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In 1952, the American Psychiatric Association released the first edition of its Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, and it quickly became the primary reference for mental health practitioners. But it’s been controversial from the start, given that diagnoses affect everything from health insurance coverage to special needs support. We talk with an author and practicing psychotherapist about the history of the manual and the newly revised fifth edition coming out later this month.
- Gary Greenberg Author, 'The Book of Woe: The DSM and the Unmaking of Psychiatry'; psychotherapist
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Excerpt from “The Book of Woe: The DSM and the Unmaking of Psychiatry” by Gary Greenberg. Copyright 2013 by Gary Greenberg. Reprinted here by permission of Blue Rider Press. All rights reserved.
MR. KOJO NNAMDIThe line between mental health and mental illness is not always completely clear. So in 1952 the American Psychiatric Association put forth the first edition of a diagnostic and statistical manual of mental disorders in an effort to bring greater understanding of and validity to a variety of conditions, and more consensus and reliability to diagnoses for patients.
MR. KOJO NNAMDIA massive undertaking that has courted controversy from the very start, and with a fifth edition due later this month, we're talking about the history and influence of this manual with Gary Greenberg. He's a practicing psychotherapist who writes about the intersection of science, politics and ethics for numerous publications. He's written several books, the latest of which is "The Book of Woe: The DSM and the Unmaking of Psychiatry." Gary Greenberg, thank you for joining us.
MR. GARY GREENBERGI'm glad to be here.
NNAMDIWhat exactly is the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM and how did it come to be the go-to guide for mental health workers?
GREENBERGWell, the DSM is a collection of mental disorders and their definitions. The definitions come in the form of criteria that are listed that a person -- clinician can look to to try to figure out which condition his or her patient has. Now how did it become the go-to guide? Well, for the first 25 or 30 year of its existence, it wasn't really the go-to guide. It was only -- it was, as you said, started in 1952 but it was only within 1980 edition, the DSM III that it took on the form that it has now, where it tried to compile all the different varieties of suffering under -- between two covers. And to give ways to identify, define and diagnose each of those.
NNAMDI800-433-8850 is our number here, if you'd like to join the conversation. Have you received or tried to get a mental health diagnosis for yourself or for a loved one? What was that experience like, 800-433-8850? You can send us a Tweet at kojoshow or email to firstname.lastname@example.org. In addition to being a journalist and an author, you are a practicing psychotherapist. How do you use this manual in your own practice?
GREENBERGWell, like the vast majority of clinicians out there, I use the manual when I want to try to help people use their insurance benefits to pay for psychotherapy. That sounds cynical and it actually is cynical but if you ask any clinician from, you know, your average guy like me to the ex-president of The American Psychiatric Association, whom I interviewed for my book, how to -- the same question you just asked. The answer is I use it to get paid.
GREENBERGSo clinically the DSM -- and to be fair to the book, it's not intended as a treatment manual. And there are some insights that you can gain into clusters of symptoms by reading it, but it doesn't go very far in the clinic.
NNAMDIYou've written that, quoting here, "Psychiatrists have never been able to establish the line between mental health and mental illness," which might start to explain why this manual has courted controversy from its very beginning. Why is it such a lightning rod and how has it withstood criticism from all sides over the years?
GREENBERGWell, it's a lightning rod I think because -- not necessarily because it can't establish the line between health and illness because actually medicine has never really done that. But it becomes a lightning rod because we're not talking about figuring out if a kidney problem is a disease or not a disease, whether restless leg syndrome is a disease or not a disease. We're figuring out whether people's inner lives are diseased. And I think people take exception to being pathologized. I also think in some ways sometimes people wish they could be pathologized so that their suffering could be identified as a disease that would therefore be curable.
GREENBERGSo I think that the problem arises because we're trying to fit our inner life into a set of categories that it doesn't fit very well. I know there was a second part to your question, but I've already forgotten what it was. I'm sorry.
NNAMDIWell, the second part of my question was why is it that this lightning rod has been able to withstand criticism from all sides over so many years?
GREENBERGIn part it's because it's the only game in town. And that's --you know, again, to be fair to the psychiatrist or The American Psychiatric Association, they're the organization that's willing to undertake this thankless job. And they do get beat up all the time every time they revise it, or certainly since 1980. Even recently they've, in the last couple weeks, had to take a serious beating from the National Institute of Mental Health, which essentially announced that it was divorcing the DSM and the APA and leaving it for a younger, possibly more attractive counterpart.
