The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg, Blue Rider Press, RRP$28.95, 416 pages
Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM5, Big Pharma, and the Medicalization of Ordinary Life, by Allen Frances, William Morrow, RRP£18.99/$27.99, 336 pages
Cracked: Why Psychiatry is Doing More Harm Than Good, by James Davies, Icon Books, RRP£10.99, 320 pages
Our Necessary Shadow: The Nature and Meaning of Psychiatry, by Tom Burns, Allen Lane, RRP£20, 384 pages
Though Sigmund Freud was a trained neurologist, he never liked the idea of other doctors practising psychoanalysis. In a paper written in 1927, he explained that a medical degree was a disadvantage to the aspiring analyst because it would leave his head full of ideas “of which he can never make use”. There was even a “danger of its diverting his interest and his whole mode of thought from the understanding of psychical phenomena”, which ought instead to be informed by “psychology, the social sciences, the history of civilisation and sociology”. Psychoanalysis was not – not on Freud’s watch – to be “swallowed by medicine”.
It is lucky he didn’t see what happened next. Today the most widely accepted method for understanding “psychical phenomena” is one practised by doctors and dependent on concepts derived from the study of physical disease. Pre-eminent in the field is a medical institution, the American Psychiatric Association (APA), whose latest taxonomy of human suffering is published this month.
The Diagnostic and Statistical Manual of Mental Disorders, or DSM, is consulted by psychiatrists and other mental health professions all over the world. Particularly in the US, it informs court decisions and insurance claims; it defines the needs that the pharmaceutical industry supplies; and it shapes our concept of the human mind and of “normality”. Criticism of its approach has been rising in the run-up to the release of the DSM-5, the first major revision in nearly 20 years. Last month, Thomas Insel, the director of the American National Institute of Mental Health (NIMH), observed that the DSM was “at best, a dictionary” and that “symptoms alone rarely indicate the best choice of treatment”. A later statement, issued jointly with the NIMH’s president-elect, stressed that the manual remained “the key resource” but still insisted on the need for a diagnostic system “that more directly reflects modern brain science”.
It all seems a far cry from 1980, when the groundbreaking DSM-III was widely credited with restoring the dignity of a profession then flailing in the wake of richly publicised exposés and an “anti-psychiatry” movement led by the charismatic (and often drunk) RD Laing. Plainly, a great deal has happened in the intervening years, and The Book of Woe: The DSM and the Unmaking Of Psychiatry, by Gary Greenberg, tells the whole wild story. Greenberg turns out to be the ideal narrator, at once reporter, thinker, and comedian. He’s also a psychotherapist. “Most clinicians don’t care what the DSM’s rules are,” he writes. “I know I don’t.” But in the US, where Greenberg practises, payment via health insurance requires a DSM diagnosis, so he and others like him “hold our noses when we put those codes on to the bill”.
Greenberg favours an “innocuous” code – one that won’t burden his patient with any future stigma. At the top of his “favorites list” is “309.28”, which denotes “adjustment disorder, with mixed anxiety and depressed mood”. He can’t always face the process, though, and over 30 years he may have “left a couple million dollars on the table by avoiding the DSM”.
It would be hard to say how many people worldwide are financially reliant on the DSM in one way or another – in the pharmaceutical industry, in psychiatry, in psychotherapy, in counselling and nursing. So when Allen Frances, who led the task force for DSM-IV (1994), writes in Saving Normal that he and his colleagues thought they were working on “a guidebook, not a bible – a collection of temporarily useful diagnostic constructs, not a catalog of ‘real’ diseases”, it seems there has been something of a misunderstanding. Frances, who criticises the “diagnostic inflation” of recent years, suggests people may not have been reading the “handbook” or introduction, which clearly states the manual’s limitations.
But, given the DSM’s princely tone and neat scoring system (five out of six symptoms and you’ve got “X” disorder, four and you don’t) this seems weirdly naive. Frances’s predecessor, the 81-year-old Robert Spitzer, is in no doubt about why the DSM-III, over which he presided, had been such a hit. With startling honesty, he told Greenberg that it “looks very scientific … it looks like they must know something”.
In fact, they know less than people think. Only 3 per cent of DSM disorders have any known biological causes. The causes of the remaining 97 per cent – and this includes depression, anxiety, schizophrenia, attention deficit hyperactivity disorder (ADHD), bipolar and all personality disorders – are not known. The theory that chemical imbalances cause mental illness – that a serotonin deficiency causes depression, for example – is unproven. Billions of research dollars have been spent on trying to establish a link between neurotransmitters and mental disorder, and the attempts have failed. For all the scientific terminology, psychiatric diagnoses are based on subjective judgments.
