The Book of Woe: The DSM and the Unmaking of Psychiatry

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9781452663494: The Book of Woe: The DSM and the Unmaking of Psychiatry
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For more than two years, author and psychotherapist Gary Greenberg has embedded himself in the war that broke out over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM)-the American Psychiatric Association's compendium of mental illnesses and what Greenberg calls "the book of woe."

Since its debut in 1952, the book has been frequently revised, and with each revision, the "official" view on which psychological problems constitute mental illness. Homosexuality, for instance, was a mental illness until 1973, and Asperger's gained recognition in 1994 only to see its status challenged nearly twenty years later. Each revision has created controversy, but the DSM-5, the newest iteration, has shaken psychiatry to its foundations. The APA has taken fire from patients, mental health practitioners, and former members for extending the reach of psychiatry into daily life by encouraging doctors to diagnose more illnesses and prescribe more therapies-often medications whose efficacy is unknown and whose side effects are severe. Critics-including Greenberg-argue that the APA should not have the naming rights to psychological pain or to the hundreds of millions of dollars the organization earns, especially when even the DSM's staunchest defenders acknowledge that the disorders listed in the book are not real illnesses.

Greenberg's account of the history behind the DSM, which has grown from pamphlet-sized to encyclopedic since it was first published, and his behind-the-scenes reporting of the deeply flawed process by which the DSM-5 has been revised is both riveting and disturbing. Anyone who has received a diagnosis of mental disorder, filed a claim with an insurer, or just wondered whether daily troubles qualify as true illness should know how the DSM turns suffering into a commodity and the APA into its own biggest beneficiary. Invaluable and informative, The Book of Woe is bound to spark intense debate among expert and casual listeners alike.

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About the Author:

Gary Greenberg is a practicing psychotherapist in Connecticut and the author of The Noble Lie, as well as a contributing writer to Mother Jones.

Excerpt. Reprinted by permission. All rights reserved.:

Chapter 1

Shortly after New Orleans physician Samuel Cartwright discovered a new disease in 1850, he realized that like all medical pioneers he faced a special burden. “In noticing a disease not heretofore classed among the long list of maladies that man is subject to,” he told a gathering of the Medical Association of Louisiana, “it was necessary to have a new term to express it.” Cartwright could have followed the example of many of his peers and named the malady for himself, but he decided instead to exercise the ancient Greek he’d learned while being educated in Philadelphia. He took two words—drapetes, meaning “runaway slave,” and the more familiar mania—and fashioned drapetomania, “the disease causing Negroes to run away.” The new disease, Cartwright reported in The New Orleans Medical and Surgical Journal, had one diagnostic symptom—“absconding from service”—and a few secondary ones, including a sulkiness and dissatisfaction that appeared just prior to the slaves’ flight. Through careful observations made when he practiced in Maryland, he developed a crude epidemiology and concluded that environmental factors could play a role in the onset of drapetomania.

Two classes of persons were apt to lose their Negroes: those who made themselves too familiar with them, treating them as equals; and on the other hand those who treated them cruelly, denied them the common necessaries of life, neglected to protect them, or frightened them by a blustering manner of approach.

But the most evenhanded treatment would not prevent all cases, and for those whose illness was “without cause,” Cartwright had a prescription: “whipping the devil out of them.”

Lest anyone doubt that drapetomania was a real disease—and, evidently, some Northern doctors did—Cartwright offered proof. First of all, he said, we know that Negroes are descended from the people of Canaan, a name that means “submissive knee-bender,” so it’s clear what God had in mind for the race. And in case a reader subscribed to the notion, taught in the “northern hornbooks in Medicine,” that “the Negro is only a lampblacked white man . . . requiring nothing but liberty and equality—social and political—to wash him white,” Cartwright called as witnesses the prominent European doctors who had “demonstrated, by dissection, so great a difference between the Negro and the white man as to induce the majority of naturalists to refer him to a different species.” Africans’ blood was darker, he said, and “the membranes, tendons, and aponeuroses, so brilliantly white in the Caucasian race, have a livid cloudiness in the African.” This historical and biological evidence, Cartwright concluded, proved that running away is neither willfulness nor the normal human striving for freedom, but illness plain and simple.

Drapetomania was never considered for the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s compendium of mental illnesses, but that may be only because there was no such book in 1850. (Indeed, the Association of Superintendents of American Institutions for the Insane, the organization that eventually became the APA, was only six years old at the time, and the word psychiatry had just come into use.) Certainly it met many of the criteria for inclusion. It was a condition that caused distress for a certain group of people. It had a known and predictable onset, course, and outcome.

