was rigidly focused on the situation at hand, trying to figure out whom to contact and what to say. I had made sure to tell my wife and mother that I loved them. I reflected that it would be a shame to die at this moment, because things had been going well recently and I was making progress in my life.

  Sometime later, I was lying on a stretcher in an emergency room. The feeling had slightly abated. I still felt terrible, but it was harder to differentiate between the initial, awful feeling and the subsequent terror of dying that had joined it shortly after. I began to think that I was going to live. The nurse did an EEG on me and took other vital signs—all were normal. Chris showed up and told me that on hearing my message, he’d panicked and stuck a toothbrush down his throat to induce vomiting.

  The Temptation of St. Anthony, by Pieter van der Heyden, after Bruegel

  “What did I sound like?” I said.

  “You sounded like you were dying.”

  I said that I now didn’t think that I was. When the on-call doctor arrived, he told me that it was a panic attack, which under the circumstances was about the best-case scenario. I spoke to my wife, who was relieved to hear that I was alive, and my mother, who told me that it did indeed sound like a panic attack. There was nothing I had been panicked about, but she replied that that was not how these things worked. Panic was a state of being, not a state of mind. Chris went with me back to the hotel and stayed with me overnight. I felt light-headed and strange in the morning, as though my head had been depressurized, but the terrible sensation had otherwise mostly passed.

  What seized me that night still defies easy description. The best visual portrayal of the sensation I know is in Pieter van der Heyden’s print after Bruegel, The Temptation of Saint Anthony. An oversize head lies in a river, dragged down by chaos and drowning in surreal torment. My vision was unaltered, but the print captures the sensory corruption and loss of bodily autonomy that I suffered. The world remains unchanged; it is just one’s apprehension of it that has gone horribly wrong. The ordinary, passive act of living and experiencing becomes painful.

  What had happened to me? The DSM-IV-TR, which was the latest edition at the time, gives the criteria for a panic attack as consisting of four or more of the following symptoms.*8 I have bolded the symptoms I experienced on that night.

  palpitations, pounding heart, or accelerated heart rate

  sweating

  trembling or shaking

  sensations of shortness of breath or smothering

  feeling of choking

  chest pain or discomfort

  nausea or abdominal distress

  feeling dizzy, unsteady, lightheaded, or faint

  feelings of unreality (derealization) or being detached from oneself (depersonalization)

  fear of losing control or going crazy

  fear of dying

  numbness or tingling sensations (paresthesias)

  chills or hot flushes

  At five symptoms, my experience qualified as a panic attack—barely. I was dissatisfied with the diagnosis, however, because the symptoms befell me in two stages. There was first the initial terrible feeling, which
I’ll call nerve corruption, as my body was reporting mysterious and awful sensations to my mind that were foreign to me—and apparently inaccurate. The feeling of nerve corruption contained, at best, the last two symptoms: numbness and chills. Everything else followed sometime later and was pretty obviously the product of my worrying about nerve corruption, not something that was intrinsically part of the nerve corruption. So was the nerve corruption itself a panic attack, or had it caused a panic attack?

  A few weeks later, the nerve corruption descended upon me again. This time, however, I was certain that as awful as it felt, I was not dying and was probably not in any real danger either. I sat down in a chair, closed my eyes, and breathed slowly, trying to track this strange sensation*9—as it oscillated and twisted inside my head of its own accord. After twenty terrible minutes, the nerve corruption slowly abated. That time there had not even been a chill, possibly owing to my being in a warmer room than I had been in in New York. There had been a tingling half-numbness alongside the indescribable nerve corruption. Chest pain? No. Hyperventilation? No. Racing thoughts? No. I had, in fact, made a point to stay as calm as possible during the nerve corruption so as to observe its essential elements.*10 I continued to experience episodes like this infrequently over the next few months, until they gradually dissipated. They usually came in the evenings or at night, sometimes when I slept, very rarely when I was active or at work. If they had any correlation to stressful events in my life, I could not identify the pattern.

  A mytho-symbolic portrayal of the epileptic’s relation to the world, from David B.’s Epileptic

  Here is what a psychologist told me: the New York episode was a panic attack, and the only panic attack I had suffered. I protested: Why should the fact that I thought I was dying the first time make it somehow different? I fully understand that working myself into a frenzy over a weird and unpleasant feeling will cause me to panic, I told him, but I’m not doing that anymore. I do not recall getting a satisfying answer. So instead of panic attacks, I was experiencing something that fell between the cracks of the DSM’s categories. Short of having an experience of nerve corruption while hooked up to assorted monitoring equipment, I expect it will remain a mystery to me and to science. My mother once proposed it might have been an unusual form of migraine, which gained some support when I found out that the frequent minor headaches I’d suffered my whole life were in fact migraines, despite lacking aura or the more severe features frequently associated with migraines. But the nerve corruption didn’t share any apparent link to anything I’d thought of as a headache either, which was a far more familiar form of pain. I found later that I could diminish the length of a nerve corruption episode by taking a small dose of a tranquilizer, which indicated panic may have been the cause again—except that, according to the DSM, I was not actually having panic attacks.

  The inability to show people my inner experience has never been more frustrating than in this case. I thought that the fundamental criteria for the diagnosis were ridiculous. I thought the doctor’s adherence to them was ridiculous. Yet the ostensible clarity granted by the numbers and the criteria undeniably give DSM-based diagnoses a greater veneer of scientific objectivity. And indeed, this was the problem that the DSM-III was created to solve. The DSM hadn’t interfered with the treatment of my nerve corruption; it just failed to taxonomize it.*11 Psychiatry’s greatest contribution had been to humanize the mentally ill and secure for them somewhat better treatment than they had been allotted in the past. This was a slow process, with many missteps and horrors, but the degree of sympathy we extend to the mentally ill is far greater now than it was in the pre-Freudian era. Nonetheless, there is little of the theoretical work in Freud and his followers—what Joyce called “Jungfraud’s Messongebook” in Finnegans Wake—that stands up to scientific scrutiny.