NNAMDIWhat do you mean by a younger more attractive counterpart?
GREENBERGThe National Institute of Mental Health, in light of the fact that no progress has been made toward making mental illness more like medical illness over the last 30 or 40 years, there's just been disappointment after disappointment. And the NIMH in recognition of that has decided to go a different way. And they didn't just make this decision last week. They made it years ago. And they've been saying this for a long time.
GREENBERGBasically they're going to try to understand the neurocircuitry of the common symptoms of various mental illnesses rather than trying to call them -- you know, to establish these categories that everybody agrees don't really exist, they're going to look at the neurocircuitry of fear, the neurocircuitry of sadness and irritability and so on. And by doing that they're going to, they hope, move toward more science-based diagnostic scheme.
GREENBERGThey're in the really early days of this thing. Nobody knows how it's going to look. The important part is that they announced -- three weeks before the DSM came out they made this definitive announcement that they're no longer really very interested in the DSM. They'll continue to use it because as a lot of psychiatrists say it is a mutt but it is our mutt.
NNAMDIWe're talking with Gary Greenberg. He is a practicing psychotherapist and the author of several books, the latest of which we're discussing today is "The Book of Woe: The DSM and the Unmaking of Psychiatry." The DSM of course being the edition of Diagnostic and Statistical Manual of Mental Disorders. You can call us at 800-433-8850. If you work in the mental health field, how do you make use of the DSM, the Diagnostic and Statistical Manual of mental disorders? 800-433-8850.
NNAMDIHave you received or tried to get a mental health diagnosis for yourself or for a loved one? You can share your experience with us at 800-433-8850. A lot of people point out that homosexuality was included as a diagnosable mental illness in this book until 1973. But you open "The Book of Woe" by telling the story of a diagnosis discovered before the DSM came about in 1850 for, I guess it's pronounced, drapetomania.
NNAMDIDrapetomania. Tell us what that is.
GREENBERGDrapetomania was the invention of a doctor in New Orleans named Samuel Cartwright who wanted to explain why some slaves ran away and others didn't. And the way he explained it was that the slaves who ran away had an illness. The illness was called Drapetomania, which means the mania to run away. And he established some diagnostic criteria for it. Nobody really knows why Cartwright did this, but what was clear was that he was trying to use the cloud of medicine to establish that it was pathological for slaves to seek freedom.
GREENBERGHe was sticking a thumb in the eye of the abolitionists. He was saying, look if you're of African descent -- and he talked a lot about races in that old fashioned way -- then it is in your nature to be a slave, to be not quite human. And therefore if you try to run away, there's something wrong with you. Now that's incendiary at this point, and I hope I'm not identified with that notion. But it's much easier to see how incendiary that is when you're 150 years later.
NNAMDIBut had the DSM existed at that point in 1850, drapetomania may have been in it.
GREENBERGWell, yes. I mean, one would hope there would've been at least some debate but certainly it could've been. I mean homosexuality survived until the gay activists within the APA, and then from outside, bombarded them for years to de-pathologize homosexuality. So yes, it could very well have been in there, and then it would've been subject to one of these embarrassing moments where the APA is caught saying, yes we're going to vote -- we're going to take a vote now. And by virtue of this vote this condition is no longer a disease. It's like the most efficient way to cure people is to vote their disease off the island.
NNAMDIAs mental health professionals anticipate the release of the fifth edition of the DSM, some are saying, well there has to be a better way. Is it a given that this manual will continue to withstand the controversy that surrounds it?
GREENBERGI sort of doubt it. I mean, I don't think it's going to go down in flames right away. But there are many problems with the approach that the APA has taken. And it worked pretty well for 30 years or so, which, you know, when you think about it that's not so bad. The APA was in terrible -- psychiatry was in terrible condition. It had a huge credibility problem among the public and among the regulators and the insurers and the funders of research. And it really reestablished itself with the DSM III in 1980. It may have run its course, and there is an alternate diagnostic scheme called the International Classification of Diseases, which isn't that many different. It has the virtue of being nearly free as opposed to the $200 that the APA gets for its manual, and that may take over.
