The Diagnostic and Statistical Manual of Mental Disorders is often called the “Bible” of psychiatric diagnosis, and the term is apt. The DSM consists of instructions from on high; readers usually disagree in their interpretations of the text; and believing it is an act of faith.
At least the Bible lists only 10 Commandments; the DSM grows by leaps and bounds with every revision. The first edition, published by the American Psychiatric Association in 1952, was a spiral-bound pamphlet that described 11 categories of mental disorder, including brain syndromes, personality problems and psychotic disorders. (The final category, “Nondiagnostic Terms for the Hospital Record,” contained Dead on Admission, the one diagnosis that psychiatrists have ever agreed on.) The DSM-II (1968) made homosexuality a mental disorder, a decision revoked by vote in 1973. In the general excitement about that progressive decision, few noted that voting didn’t seem to be the most scientific way of determining mental illness. Narcissistic Personality Disorder was voted out in 1968 and voted back in 1980; where did it go for 12 years? Doctors don’t vote on whether pneumonia is a disease.
.The DSM-III (1980) was an effort to jettison outdated theories and terms such as “neurosis” and replace them with an objective list of disorders with agreed-upon symptoms. The DSM-IIIR (1987) was 567 pages and included nearly 300 disorders. The DSM-IV (1994, slightly revised in 2000) was 900 pages and contained nearly 400 disorders. The new DSM-5, with its modernized Arabic number, is 947 pages. It contains, along with serious mental illnesses, “binge-eating disorder” (whose symptoms include “eating when not feeling physically hungry”), “caffeine intoxication,” “parent-child relational problem” and my favorite, “antidepressant discontinuation syndrome.” Now psychiatrists can treat the symptoms of going off antidepressants, which is good because the expanded criteria for many disorders allows doctors to prescribe antidepressants more often for more problems. Gone is the “bereavement exemption,” for example. You used to get two weeks after a loved one died before you could be diagnosed with major depression and medicated. Now you get two minutes.
If people treated the DSM the way most treat the other Bible—nod their heads to it, say they believe in it and continue sinning—we might be all right. Many psychotherapists who still practice therapy, rather than prescribe a cocktail of Zoloft and Risperdal with a tincture of Ritalin, do just that. They find a label that suits, for insurance purposes, and then get on with helping the client.
.But the DSM has grown too powerful to ignore; it is the linchpin of the pharmaceutical-medical complex. Adding more disorders allows doctors to be compensated for treating any kind of problem, from garden-variety sorrow to incapacitating depression. Drug companies encourage new disorders so that they can create medications or repackage old ones: Prozac, when its patent expired, was renamed Sarafem to treat “Premenstrual Dysphoric Disorder.” PMDD had been relegated to the kids’ table (that is, an appendix) in the DSM-IV, thanks to protests by women clinicians who wondered why menstrual symptoms constitute a “mental disorder” when, say, Hypertestosterone Hostility Disorder is nowhere to be found. Alas, PMDD has moved to the adults’ table in the DSM-5. HHD is still MIA.
.Criticism of the DSM began to coalesce in the 1990s, with Stuart Kirk and Herb Kutchins’s “The Selling of DSM” (1992) and “Making Us Crazy” (1997), as well as Paula Caplan’s “They Say You’re Crazy” (1996). Now, Gary Greenberg, a psychotherapist and the author of “Manufacturing Depression” (2010), and Allen Frances, a psychiatrist who was task-force chair of the revision of the fourth DSM, have joined the chorus of critics. Their books share the goal of skewering the pretensions of the latest revision and using what is wrong about the DSM to remind us of what diagnosis and therapy should be for. But they diverge in one crucial way: Dr. Frances is sitting on the fence about what the DSM’s power means for psychiatry; Mr. Greenberg has leapt over it.
In “The Book of Woe,” Mr. Greenberg takes us on a rollicking journey from the DSM-5′s inception to its publication, regaling us with stories, alternately hilarious and infuriating, of internecine battles, personality clashes and political machinations. Mr. Greenberg is an outsider by virtue of not being a psychiatrist but an insider by virtue of serving as one of the investigators involved in field-testing some proposed diagnoses on actual patients. He interviewed the major players; he watched as feathers were ruffled and smoothed; he attended conferences, documenting with growing disbelief the failures of the American Psychiatric Association’s task forces to produce the scientific results they had aimed for.
And he was there when those scientific aspirations met reality and all hell broke loose. Mr. Greenberg gives us a front-row seat at the APA’s annual meeting in 2011, when results of the field trials were reported. Field trials are intended to test the reliability of diagnostic criteria—meaning that two psychiatrists observing the same person’s symptoms should have a pretty good chance of agreeing on a diagnosis. But the results were dismal. Agreement on identifying even Major Depressive Disorder and Generalized Anxiety Disorder—what Mr. Greenberg calls the “Dodge Dart and Ford Falcon of the DSM, simple and reliable and ubiquitous” disorders—was low. Moreover, the field testing on patients failed miserably: 5,000 clinicians signed up to participate, 195 finished training for it, and only 70 enrolled any patients in trials. The APA tried to put a good spin on these numbers —”nearly 150 patients have joined the study”—ignoring, Mr. Greenberg notes, that their goal was 10,000. Only two months before the data had to be in, the clinician field trials had barely begun.