Its diagnostic criteria could be listed in clear language that a doctor could use, for instance, to distinguish normal stubbornness from pathological dissatisfaction, or to determine whether a slave was running away because he was sick or just evil. Many people besides Cartwright had observed it. Its discovery was announced in a respected professional journal. Its definition was precise enough to allow other doctors to develop tests that distinguished normal (or, as the DSM puts it, expectable) from disordered dissatisfaction, and to conduct research that confirmed (or didn’t) that most runaway slaves had been sulky prior to absconding, or that slaves treated too familiarly or too cruelly were more likely to contract drapetomania, or that whipping prevented the disease from running its full course. Still other doctors might have recommended potions that would relieve its symptoms. As the years wore on, some doctors might have objected that the disease pathologized a normal response to atrocious conditions, while others might have fought bitterly and publicly over smaller issues: whether or not defiance also belonged on the list of criteria; whether to add Dr. Cartwright’s other discovery, dyaesthesia aethiopica, the malady causing slaves to “slight their work,” to the diagnostic manual; which gene predisposed slaves to drapetomania and dyaesthesia; where the thirst for freedom could be found in the brain; and, perhaps, whether or not these were real illnesses or only constructs useful to understanding what Dr. Cartwright called the “diseases and physical peculiarities of the Negro race.”

Dr. Cartwright’s disease, in short, and the promise it held out—that a widely observed form of suffering with significant impact on individuals and society could be brought under the light of science, named and identified, understood and controlled, and certain thorny moral questions about the nature of slavery sidestepped in the bargain—might have spawned an entire industry. A small one, perhaps, but one that would have no doubt been profitable to slave owners, to doctors, maybe even to slaves grateful for their emancipation from their unnatural lust for freedom—and, above all, to the corporation that owned the right to name and define our psychological troubles, and to sell the book to anyone with the money to buy it and the power to wield its names.



Even if you’re one of the many people who are suspicious of psychiatry and skeptical of its claims to have identified the varieties of our suffering and collected them in a single volume, you might be thinking that I’m not being entirely fair here, that even if the Civil War hadn’t come along ten years later and rendered Cartwright’s outrageous invention moot, doctors would have quickly consigned drapetomania to the dust-bin of medical history. You might point out that even at the time sensible people objected—Frederick Law Olmsted, for instance, whose Journeys and Explorations in the Cotton Kingdom includes a mordant account of “the learned Dr. Cartwright” and his diseases, and the unnamed doctor who satirized Cartwright in the Buffalo Medical Journal by suggesting that drapetomania occurs when “the nervous erythism of the human body is thrown into relations with the magnetic pole . . . thus directing [the slave’s] footsteps northward.” You might say that in introducing a book about the DSM with an anecdote about a diagnosis that is so obviously specious, and in implying that this is somehow emblematic of the diagnostic enterprise, I am taking a cheap shot.

And you may be right.

On the other hand, especially if you are a gay person, you might not be so quick to think that drapetomania is merely a low-hanging cherry that I’ve picked to flavor my tale. Because you might be old enough to remember back forty or fifty years, to a time when homosexuality was still listed in the DSM. Which meant that doctors could get paid to treat it, scientists could search for its causes and cures, employers could shun its victims, and families could urge them to seek help, even as gay people conducted their intimacies in furtive encounters, lived in fear and shame, lost jobs, forwent careers, and chained themselves to marriages they didn’t want. They underwent countless therapies—shocks to the brain and years on the couch, behavior modification and surrogate sex, porn sessions that switched from homo to hetero at the crucial moment—in desperate attempts to become who they could not be and to love whom they could not love, to get free of their own deepest desires, all in the name of getting well. And all this, at least in part, because a society’s revulsion had found expression in the official diagnostic manual of a medical profession, where it gained the imprimatur not of a church or a state, but of science. When doctors said homosexuality was a disease, that was not an opinion, let alone bigotry. It was a fact. When they wrote that fact down in the DSM, it was not a denunciation. It was a diagnosis.

Or maybe you’re among the 11 percent of the U.S. adult population whose daily regimen includes taking a dose or two of Lexapro or Paxil or some other antidepressant, and you’ve been doing that for years, ever since a doctor told you that you had Major Depressive Disorder (or maybe she just said you had clinical depression), meaning that your sulkiness and dissatisfaction were symptoms of a mental disorder, and that this was a chemical imbalance that those drugs would fix. And maybe they did, because at least for a little while you felt better; but then you got tired of feeling numb, of gaining weight, of not wanting sex and not being able to have an orgasm even if you did; and then you tried to get off the drugs only to find that your brain off drugs is an unruly thing, that your old difficulties returned or new ones arose when you stopped taking them. Which might mean, you told yourself, that you indeed have that disease, but every once in a while—when you read about the placebo effect, or you hear that this chemical imbalance does not, as far as doctors know, really exist, or when you look at the DSM and realize that there are more than seventy combinations of symptoms that can result in this one diagnosis and that any two people with the diagnosis may have only one symptom in common—you wonder whether what your doctor told you is true and whether you have now changed your brain chemistry, perhaps irreversibly, to cure a disease that doesn’t exist.