GREENBERGThe APA itself is walking away from the DSM model in the sense that they are turning it into what they call a living document to be updated a little bit at a time instead of all at once, thus avoiding the kind the controversy that I've written about in my book. So this may be the DSM's last -- it may the DSM's swan song.
NNAMDI800-433-8850. What changes would you like to see or not see in the way mental illnesses and disorders are diagnosed? You can send email to email@example.com. You can send us a tweet @kojoshow. Here is Lynn in Woodbridge, Va. Lynn, you're on the air. Go ahead, please.
LYNNGood afternoon, Kojo. I just wanted to say that I think the DSM is a really great resource, just in providing people with a way to understand mental illness. I mean, so many people will put it off and say, hey, you know, you're just feeling bad for one day, you're just feeling bad, you know, for a couple of months, and for me, it was that for about 24 years until I had a breakdown, and then I had to go and find out that I had a mental illness, and I think that if we had more things like the DSM out, that people would be able to understand, and we'd be able to diagnose quicker, we -- you know, just have a more -- a better community around mental illness and a place for people to feel safe.
NNAMDIWhat do you say to that, Gary Greenberg?
GREENBERGI think that's probably the single virtue -- the single most important virtue of any diagnostic scheme regarding mental illness, which is that it gives people a way to identify themselves, and identify their symptoms as still belonging to the realm of humanity. The DSM is successful at providing those labels, and it obviously has given Lynn comfort to have them. Where the problem becomes is when people think that those labels correspond to actual diseases in nature, which the psychiatrists will tell you very quickly they don't.
GREENBERGAnd this is more than an academic problem. I mean, if we're spending our time and our money researching and treating disorders that don't really exist that are fictional, and then -- then you've got a problem. You've got at least a credibility problem when someone comes along and says hey, to depress -- to diagnose depression there are nine symptoms of -- criteria for depression, any five of them qualify for the diagnosis, meaning that any two people could have the same label, major depressive disorder, and completely different symptoms. That's not like the rest of medicine. And when you get people showing these inconsistencies, then you reason back into the credibility problem.
NNAMDIWhat happens when the definition changes? It's also expected to in this fifth edition that one diagnoses that had a place in the fourth edition is likely to be included, but under a broader umbrella. Asperger's. How does that move highlight the perhaps unintended consequences of taking a diagnosis away?
GREENBERGRight. So nobody really knows. I mean, it's clear it was a good thing to delete homosexuality, but in the case of Asperger's, there are problems. There are many, many people who have derived exactly what Lynn was talking about from their diagnosis. They've also derived benefits from -- educational benefits and therapy benefits and so on, and they have an identity that is very powerful. I mean, Asperger's is probably, in that respect, one of the most successful diagnoses ever to come along.
GREENBERGSo now they're going to remove it, and two things will happen. One of them is that many people who have Asperger's will be reclassified as autistic, which really bothers a lot of Asperger's people. The second thing that will happen is many people who otherwise would have qualified won't qualify, and that's a huge problem. Will some people lose their diagnoses? Will some people lose whenever the diagnosis brought them? And it's been done -- it's not clear why it's been done, but one thing is for sure. When the APA learned that the Asperger's community was upset about losing their diagnosis, they were surprised, which, when you think about it...
NNAMDIWould surprise you.
GREENBERGYes. It's very surprising.
NNAMDITheir surprise surprises me.
NNAMDIGot to take a short break. If you have called, stay on the line. If you haven't yet, the number is 800-433-8850. Do you think there's still a stigma associated with seeking help for mental health issues? 800-433-8850. You can send email to firstname.lastname@example.org. We're talking with Gary Greenberg. He's a practicing psychotherapist. His latest book is called "The Book of Woe: The DSM and the Unmaking of Psychiatry." I'm Kojo Nnamdi.
NNAMDIWelcome back. Our guest is Gary Greenberg. He's a practicing psychotherapist who writes about the intersection of science, politics, and ethics for numerous publications. He's written several books, the latest of which is called "The Book of Woe: The DSM and the Unmaking of Psychiatry." We mentioned Asperger's. Another diagnosis that is not expect today be found in DSM V, a centuries old diagnosis. Some proposed reintroducing in this edition, melancholia, or what does the failure of that proposal tell us about how decisions are made about what to include and what to leave out?
