When I think of psychiatry, my first thoughts are unkind. I think of mildly sad people on antidepressants. I think of upper-middle-class parents putting their kids on Ritalin as soon as they flunk math, or misremember the lyrics to Dave Matthews songs. Pills seem so overabundant in our country that it’s possible to forget there are Americans who really and desperately need a pharmacological fix for an illness of the mind.
Early in The Book of Woe: The DSM and the Unmaking of Psychiatry, Gary Greenberg describes one such American, a patient who locks himself in a hotel room and gibbers into the phone that his family has sucked out his bones. People like this look to psychiatry for salvation, and so, Greenberg argues, we must save the profession from overreach and corruption. These twin problems have become so dire in the last few years that even pillars of the psychiatric establishment have started to howl in protest. The Book of Woe is the behind-the-scenes story of the new, fifth edition of the American Psychiatric Association’s bible, the DSM-5, and it’s entertaining in some of the same ways that Moby-Dick is entertaining. The psychiatrists Greenberg interviews are willful, sharp-tongued men—they are mostly men—stuck on the same rickety ship, trying to chart a common course, and bound for disaster.
Greenberg quotes Melville, declaring that too many psychiatrists “cherish expectations with regard to some mode of infallibly discovering the heart of man.” (Melville was referring to “earnest psychologists,” but that’s because psychiatry didn’t yet exist as a profession.) He wants them to stop acting like they know the truth about their patients’ minds. The repository of their contested knowledge is the DSM, which stands for Diagnostic and Statistical Manual of Mental Disorders, a wildly profitable taxonomy of illnesses that costs $189 and projects an air of medical authority by defining disorders with lists of criteria. The problem with these disorders, Greenberg argues, is that they treat the mind like the body. Trying to make their profession look like any other branch of medicine, psychiatrists treat undefinable mental states like “anxiety” as if they were scarlet fever.
For example, as of June 2011, the first three criteria for Generalized Anxiety Disorder (GAD) in a draft of the DSM-5 were:
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
With scarlet fever, you can trace the symptoms to the presence of strepococcus bacteria in the body. With GAD, you must hope that you and your patient are properly measuring unquantifiables like “excessive,” “restlessness,” and “keyed up.” Greenberg is a psychotherapist—as well as a widely published journalist and author—and he believes psychiatrists must make clear to patients that such disorders are not diseases but “provisional categories.” This, he predicts, will mean “fewer patients, more modest claims about what [psychiatry] treats, less clout with insurers, and reduced authority to turn our troubles into medical problems simply by adding the word disorder to their description.”
He sees this humbling of the discipline as the path to an “honest psychiatry.” A nimble rhetorician, Greenberg implies that in its current state psychiatry is like the titular swindler of Melville’s The Confidence-Man, from which that “heart of man” quotation is drawn. Psychiatrists, he says, must learn restraint. They must say “I don’t know” more often. Because, from some angles, the profession looks like a confidence game. If it’s a scientific study of the mind, rather than simply a mirror of our cultural values, why was homosexuality listed as a disorder in the DSM until 1973? Go back even further in the annals of mental illness, and you find drapetomania, proposed by the New Orleans physician Samuel Cartwright in 1850: “the disease causing negros to run away.”
Lest you believe we are in an era free from politically fraught mental disease, Greenberg notes that the DSM-5 looks set to apply Hoarding Disorder to people who collect piles of old newspapers, but not to people who collect astounding compensation packages while laying off employees. And lest you deem these concerns academic, Greenberg points out that psychiatrists hungry for grants from Big Pharma can, for instance, revise the boundaries of bipolar disorder so that disobedient toddlers are prescribed antipsychotics. Harvard psychiatrist Joseph Biederman advanced the notion of childhood bipolar disorder while accepting research funds from Johnson & Johnson, manufacturer of one of the antispsychotics often prescribed to the allegedly bipolar children. Eventually Sen. Chuck Grassley of Iowa ordered an investigation of Biederman’s activities and Harvard determined that Biederman violated its policies.
Greenberg’s case is compelling. But he smartly devotes equal time to an alternative rescue plan advocated by Allen Frances, chief architect of the DSM’s previous edition, the DSM-IV. (The APA has switched from Roman to Arabic numerals.) Much of the drama in The Book of Woe flows from the tortured intellectual bromance of Greenberg and Frances, who are a bit like Ishmael and Ahab. Frances has a white whale he wants to slay, the DSM-5, which he considers rife with imprecision. He has launched a ferocious publicity campaign against it, arguing that its methodology must be overhauled if psychiatrists are to retain their credibility. Greenberg, like Ishmael, plays the bemused outsider. He’s not sure there should be a DSM at all. His role is mostly to stand by and watch the bloody spectacle.
As presented by Greenberg, Frances’ view is that psychiatry can maintain the public trust and protect patients by being both more stringent and more open about the way mental disorders are defined. The DSM needs better field trials, clearer boundaries for many mental illnesses, and less deference to well-placed experts who want to get their off-the-cuff diagnoses in the book. He believes the manual-in-progress is full of the mischief he regrets allowing in DSM-IV: sloppy, poorly tested diagnostic categories and pet disorders promoted by insiders. Frances wants a “black-box warning about the dangers of overdiagnosis.”
But—and this is where it gets really interesting—Greenberg depicts Frances as having much the same doubts about psychiatry’s fundamental scientific validity as Greenberg himself. He suspects that Frances, despite having supervised the writing of the DSM-IV, knows just as well as he does that psychiatry is “built on air.”
But Frances says that if patients come to understand the limitations of psychiatry, they might fail “to do the calculation.” They might fail to conclude, “Well, maybe this isn’t perfect, but it’s still the best way available, and we shouldn’t just throw it out.” They might “get disillusioned and stop taking their medicine.” Frances wants to maintain the prestige of the profession until neuroscience improves, and “the complexity begins to clarify out of the mist.” Until then, “the full truth is usually best, but sometimes we may need a noble lie.” Frances, whom the New York Times once called “perhaps the most powerful psychiatrist in America,” understands, according to Greenberg, that because we cannot yet create “a taxonomy of disorders validated by biochemical findings,” psychiatry as we know it is a collection of fictions.