Or maybe you’re a parent of a child who drove you to despair with his tantrums and defiance, whom you took to doctor after doctor until finally you found the one who told you that he had Bipolar Disorder, but that this was really good news, because that disease could be cured with a daily dose of Depakote or Risperdal. And sure enough, your kid calmed down, but now he weighs twice what he should and there’s sugar in his urine and dark circles under his eyes, and you’re beginning to think—especially since you heard about how drug industry money influenced doctors to make that diagnosis and how pharmaceutical companies still haven’t fully tested these drugs on children and how doctors massaged those diagnostic criteria to fit your kid—that maybe your psychiatrist was wrong when he said that Bipolar Disorder is the same kind of disease as diabetes, a chemical problem that you leave untreated only if you are a bad parent.

Or maybe you’re like me—a mental health professional who has been faithfully filling out insurance forms for thirty years, jotting down those five-digit codes from the DSM that open the money taps, rendering diagnoses even though you are pretty sure you’re not treating medical conditions, and for just a moment you hesitate, contemplating the bad faith of pouring a lie into the foundation of a relationship whose main and perhaps only value is that it provides an opportunity to look someone in the eye and, without fear of judgment or the necessity to manipulate, speak the truth. And, having contemplated it, you tell yourself whatever story you have to and you sign the paper, and the best you can do is to curse the DSM in a kind of incantation against your own bad faith.

Or maybe you’ve never had truck with the mental health industry, but the other day you were talking with a friend and explaining to her that you had to wash your dishes before you could leave your house, and you found yourself saying, “I’m just so OCD, you know?” Or you’ve heard your friends do the same thing with their own or others’ quirks. “He’s pretty ADHD,” they might say. Or, “She’s clinically depressed.” Or, “Sorry, that’s just my PTSD.” And maybe you’ve been brought up short by the way the DSM’s lingo has infiltrated our self-understanding or wondered what it says about us that we describe the habits of our hearts in a pastiche of medical clichés.

If you are one of those people, which is to say if you have had occasion to take the DSM seriously (and even the book’s most ardent defenders will tell you this was your first mistake), then you may be sympathetic to my rhetorical move. You may understand that Dr. Cartwright did what he did because he could, because the power to give names to our pain is a mighty thing and easy to abuse. Cartwright seems to have intended to serve the interests of slave owners and white supremacists and their economic system by providing “another [of ] the ten thousand evidences of the fallacy of the dogma abolition is built on,” but surely the doctors who insisted that homosexuality was a disease were not all bigots or prudes. Nor are the doctors who today diagnose with Hoarding Disorder people who fill their homes with newspapers and empty pickle jars, but leave undiagnosed those who amass billions of dollars while other people starve, merely toadying to the wealthy. They don’t mean to turn the suffering inflicted by our own peculiar institutions, the depression and anxiety spawned by the displacements of late capitalism and postmodernity, into markets for a criminally avaricious pharmaceutical industry.

The prejudices and fallacies behind psychiatric diagnoses, and even the interests they serve, are as invisible to all of us, doctors and patients alike, as they were to Dr. Cartwright’s New Orleanian colleagues or to all those doctors who “treated” homosexuals. The desire to relieve suffering can pull a veil over our eyes. And sometimes it takes an incendiary example or two to rip that veil away. So I apologize for my cheap shot. I apologize to the epidemiologists and sociologists alarmed by ever-rising rates of mental illness and disability; and to the patients who have benefited from a diagnosis; and to the interested civilians who have the intuition that there is such a thing as mental illness, that it belongs under the purview of medicine and that as such it ought to be cataloged, whatever the difficulties; and to the doctors who can argue cogently that the advantages of doing so far outweigh the costs. I apologize to the reasonable folks who think, reasonably, that the DSM is the culmination of a lot of honest hard work by smart and well-intentioned people doing their best at an impossible task, and that it should be given the benefit of the doubt. I apologize to the people who acknowledge that even if the DSM is not the Bible it’s cracked up to be, it still, as the backbone of a medical specialty that has done yeoman service, deserves its authority over our inner lives.

But that doesn’t mean I’m sorry. By apologize, I mean what the ancient Greeks meant. I mean to explain. Because I think drapetomania is not a historical novelty or an anomaly or an accident. It is not the exceptional error that proves the rule that science is self-correcting and will ultimately punish arrogance and incompetence. The story of drapetomania is a cautionary tale, just as the ones about homosexuality and childhood Bip...

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