  As psychotherapy became mainstream and institutionalized in the United States, medical authorities criticized it for lacking diagnoses. Certainly there were extreme forms of delusional schizophrenia that fit a reasonably consistent pattern, but for more minor ailments, the psychotherapeutic approach offered few ways to summarize what precisely was wrong with a patient and couldn’t guarantee that different psychiatrists would agree on a diagnosis. The DSM-II notoriously classified homosexuality as a mental disorder, listing it alongside other “Sexual Deviations” such as sadism, masochism, and transvestitism. Other artifacts included “neurasthenia,” “psychotic depressive reaction,” and “involutional melancholia.” The homosexuality classification was rectified in 1973, thanks to an effort led by the quantitatively oriented psychiatrist Robert Spitzer, but it was increasingly clear that many of the other categories, while less controversial, were terminally vague, overlapping, and sometimes incoherent.

  Spitzer went on to be the central figure behind the full-bore rewrite of the DSM-II into the DSM-III, which was published in 1980. The DSM-III cleaned up the terminology of the DSM-II and separated mental illnesses out into more logical and hierarchical categories, yet the DSM-III still was based on the taxonomical foundation of the DSM-II. Indeed, the DSM-II’s overall division of psychiatric illnesses into affective syndromes like depression, psychoses like schizophrenia, and personality disorders like borderline remained in the DSM-III. The revolution of the DSM-III lay instead in the introduction of a criterial approach to diagnosis. The DSM-II provided only a general description of each syndrome, so that the individual physician judged whether a patient fit it or not. The DSM-III did not require psychiatrists to match those generalized descriptions to patients. Instead, diagnosis was to be obtained through behavioral markers, the “5 out of 7” approach I mentioned above. Whether or not this produced a better taxonomy of actual diseases, it did accomplish something significantly more important, which was to allow for replicability and to explain a lack of replicability. If two psychiatrists disagreed on a patient’s diagnosis, they could simply go down the checklist for each diagnosis and see which markers were met. Just as significantly, the DSM-III allowed for quantitative research to be performed on groups of patients. If a psychiatrist wanted to see the effect of a treatment on a particular disease, he or she could study patients diagnosed with that particular DSM-III classification. This proved crucial for the pharmacological boom ushered in by Prozac in 1986. The FDA required drugs to be prescribed for a specified set of diagnoses, so the increased standardization of the DSM-III enabled psychiatric drugs to enter the mainstream. Diagnoses were now much easier to fit not just onto severely mentally ill patients, but also higher-functioning people.

  This transition bolstered the shift from psychoanalysis to psychopharmacology. The individual, unpredictable, and inexorable course of analysis, with its personalized, irreproducible hours of dialogue, was ill suited for any sort of standardized, quantifiable treatment regimen, and therefore a very bad match for the increasingly actuarial health insurance industry. For those wealthy enough to pay out of pocket, psychoanalysis remained relevant, particularly in places like New York where it was nearly a cultural signifier.*12 For everyone else, though, the DSM-III enabled a new sort of psychiatric treatment that did not equate mental illness with severe pathology or Freudian analyses. Everyday neurosis could now be quantified and treated as one would treat any other physiological symptom.

  For all the alarm bells that have rung about overdiagnosis and the inflation of mental illness, the problem is not with increasing the number of diagnoses per se, but with how society then deals with that greater pool of “mentally ill” people. And here both doctors and drug companies have a lot to answer for, as DSM-IV architect Allen Frances says:

  The business model of the pharmaceutical industry depends on extending the realm of illness….The real problems begin at the intersection between DSM diagnoses and FDA drug indications. Once a drug is approved for a more popular DSM diagnosis, it sells much more. This has caused a vicious feedback loop, as newfangled drugs are pushed toward treating
the most popular diagnoses. As the most popular diagnoses tend to be by nature the more mild diagnoses, this results in a trend toward overtreatment.

  The slippery nature of the DSM categories exacerbated this feedback loop. Because they were not based in anatomical or neurophysiological reality, but were rather folk categories inherited from years of vague consensus among psychiatrists, these diagnoses were not set in stone in the way that, say, heart ailments are. Peer pressure from colleagues and financial pressure from drug companies could shunt these categories in directions that were not in patients’ best interests. This played out disastrously in the case of childhood bipolar disorder, a new diagnosis meant to supplant some existing diagnoses of ADHD. Harvard professor Marcia Angell tells the story:

  Take the case of Dr. Joseph L. Biederman, professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Harvard’s Massachusetts General Hospital. Thanks largely to him, children as young as two years old are now being diagnosed with bipolar disorder and treated with a cocktail of powerful drugs, many of which were not approved by the Food and Drug Administration (FDA) for that purpose and none of which were approved for children below ten years of age.

  Biederman’s own studies of the drugs he advocates to treat childhood bipolar disorder were, as The New York Times summarized the opinions of its expert sources, “so small and loosely designed that they were largely inconclusive.”

  The scandal broke out, as Angell tells it, when it became known that Biederman had received $1.6 million from drug companies, including those that made the very same drugs prescribed to those diagnosed with childhood bipolar. Instead of diagnoses driving the prescriptions, the prescriptions were driving the diagnoses. Psychiatric labels had been prodded in one particular direction—a more profitable one.