Manufacturing depression (34 page)

Katz even tried manipulating how much information he gave the doctors. He had a film of a “clearly depressed” woman in her fifties who, because she had had a manic episode, seemed to have an obvious case of manic-depressive psychosis. He showed one group of psychiatrists a version of the movie in which her history of mania was edited out. Those doctors came up evenly divided about whether she was psychotic or neurotically or involutionally depressed. When he showed the whole movie to the other group, despite what he thought would be a slam-dunk for a manic-depression diagnosis, the vote was again split; even when they were telegraphed the desired answer, only half the psychiatrists got it right.

The bad news was compounded when Katz showed the interview to a group of British doctors. Only one thought the patient was psychotic, seven that she was neurotic, nineteen went with personality disorder, and four split their tickets, voting for
mixed diagnosis
. This study, along with others that specifically investigated schizophrenia and manic-depressive illness, helped to explain a mystery brewing since the late 1950s, when epidemiological studies showed that
manic depression was much more common
in Great Britain than schizophrenia, while the reverse was true in the United States. It turned out that the diagnostic problem wasn’t a result of, say, the differing genetic stocks of the two countries or their different approaches to childrearing. It wasn’t in the patients at all, but in the doctors. Something in their educations, their training, perhaps
even their countries’ differing cultures made transatlantic psychiatry a profession divided by a common language.

The difficulty that doctors had agreeing on the meaning of the words they were using not only worried them; it made them feel inadequate.
“There is a terrible sense of shame
among psychiatrists,” one of them wrote, “always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.” They might have kept their shame in the closet, however, had it not been for some of their colleagues who were tired of remaining in a closet of their own. In 1970, gay psychiatrists began to object loudly to the fact that their sexual orientation was considered a mental illness. Emboldened by the activism (and by the sexual revolution) of the sixties,
they disrupted APA meetings
around the country, picketing and protesting, sitting in to demand that homosexuality be deleted from the DSM, then in its second edition. At one annual meeting, a masked man appeared at a panel discussion and announced that he was both gay and a psychiatrist and that there were at least two hundred others like him at the convention. Donnybrooks like this could not help but attract widespread media attention.

After bruising and embarrassingly public bureaucratic battles,
the protestors got what they wanted
. In April 1973, an APA committee recommended deleting homosexuality from the DSM, then in its second edition. As part of the decision, the APA nominated a new disease, ego-dystonic homosexuality, which occurs when a gay person is distressed by his or her sexual orientation. Later that year, the APA’s board of trustees voted in these changes to the DSM-II. In 1974, after a rearguard action had forced a referendum, a majority (58 percent) of the voting membership ratified the decision. This may have been the first time in history that a disease was eradicated at the ballot box.

Some psychiatrists, mostly those who opposed deletion, pointed out the obvious problem raised by this solution.
“Referenda on matters of science
makes [
sic
] no sense,” said one dissenter.
“If groups of people march
and raise enough hell,” another observed, “they
can change anything in time…Will schizophrenia be next?” These doctors understood that they were dealing with a much different problem from the one uncovered by Katz. It was one thing to say that psychiatrists couldn’t agree on which illness a given patient had, that, in the parlance of experimental science, diagnosis was not
reliable
. But it was another matter entirely to say that even when psychiatrists achieved reliability, the diagnosis they rendered was not
valid
because the condition in question was not a disease. The lack of reliability may have been shameful, but it was correctable; all that was needed, most thought, was a tightening of standards, better education, more research. But the validity problem was a downright disaster. What kind of doctor doesn’t know the difference between sickness and health?

The answer, it seemed, was psychiatrists. And as humiliating as they might have found their lack of reliability, the possibility that the best they could do was to reliably diagnose illnesses that didn’t really exist was even worse.

Some psychiatrists had noticed the validity problem long before gay people started raising hell—notably Britain’s R. D. Laing and Thomas Szasz, an American.
Laing focused on schizophrenia
, which he argued was the result of people finding themselves in a social environment that didn’t make sense to them; the insane place in which they were sane was not an asylum but a world filled with nuclear weapons, economic exploitation, ecological degradation. Szasz, less explicitly political, had a different idea, one that was less fanciful but that struck closer to the heart of the validity question. Psychiatric problems are not medical problems at all, he argued in
The Myth of Mental Illness,
but
“problems of living.”
This didn’t mean that people shouldn’t seek therapy or that therapists did not provide a valuable service. But that service was not, properly speaking, a medical one, the illnesses psychiatrists claimed to treat were not valid, and most of their patients were not, strictly speaking, sick.

Psychiatrists may have hoped that deleting homosexuality from the DSM would strengthen their validity case—the fact that they had read an impostor out of the kingdom overshadowing the fact that he’d slipped past the gatekeepers in the first place—and that better training would solve the reliability problem, but their important patrons saw it differently. A 1978 presidential commission with influence over federal funding decisions warned that
“documenting the total number of people
who have mental health problems…is difficult not only because opinions vary on how mental health and mental illness should be defined, but also because the available data are often inadequate or misleading.” In 1975, a Blue Cross executive told
Psychiatric News
that his industry was reducing mental health treatment benefits because “compared to other types of services, there is less clarity and uniformity of terminology concerning mental diagnoses,” and added that because “only the therapist and the patient have direct knowledge of what services were provided and why,” the insurers couldn’t be sure they were even paying for the treatment of an illness.

To make matters even worse for psychiatrists, all kinds of non-medical professionals—social workers, psychologists, counselors, even nurses—were claiming (and getting) the right to deliver psychotherapy services. This was an indication that Freud had been correct about lay analysis, and that whatever else therapy was, it wasn’t strictly speaking medicine. The diagnosis was obvious, the prognosis grave: as the president of the APA put it in 1976, the biopsychosocial model,
“carrying psychiatrists on a mission
to change the world, had brought the profession to the edge of extinction.”

