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In search of a way to diagnose mental disorders — and to make money

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“All of our provisional ideas in psychology will presumably one day be based on an organic substructure,” Sigmund Freud wrote. By clarifying the biological foundations of the symptoms of mental disorders, science would be able to find the appropriate description of and treatment for specific illnesses. For most of the 20th century, though, clinicians didn’t worry too much about precise classification; most patients sought treatment for combinations of depression, anxiety and other forms of distress. But by the 1970s the classificatory impulse as a vehicle for scientific legitimacy came to the fore. In “DSM: A History of Psychiatry’s Bible,” Allan V. Horwitz tells the story of how the third incarnation of the Diagnostic and Statistical Manual of Mental Disorders revolutionized our understanding of psychological suffering. As with so many revolutions, it’s a cautionary tale.

The manual sold well and seemed to convince many, but, as so often happens with revolutionaries, the creators of DSM-III were in turn overthrown by a new generation of researchers with a different agenda. Each group of changemakers thinks it is being scientific, but, as Horwitz’s subtitle suggests, they are more like fundamentalists trying to convert others to their way of seeing the world. And just as learning about the history of the texts that compose the Bible makes it harder to take the Good Book seriously as the literal word of God, so reading this history of how the DSM was put together makes it harder to sustain faith in scientific progress in psychiatry.

In this history, as in his 2013 book on the concept of anxiety, Horwitz emphasizes the social construction of scientific concepts. This account underscores the economic incentives in play as psychiatrists tried to reach consensus on how to describe specific disorders so that they could treat them — and be paid well to do so. If these clinicians were going to live up to their medical credentials, the thinking went, they should be able to prescribe medications for a specific disease regardless of the particular circumstances of the person who had it. Treat the disease and not the patient. The problem is, says Horwitz, an emeritus professor of sociology at Rutgers University, “almost all psychotropic drugs do not work specifically for particular DSM mental disorders.” But there was money to be made in making it seem like they did.

Published in 1980, the DSM-III seemed to summarize the best science of the time, but Horwitz’s account of how the sausage got made is, while restrained, damning. Two of the most important diagnostic categories were particularly incoherent. Major depressive disorder became a popular vehicle for diagnosing patients so that one could prescribe medications for them, but how this condition was different from others like anxiety disorder, or crushing sadness because of intense loss, was never made clear. And post-traumatic stress disorder was included in the manual because people suffering in the wake of horrible events demanded it be so. If your symptoms weren’t recognized as a particular disease, then your insurance wouldn’t pay for help, and many people lobbied hard for PTSD. Although the psychiatric establishment hoped to make the particular life stories of patients irrelevant in determining their disorders, this was impossible with PTSD. Every trauma, after all, has a particular context. In subsequent DSM revisions, the “criteria for traumatic exposure were so expansive that they encompassed virtually everyone,” Horwitz writes. And so the “trauma industry” was born.

Psychiatry’s bible wasn’t relevant only to doctors; patients “acquired a new language to interpret their distressing experiences and explain their emotional lives.” The manual also influenced the development of drugs and how they were marketed. The DSM categorizes distress, which can then be linked to a prescribed remedy. (That is, until the popularity — or the patent — of the drug expires, after which a new wonder remedy is marketed for people needing a way to ease their suffering or change their lives.) What was once shyness, for example, gets coded as social anxiety disorder. There’s a drug for that, of course. The most egregious example of marketing to create a demand for a diagnosis was in DSM-IV’s description of bipolar disorders, especially in children (who can become lifelong customers). “The common denominator among youth treated for this condition,” Horwitz notes, “seems to be that their conduct is extremely disturbing to their parents or teachers.”

DSM-III and subsequent revisions (III-R and IV) revolutionized the treatment of mental illness in the United States — and made lots of money for the American Psychiatric Association, which owned the publications. Surprising almost everyone, the DSM-III-R sold more than 1 million copies, and revenue from subsequent revisions became a “financial pillar” of the organization. When it came time to create DSM-V, a new group of researchers wanted to put diagnoses on a genetic basis, or at least at the level of the brain. Would Freud’s prediction of an “organic substructure” at long last be realized? Even as those who worked on the project trumpeted transparency, they signed nondisclosure agreements, making it difficult to trace conflicts of interest. Despite their efforts, research has revealed that most members of the work groups for DSM-V had financial ties to the drug industry. But their attempt to link specific disorders to specific genes was a failure. General genetic vulnerabilities can be found, but (as clinicians knew 100 years ago) this vulnerability is expressed differently in different contexts. Steven Hyman, then director of the National Institute of Mental Health, called the manual “an absolute scientific nightmare.”

“Context is an intrinsic aspect of deciding what a mental disorder is or is not,” Horwitz writes. It is also an intrinsic aspect of understanding cultural artifacts, like the DSMs. When we look at the context for these manuals, we see that there has been little progress in psychiatric diagnosis, except that we now diagnose a lot more behavior as needing treatment than we did before.


A History of Psychiatry’s Bible

By Allan V. Horwitz

Johns Hopkins University.
215 pp. $35