GREENBERGWell, this is an interesting case. The DSM process is a legislative process as much as a scientific process, and it has a lot to do with who's arguing and how they're arguing, and it also has to do with appearances. In the case of melancholia, what happened was that as you say, this ancient version of depression, which is very distinctive was removed in favor of this larger category called general -- I'm sorry, major depressive disorder back in 1980. And these -- a group of scientists, doctors, got together and proposed reestablishing it in the DSM V, because they argued it was a very distinctive diagnostic group.
GREENBERGThey had distinctive symptoms, and there were lab studies, something that's completely missing otherwise from the DSM, that corresponded -- people who had the symptoms tended to show up in certain lab tests in a similar way that distinguished them from the rest of the people in the world, and more interesting, from the rest of the depressed people in the world. So you had this really distinct clinical and physiological entity. In other words, you had an ideal medical diagnosis. It wasn't a hundred percent, but it was a lot closer to a hundred percent than anything else in the DSM.
GREENBERGAnd the people on the work group, at least the one guy they were dealing with on the work group actually agreed with them. He told them he thought they were right, but that it wasn't going to be able to be included in the DSM V, because it would be the only diagnosis with a laboratory component to it, meaning that it would make the rest of the DSM V look bad by comparison. So in other words, it would only show how weak the paradigm was, and on that basis, the proposal wasn't even considered by the committee.
GREENBERGIt never got past this fellow who was sympathetic, but said, look, I cannot sell this. And that sounds a lot like the legislative process to me anyway. It was the politics that undid it, not the science.
NNAMDIOnto the telephones. We start with Jim in Potomac, Md. Jim, you're on the air. Go ahead, please.
JIMHi. I'm a retired psychiatrist, and I can say that I've probably used 10 of the codes or maybe 15 in my practice. It was primarily for billing. It didn't seem to have scientific basis, and especially because I was interested in treating individuals in the context of their families. So I did a lot of couples and family work, and they're -- that doesn't fit the medical model. You can't put a stethoscope on a family, and you can't give a pill to a family, and so that side of psychiatry is dwindling in favor of drugs and things that can be done that look like we're recall doctors.
JIMWe are, and I think neuropsychiatry is an important area, but the humanistic side is dwindling, and we see that with the failure of the American Psychiatric Association, for example, to say anything about advertising of drugs for erectile dysfunction that could be a blood problem -- a circulation problem, but it could be a relationship problem, and 80 percent of the time that's what it is, but there's no interest in interviewing the couple or finding a way to understand that.
NNAMDIHere's Gary Greenberg, Jim.
GREENBERGWell, it seems to me that Jim's comments I've heard many times from -- particularly from psychiatrists. And it seems to me it's important to make this distinction. There's this official manual, and it has many uses for many people, but there are many psychiatrists who use it exactly the way Jim...
GREENBERGBilling purposes. And who not only -- not only that, but as Jim said, they're really concerned about the direction in which psychiatry is moving, which is more and more towards the medical management model, which is probably appropriate for some small number of mentally disordered people, but probably not for the vast majority. And I say probably, the problem is psychiatry has yet to delimit its domain. It has yet to tell us who it really should be treating and who it should be considering sick.
NNAMDIMore than 10 percent of American adults take antidepressants at present, but the connection between a rate of diagnosis and number of prescriptions isn't necessarily what we might think. What's the connection?
GREENBERGAll right. So you -- this is like going down the rabbit hole, right? So we have all this stuff about -- I mean, I've written a whole book about the DSM, and there's all this news about the DSM. In fact, the DSM V may only be a new manual for psychiatrists to ignore, and what we see is that in the case of antidepressants, 72 percent of antidepressant prescriptions are written in the absence of a psychiatric diagnosis. They don't have a make a diagnosis to render a treatment. And so what is actually the relationship between diagnosis and treatment? Well, it isn't direct.
NNAMDIThank you very much for your call, Jim. We move onto Ellen in Fairfax, VA. Ellen, you're on the air. Go ahead, please.
ELLENHi. I had a question about the specific diagnosis of Narcissistic Personality Disorder. I grew up in a very strange household, and it wasn't until I did some research as an adult that I had finally found a name to a problem, and then I found out that there were going to take it out of the DSM, and I was just curious why that would be, and why they take certain things out that seem like not crazy like homosexuality or whatever, or hysteria for example. To me that's a valid diagnosis.