The second edition of the DSM appeared in 1968. The spiral-bound 132-page manual tried to be user-friendly. It offered a handy listing, in numerical order, of all 158 official mental illnesses, a set of sample tables for clinicians who might wish to keep track of their diagnostic habits, and even a postage-paid card on which users could
send “criticisms and recommendations” back to the APA. The book also included, as its last chapter, “A Guide to the New Nomenclature,” which explained, among other things, how this edition differed from the earlier one. Of particular note was the elimination of the word
reaction
from the diagnostic labels.
Schizophrenic reaction
had become
schizophrenia
,
manic-depressive reaction
was now
manic-depressive illness
,
depressive reaction
had been rechristened
depressive neurosis,
and so on. This explanation came with a reassurance.
“Some individuals may interpret
this change as a return to a Kraepelinian way of thinking, which views mental disorders as fixed disease entities,” the authors wrote. “Actually, this was not the intent of the APA Committee on Nomenclature and Statistics.”

It’s possible that Robert Spitzer, lead author of the chapter, really meant that Kraepelin was the farthest thing from his mind and only subsequently came to see the old German’s wisdom. Or that he was splitting hairs by writing about the committee’s intent while remaining silent on his own; he, after all, was only a consultant to the committee. Or that his denial was, as any psychoanalyst would suspect, an unconscious affirmation of his wishes, his protestations of peaceful intent really a warning of impending hostility. But this much is certain: when the smoke cleared twelve years later to reveal Spitzer’s magnum opus, the DSM-III, with its more than 225 diagnoses, its symptom lists, and its differential diagnoses (and no comment card), psychiatry had indeed returned to a Kraepelinian way of thinking. It had also, not coincidentally, been plucked from the precipice and restored to respectability—although
some argued, and continue to argue
, that Spitzer had destroyed the profession in order to save it.

Spitzer’s affinity for Kraepelin might well have been personal. They shared a distrust of inner life, saw it as too raw and unruly to be of much use to doctors. The reasons for their antipathy differed, however. While Kraepelin thought the patients were untrustworthy, for Spitzer the doctor was the culprit.
“I was uncomfortable with not knowing
what to do with their messiness,” he once said. “I
don’t think I was uncomfortable listening and empathizing—I just didn’t know what the hell to do.”

Spitzer did know what to do about diagnostic messiness. The problem was obvious. A manual that defined, say,
depressive neurosis
, as “an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object” was bound to get its users into trouble. What’s a neurosis? What does
depression
mean? Isn’t that the term the diagnosis is supposed to define? How much of it is excessive and how should that be measured? And what is the guarantee that one clinician’s internal conflict or identifiable event will match another’s, or that the same patient will provide the same story to two different therapists? Too much depended on the rendering of inner life into language, the ineffability of the one compounded by the approximations of the other, and both entirely dependent on a prior theoretical understanding of how the mind worked.

The solution was also obvious. As Kraepelin had discovered, there’s no need to go on a Nantucket sleighride while the patient—who is, after all, sick in the head—sounds his woes. A doctor is much better off with pure description of what he sees and hears, which is presumably what any other person with trained eyes and ears will see and hear. If you want reliability, in other words, you have to stick with observation; a mental illness is no more or less than the group of symptoms that a careful observer has noted—perhaps by sorting index cards—to occur together.

That’s not the kind of psychiatry Spitzer had learned while training at the Columbia Psychoanalytic Institute. If the Kraepelinian approach had come up at all, it would have been as a cautionary case, an example of how
not
to eliminate messiness in service of an account of suffering that, while tidy, does not get at the real nature of the problem. Psychiatry had, or so its practitioners thought, long ago left Kraepelin’s therapeutic nihilism and dry categorizing behind in favor of the Freudian/Meyerian synthesis, its promise that with a little hard work and introspection, and a great deal of money, suffering could be treated at its source in the mind.

Which is why Spitzer, in perhaps his first act of what he would come to call “nosological diplomacy,” had to issue his denials in the first place. He knew that
reaction
was central to the way that psychiatrists viewed and assessed mental illness—as the various, highly individualized ways that mental disorder manifests itself when a dynamic psyche is exposed to a traumatic environment. To eliminate that word was to eliminate an entire view of suffering—and, by extension, of human nature. But, Spitzer protested, nothing could have been farther from the committee’s mind. To the contrary, it had only purged
reaction
as part of an
overall attempt “to avoid terms
which carry with them
implications
regarding either the nature of a disorder or its causes” (emphasis in original). The problem with
reaction
was that it implied both nature and causes: that mental disorder was the result of “Man in transaction with his universe,” as Karl Menninger had put it, that there was a healthy way of conducting that transaction, and that psychiatrists knew what it was. These notions didn’t pass scientific muster. If psychiatry wanted to remain in the scientific camp,
reaction
and all its attendant metaphysics would have to go.

Editing a single word out of the DSM proved much easier than eradicating the idea that our discontents are the result of the interaction between psyche and world, and the committee’s reassurances that they meant no harm did not buy off professional resistance forever. But by the time the battle was joined, Spitzer had a huge advantage. Up until the mid-1970s diagnostics was a sleepy backwater of psychiatry, a subject of interest to most doctors only as the key to the insurance treasury,
its professional discussions relegated
(according to Spitzer) to poorly attended late afternoon sessions at professional meetings. While his colleagues were getting a head start on cocktail hour, however, Spitzer and a small group of researchers were busy at work, creating a reliable nosology. And when it came time to write a third edition of the DSM, in the late 1970s, these doctors were ready with their diagnostic criteria—lists of observable symptoms, cleansed, presumably, of any ontological
implications, that would define mental illnesses in a way that was reliable.