Shrinks (38 page)

Meanwhile, the Internet was still teeming with accusations. One of the most prominent was the claim that the
DSM-5
was pathologizing normal behavior. Ironically, the pathologization of the ordinary had been one of Robert Spitzer’s most pointed criticisms of the psychoanalysts, who quite explicitly talked about the psychopathology of everyday life and argued that everyone was a little mentally ill. One of the great contributions of Spitzer and the
DSM-III
was to draw a bright, clear line between the mentally ill and the mentally well, and even within the chaos of the
DSM-5
that division was being adhered to.

Most of the invective about pathologizing normal behavior was provoked by diagnoses that sounded trivial or sexist to casual observers, such as hoarding disorder, binge eating disorder, and premenstrual dysphoric disorder. Yet the case for designating each of these conditions a disorder was supported by data or extensive clinical experience. Take hoarding disorder, one of the new entries in the
DSM-5
. This condition is associated with the compulsive inability to throw things away, to the point where detritus obstructs one’s living environment and substantially reduces the quality of one’s life. Though we all know pack rats who are reluctant to throw away old items, individuals suffering from hoarding disorder often accumulate so much
stuff
that the looming heaps of debris can present a serious health hazard.

I once treated an affluent middle-aged woman who lived in a spacious apartment on the Upper East Side of Manhattan but could barely open the door to get into or out of her apartment because of the wobbly towers of accumulated newspapers, pet magazines, unopened purchases from cable shopping networks, and accouterments for her nine cats. Finally she was threatened with eviction when neighbors complained of the foul odors and vermin emanating from her unit. Her family hospitalized her, and she was treated for the first time in her life for her hoarding disorder. Three weeks later, she was discharged and returned home to a pristine apartment that her family had cleaned out. She now takes clomipramine (a tricyclic antidepressant often used to treat obsessive-compulsive disorder) and receives cognitive-behavioral therapy to help her manage her impulses. So far, she lives a much happier life in her clean and roomy apartment, with no complaints from her neighbors or family.

As someone intimately involved with the
DSM-5
development process, I can tell you that there is no institutional interest in expanding the scope of psychiatry by inventing more disorders or making it easier to qualify for a diagnosis. We have more patients than we can possibly handle within our current mental health care system, and we already face enough challenges trying to get insurance companies to reimburse us for treating diagnoses that have been established for decades. Perhaps the strongest piece of evidence that psychiatry is not trying to pathologize ordinary behaviors can be found in the changing number of diagnoses: the
DSM-IV
had 297. The
DSM-5
reduced it to 265.

When I became president-elect of the APA in the spring of 2012, I inherited the responsibility for the
DSM-5
. It would be completed and published during my term, and its success—or failure—would play out on my watch. I was somewhat consoled by the fact that the ad hoc committees established by my predecessors had been effective and had substantially improved the
DSM
development process. The internal grumbling had ceased, a clear and rigorous process for creating or changing disorders was established, and most important, each tentative set of diagnostic criteria was accumulating more evidence and undergoing more deliberation than during any previous
DSM
.

In the final six months before the
DSM-5
was to be presented to the APA Assembly for a vote, APA president Dilip Jeste and I set up a systematic “Summit” process to conduct a final review and approve or reject every proposed disorder. The final set of approved diagnoses would then be presented en masse to the APA Assembly, just as occurred with Spitzer’s
DSM-III
thirty years earlier. Representatives of the Task Force, work groups, and committees all participated, and every one of us knew exactly what was at stake: the credibility of psychiatry in the twenty-first century, and the welfare of every patient whose life would be affected by the decisions we made.

During the Summit review process, we always sought consensus. If there was not clear scientific evidence or a compelling clinical rationale supporting a new diagnosis or a revision to an existing diagnosis, then the version in the
DSM-IV
was left unchanged. The majority of the disorders were approved without controversy, though there was heated debate over personality disorders—a perennial source of contention among psychiatrists with roots in Freud’s earliest psychoanalytical theories. There were also disagreements about whether to include a new diagnosis for children called “disruptive mood dysregulation disorder”; whether someone could be diagnosed with depression while still grieving the death of a loved one; and whether the criteria for schizophrenia should be modified. These three changes were eventually approved, though the newly proposed configuration of personality disorders was not.

Finally November 10, 2012, arrived—the day of the
DSM-5
vote. The APA Assembly convened in the JW Marriott in Washington, DC, exactly two blocks from the White House, less than a week after Barack Obama had won the right to reside there for another four years. After all of the thunderous controversy over the
DSM-5
online and in the media, when the final vote to approve it came, it was downright anticlimactic. There was very little discussion on the floor of the ballroom, and the vote itself was quick and unanimous, a far cry from the frenzied activities and last-ditch efforts to rework the
DSM-III
.

The
DSM-5
was published on May 19, 2013, concluding the longest period of development of any
DSM
(seven years) and the longest period between
DSM
editions (nineteen years). But this delay was not so much due to the controversy and unwieldy process as it was a reflection of the unprecedented scope of work that went into the
DSM-5
’s development. The new edition of the Bible of Psychiatry incorporated more data, evidence, and discussion than the previous four editions combined: 163 experts, including psychiatrists, psychologists, sociologists, nurses, and consumer advocates, devoted more than one hundred thousand hours of work, reviewed tens of thousands of papers, and obtained input on diagnostic criteria from hundreds of active clinicians. Except for the chair and vice chair, none of these contributors received any payment for their efforts.