Still, the chemical imbalance idea has certainly shifted a lot of pharmaceuticals, which has made a lot of people rich – many of them psychiatrists involved in the DSM. It has also helped millions of unhappy people to believe they are receiving treatment for a medical disorder, rather than drugging themselves against the strains of everyday life. In his diligent study Cracked: Why Psychiatry is Doing More Harm Than Good, the British psychotherapist James Davies describes a “meta-analysis” undertaken in the 1990s that compared the effectiveness of antidepressants versus placebo – sugar pills made to resemble medication. The study found a tiny overall improvement in antidepressant groups over placebo groups but even this was accounted for by side-effects. When subjects got constipation or loss of libido, for example, they felt sure they were on the real drug, and this created “expectation of recovery”. The researchers concluded that “85 to 90 per cent of people being prescribed antidepressants are not getting any clinically meaningful benefit from the drug itself”.
Over recent years there has been an increasing tendency to view the public as victims of drug-mongering. But millions have been strikingly eager to believe they and their children are entitled to a life free of anxiety, grief, rage, confusion, shyness and periods of deep suffering – and more than ready to accept that they can buy a product to ensure this. It may be that the pharmaceutical industry has shown us what a capitalist response to a spiritual problem looks like.
But there is an important distinction to be made between treating “the worried well”, who account for most GP prescriptions and antidepressant sales, and treating, for example, a person who believes her organs have been filled by aliens with toxic material and that the only way to save humanity is to kill herself. We rely on psychiatrists to medicate patients out of horrors unknown to the rest of us. If there were any placebo effects at play, would we really wish to argue them out of existence or should we be glad that there is something, real or illusory, its effects understood or not, that offers relief? In his cool and rational book Our Necessary Shadow: The Nature and Meaning of Psychiatry, Tom Burns insists that psychiatry can treat “awful illnesses”. Surely, he asks, “the current situation”, for all its flaws, is preferable to “tolerating unnecessary suffering”?
Burns, a professor of social psychiatry at Oxford university, makes a powerful case when it comes to the most debilitating conditions. But the current row over psychiatry is less about its treatment of severe illnesses than its impact on normality. The number of disorders listed in the DSM rose from 106 to 374 between the first and fourth editions; similarly, the criteria by which a diagnosis is reached have grown ever more inclusive. This has led to apparent epidemics of depression, bipolar disorder and ADHD. It has also drawn what appears to be a neat distinction between “disorders” and normal behaviour. But the reality is more nuanced. Anyone who crosses their fingers for luck, for example, has had a taste of obsessive compulsive disorder; anyone who has ever forgotten what they went upstairs to fetch has experienced a dissociative episode. Mental illness is an intensification of normal behaviour, not something different from it in kind. By gradually slackening its criteria the DSM has estranged us from our eccentricities, our survivable rough patches, our shyness and sorrows, and made them sound like diseases.
There have been attempts to guard against this over-inclusiveness. The DSM-IV definition of “major depressive disorder” included a “bereavement exclusion”: if you had just lost your partner, you wouldn’t be called depressed. But the exclusion begged a lot of pesky questions. What about other life circumstances? On what authority does a psychiatrist or GP decide whether my reaction to divorce or to the loss of my job is not worth noting? There will be no “bereavement exclusion” in the DSM-5. When Greenberg asked Spitzer whether psychiatric diagnosis shouldn’t always take into account a person’s life circumstances, the old king of American psychiatry replied: “If we did that, then the whole system falls apart.”
The system is not particularly stable as it is. Although psychiatric diagnoses can have a greater impact on identity than those of physical medicine, the APA can decree at any moment that one of its “temporarily useful constructs” is of no further assistance. Anyone with Asperger’s, for example, will, as of late May, be considered to have an autistic spectrum disorder if their symptoms are severe – or be given a miraculous clean bill of health. There are thousands of comments on the DSM-5 website from patients begging for their diagnosis not to be removed.
The most curious aspect of the status quo in psychiatry, though, is how a scientific-looking manual put out by a small organisation with no public accountability has come to be viewed with such reverence. Not for nothing is the DSM known as “the psychiatric bible”. Perhaps its bullet-pointed diagnoses do satisfy a religious need, the old existential ache for reassurance that “even the hairs of your head are all counted” and there’s no reason to be afraid.
Talitha Stevenson is a writer and psychotherapist