Why would the APA rush publication in spite of unfinished field trials and failures to find high reliability among clinicians, the very things that their claims to a scientific DSM rely on? Do the math, Mr. Greenberg answers. In recent years, the APA has been steadily losing income from dwindling membership and dwindling ad revenues for its journals. The DSM-IV, which has earned $100 million, keeps the organization in the black. Faced with a looming deadline and terrible data, Mr. Greenberg suggests, the DSM directors did what any reasonable, self-protecting institution would do: They lowered the statistical criteria for acceptable standards of reliability and turned defeat into victory. As Allen Frances puts it in “Saving Normal,” they accepted agreements among raters that were “sometimes barely better than two monkeys throwing darts at a diagnostic board.”
I encountered Allen Frances in the pages of Mr. Greenberg’s book before I read his own. Mr. Greenberg’s conversations, emails, and debates with Dr. Frances are woven through his narrative, and Dr. Frances emerges as funny, furious, defensive and courageous. Allies and adversaries, they never agree on whether criticizing the DSM is good for psychiatry or bad. Mr. Greenberg wonders whether he is helping to undermine a profession “that offers the last and only hope for some patients” with psychosis and other severe disorders. But he concludes that the truth needs to be told: Even in the hands of “honest and eloquent men” such as Dr. Frances, he writes, “psychiatric diagnosis is built on fiction and sold to the public as fact.”
Dr. Frances can’t go that far. “My critique,” he makes sure we know, “is directed only against the excesses of psychiatry, not its heart or soul.” In conversations with Mr. Greenberg, he worries that his words will be misused “by the antipsychiatry fanatics” who oppose psychiatric diagnosis and treatment altogether. “The field is a lot better,” he says, “than anyone would assume watching the DSM-5 follies unfold.”
Accordingly, in “Saving Normal,” Dr. Frances attempts the delicate task of debunking the DSM-5 while justifying his own DSM-IV. He was alarmed by the DSM-5′s proposals of “new diagnoses that would turn everyday anxiety, eccentricity, forgetting, and bad eating habits into mental disorders.” His 6-year-old twin grandsons wouldn’t have tantrums any more but “disruptive mood dysregulation disorder,” and his own normal forgetting of names and faces would be “mild neurocognitive disorder.” Yet the DSM-IV gave us a Disorder of Written Expression, Caffeine-Induced Sleep Disorder and Age-related Cognitive Decline, all of which I suffer on every deadline.
Dr. Frances describes his book as “part mea culpa, part j’accuse, part cri de coeur.” The mea culpa is admirable but also gives him the greatest difficulty. When he was at the helm, he contends, pet proposals were “consistently shot down” if the science wasn’t there to support them. The DSM-IV committees were “boringly modest in our goals, obsessively meticulous in our methods, and rigidly conservative in our product.” “Methodological rigor,” he claims, was their hallmark, even as he acknowledges that “all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change.” It wasn’t the DSM-IV’s fault that it did not prevent “the rampant diagnostic inflating” or the “national drug overdose of medication” that followed its publication. The framers of the DSM-IV were, at worst, “naïve” in failing to worry that 56% of their experts had financial ties to drug companies.
Dr. Frances repeatedly chastises the writers of the DSM-5 for failing to ask Hippocrates’ question: Will this new diagnosis help patients or harm them? But the DSM-IV failed to ask the same question when, for example, it retained Multiple Personality Disorder. After the DSM-III included MPD in 1980, thousands of spurious cases emerged in the next two decades, and special psychiatric clinics arose to treat them. Yet faced with evidence of this disastrous epidemic, the DSM-IV did not delete the diagnosis. Instead, the manual renamed it Dissociative Identity Disorder. “MPD presented a dilemma for me,” Dr. Frances says. “We took scrupulous pains to present both sides of the controversy as fairly and effectively as possible—even though I believed one side was complete bunk.” How do you “fairly” argue for a diagnosis you think is complete bunk? Where’s the methodological rigor? Why did it take malpractice suits to close the psychiatric MPD clinics and not the presumed voice of scientific authority, the DSM? Dissociative Identity Disorder remains in the DSM-5.
Nonetheless, Dr. Frances does his best to save psychiatry. It is impossible to define “normal,” he explains, let alone “mental disorder.” But that doesn’t mean, he adds, that we can’t talk about the problems that cause human suffering. Mental disorders should be diagnosed only when a person’s symptoms are obvious, severe and haven’t gone away on their own. Watchful waiting should be the first step in treatment, and medication a last resort. A wise, and increasingly rare, approach.
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