Despite all the drama, fear, and ambition that played out during the creation of the
DSM-5
, the final product ultimately proved to be a rather modest revision of the
DSM-IV
. It retained most of the elements that Spitzer introduced in his transformative edition, including his basic definition of mental illness as a consistent and enduring pattern of symptoms that causes subjective distress or impairment of functioning.

After its launch, Jeste wrote, “the successful publication of the diagnostic manual—on a tight deadline and in the face of massive public scrutiny—is an unqualified victory for psychiatry. In May of 2012 it looked like it would be a difficult task, and there were articles appearing in the press, mostly critical. We responded to the criticism in a very constructive way, without bashing the critics. If it had not gone well, it could have been a black eye, not just for APA, but the profession of psychiatry. This has to be the most reviewed diagnostic system in the history of medicine. I think we should all take pride in this remarkable achievement.”

You can count me among those who take pride in the result. But for others, the final product was a severe disappointment. Just as the
DSM-5
was being launched, the director of the National Institute of Mental Health posted a highly critical blog that caused the greatest
DSM
media uproar of them all. While Tom Insel’s condemnation of the digital-age
DSM
appeared to threaten psychiatry’s integrity yet again, his challenge provided an opportunity to demonstrate the true strength and resilience of contemporary psychiatry.

Toward a Pluralistic Psychiatry

In his April 29, 2013, blog, the top government psychiatrist and director of the world’s largest funder of psychiatric research declared, “Patients with mental disorders deserve better than the
DSM-5
. That is why NIMH will be re-orienting its research away from
DSM
categories.” Tom Insel’s broadside immediately went viral, and the media reported his declaration as an official rejection of the
DSM
by the NIMH. Insel seemed to be announcing to the world that psychiatry’s diagnoses were not scientifically sound. In place of the
DSM-5
, Insel advocated the creation of a new diagnostic system based upon genetics, neurobiology, brain circuits, and biomarkers.

Insel was expressing the perpetual dream of biological psychiatry to establish neural definitions of psychopathology, as first articulated by Wilhelm Griesinger and his German cohorts a century and a half ago. As we’ve observed over psychiatry’s two centuries of history, however, most attempts at providing a biological accounting of mental illness have been stymied. Griesinger himself failed, Kraepelin turned to symptoms and illness course in frustration, Freud appreciated the futility and developed psychoanalysis, Egas Moniz’s lobotomy-justifying theory of functional fixations failed, John Cade’s toxin theory of mania failed, the mauve and pink spots of the chromatography psychiatrists failed. The only undisputed biological explanations of the origins of a mental illness are for General Paresis of the Insane (caused by the syphilis bacteria), pellagra (a form of dementia caused by vitamin B-12 deficiency), and more recently Alzheimer and other forms of dementia and drug-induced psychoses. We have a reasonable understanding of how addiction and post-traumatic stress disorder develop in the brain, though we still have much to learn. While biological psychiatry has uncovered tantalizing clues, if we survey the entire history of psychiatry, we find that biological theories of mental illness have tended to fare no better or worse than psychodynamic theories, with neither school of thought yet providing a convincing accounting of the precise origins of schizophrenia, depression, or anxiety and bipolar disorders. If we’ve learned anything from the repeated pendulum swings back and forth between brain and mind, it’s that any narrow perspective on mental illness usually proves to be inadequate to account for the complexity that is mental illness.

Ironically, sixty years before NIMH director Tom Insel blogged about the need to embrace a purely biological psychiatry, the first director of the NIMH, Robert Felix, denounced biological psychiatry and declared that NIMH would not fund any biological research (a promise he regrettably made good on). Instead, Felix urged psychiatrists to focus on social pathologies like poverty, racism, and family strife. Later, as psychiatry’s pendulum began to swing back toward the brain in the early 1980s, propelled by advances in imaging, genetics, and neuroscience, the chair of psychiatry at Yale, Morton Reiser, remarked, “We are going from a brainless psychiatry to a mindless psychiatry.”

Robert Spitzer’s genius was to remain agnostic on the question of whether the biological or psychodynamic camp had more to offer, and he created a diagnostic framework that could incorporate research from both perspectives—or neither. The reason that genetics, neurobiology, brain circuits, and biomarkers are absent from
DSM-5
diagnoses is that there was not yet enough evidence to support their inclusion, and not because of some kind of oversight, theoretical bias, or deliberate rejection of biological psychiatry. Rather, it was a reflection of a responsible and mature view of mental illness embodied in the
DSM
’s dispassionate attitude toward psychiatric theorizing. Ultimately it was the empirical data that mattered, as recalcitrant or uninnovative or same-old as that data might be.

The wild conceptual gyrations throughout the history of psychiatry underscore the value of Spitzer’s open-minded agnosticism, since psychiatry has always fared best when it managed to avoid both extremes of reductionist neurobiology and pure mentalism, instead pursuing a path of moderation that is receptive to findings from all empirically based sources. Though it’s still possible to find individual psychiatrists today who adhere exclusively to a psychodynamic, biological, or sociological perspective, the field of psychiatry as a whole has come to realize that the best way to understand and treat mental illness is by simultaneously addressing the mind
and
the brain.