NNAMDIGary? Legislative process?
GREENBERGYes. And in this -- the narcissistic story is a brilliant story. As, you know, what happened was that the APA undertook to revise the entire personality disorder section of the DSM, and the result was chaos and mutiny and it got really ugly. And one of the proposals was indeed to remove narcissistic personality disorder along with four others. So suddenly there would be half as many personality disorders as there used to be.
GREENBERGAnd what happened that was some of the really influential members of the committee had sort of made their careers on Narcissistic Personality Disorder. Now, we'll never know the truth, because the APA claims copyright ownership -- intellectual property ownership of all of the proceedings. They're all confidential, they're all secret, and so we never really will know what happened, but it's very suspicious that we have a lot of people involved with Narcissistic Personality Disorder and the move to get rid of it suddenly was reversed, and so you can be assured that your father, if that's who you said it was, will continue to warrant a label that's officially in the DSM.
NNAMDIWhat do we stand to gain, the public, the profession, if there was transparency to those proceedings?
GREENBERGWell, first of all, history is really important because you never know what you don't know. I don't want to sound like Donald Rumsfeld, but you don't really ever know what you're going to want to know in the future. But another thing we stand to gain is we stand to gain an understanding of just how tentative and provisional these things are. You know, knowledge of that is not antithetical to good medicine.
GREENBERGKnowing that your doctor is uncertain doesn't necessarily mean that you won't feel that he helps you, and in fact, can help you help him help you. So I think we stand to gain knowing exactly how the sausages are made. It helps you decide whether or not to eat them.
NNAMDIHere's David in Arlington, Va. David, you're on the air. Go ahead, please.
DAVIDHi. I just -- I've really been enjoying this program. You're guest sounds like an extremely sensible individual, but I think he needs to be radicalized a little more, and really look at the picture. I think the DSM is all about money and it reflects the manifestation of the general failure of psychology and psychiatry and the confusion that reigns in that field. It's the most unmedical of the medical specialties by far, and I really do think it's all about the money and the psychiatric industry has for over 60 years now ignored will real basis of nonorganic mental illness, which was described in 1950 in "Dianetics." That's all I've got to say.
NNAMDIWell, that's a whole other ball of wax if you're going to bring up L. Ron Hubbard and "Dianetics."
GREENBERGI'd like to comment on part of that.
GREENBERGWhich is that, you know, I've been called an extremist and so on. One of the problems that -- particularly because of the efforts of Scientology, psychiatry has become an extremely paranoid profession, particularly the American Psychiatric Association, and it's very hard to distinguish dissent or disagreement with the APA from what they all antipsychiatry. They're sure that my view and the view of the last caller are exactly the same, and that's a shame. We've lost a lot of nuance here, and...
NNAMDIWell, let's talk a little bit about that, because we don't have much time left, but thanks to advances in medical science, we've come to expect speedy, clear-cut diagnosis, but in the mental -- in mental health, blood tests and body scans don't give us answers. Do we need to some ways to adjust our expectations?
GREENBERGAbsolutely. And I think that's going to be increasingly true of all of medicine. Our idea of what medicines' supposed to do is shaped by developments in the 19th century having to do with discovering germs. I think we've got most of the diseases that are caused by germs, but we continue in physical, and in mental illness, to expect that, and I think as time goes on, that model is not going to work. Psychiatry in this respect may be out ahead of everything else in the sense that it is a leading indicator of diagnostic uncertainty coming down the pike.
NNAMDIIn your experiences, how frustrated are both patients and doctors when it comes to the court of moving targets that diagnoses have become? We only have 30 seconds.
GREENBERGThe doctors are frustrated because it cuts into their ability to -- as Jim said, to feel like real -- they're practicing real medicine. The patients are confused because they're getting medications that they get switched on that don't really work, and there's no apparent reason because psychiatrists aren't really treating mental disorders, they're treating symptoms.
NNAMDIGary Greenberg. He's a practicing psychotherapist who writes about the intersection of science, politics, and ethics for numerous publications. He's written several books. We've been discussing the latest of his books. It's called "The Book of Woe: The DSM and the Unmaking of Psychiatry." Gary Greenberg, thank you for joining us.
GREENBERGWell, it was my pleasure.
NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.
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