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

This book starts in 1851, with Samuel Cartwright's proposal of a new psychiatric disorder: drapetomania, or, runaway slave disorder. Slaves, he said, run away not because they quite naturally want human freedom, but because they suffer from a disorder. Of course, I don't want to give the impression that Book of Woe is an argument based on ad hominem. It is not. But the point of this story is revealing: even if Cartwright got it wrong, there is no way to tell how he got it wrong. Psychiatric disorders (at this stage of the game) are largely diagnosed by reference to behaviors, and often involve some normative judgment (that we classify as disorders only behavior clusters we think are bad in some way). And if there is a message to the book, it is that knowing whether a trait (a slave's urge to run away) is just a behavior or a disorder is much more an art than a science, even though we try to make it look like a science.Now, I am not a conspiracy guy, and as far as I can tell, neither is Gary Greenberg. But this book - which takes us through the writing of the DSMII, III, IV, and mostly 5 (yes, they switched from roman to arabic numerals so that they could allow for revisions expressed in decimal points) suggests that how the DSM's have been constructed look a lot less like science and more like a social construction of something. How many sciences do you know that decide to call for a scientific revolution by committee? How many do you know hold their deliberations on the results of experiments behind closed doors with orders from members not to disclose - even to colleagues - the discussions? (The folks at the AMA apparently explained this by saying that they did not want outside influence on the groups deliberating on new classifications for disorders, but that still doesn't seem like how most sciences do it.) How many sciences do you know copyright their results so that no one but their professional organization can publish them without permission? And how many do you know spend a lot of time hankering over what name for a theory will go over best with psychiatrists and the general public (we can call it either temper dysregulation disorder, or disruptive mood dysregulation disorder)?Anyhow, the book spends most of its time as a narrative of how the DSM5 was written. Basically, the APA realized (in 2007) the huge potential that neurology could have in the diangosing of disorders, where before, disorders were almost exclusively based on observing behaviors. So, they called meetings with the intent to create the DSM5 out of the DSMIV. Now, as I said before, the fact that no other science calls meetings to force a breakthrough quite the way the APA was doing, but still... Greenwald follows several figures who have been involved with the process with either (or both) the creation of the DSMIV and DSM5, focusing disproportionately on critics like Eliot Spitzer and Allen Frances, and their attempts to convince the world of psychiatry that while psychiatry was necessary - this is not Thomas Szasz or Scientology - the DSM made psychiatry look more like a science that, at this point, it is.The most interesting chapters, I thought, were the last 7 or so, which focused on some of the skirmishes that resulted from the creation of the DSM5. Controversies include whether Major Depressive Disorder requires only 2 weeks of depression or 5, whether it should include people grieving deaths of loved ones, whether Aspergers Syndrome was or should be its own separate classification (or just placed on the Autism Spectrum), whether Gender Identity Disorder is a disorder that needs treating or a state of mind that doesn't, and whether Temper Dysregulation Disorder should be renamed. All of these, of course, highlight the highly social and somewhat unscientific ways these decisions are arrived at.Again, though, I want to stress that this is not reading Thomas Szasz or R.D. Laing. This is not a work of anti--psychiatry or a conspiracy theory about how psychiatrists aspire to social control (though Greenberg is aware that the latter is always a possibility). Rather, Greenburg's history is supposed to cause us to question whether the DSM deserves the status of being a scientific work of classification. In some sense, it is the same theme is discussing whether Drapetomania (or homosexuality) can ever SCIENTIFICALLY be called a disorder, or whether calling either a disorder has more to do with elements of judgment that may never yield fully to their scientific aspirations.

Gary Greenberg gets it right and dishes it out on a sumptuous platter of history with a whole lotta gentle direct humor woven through his very exposing/disclosing book. In a down to earth readable style (not psychedelic, psychiatric, psycho, academic bureaucratic mumble jumble jargon) he's drawn the curtain back and exposed the Wizard of Id? Or maybe the Wizard of Ego? The Wizard of War? The DSM-5; a book written by committee; members who sit around a table every so many years and make up stuff, a book that has no scientific basis.We had to study the Diagnostic and Statistical Manual (DSM) when I was in graduate school (and who didn't like looking up what was wrong with their family members and self-diagnosing themselves?). It's merely a checklist of symptoms, not causation, not a mental health diagnosis, not a scientific diagnosis, not a medical diagnosis. "Check, check, check, check." "OK now this is who you are." Then a few years down the line: "Check, check, oh?" "OK now you're not that anymore".And it's very political. "Combat fatigue" was taken out at the height of the Vietnam War. It was veterans who studied then lobbied to get "post traumatic stress" in not only for themselves but also for children who were horribly abused. That is a label that at least speaks to causation. Then homosexuals lobbied to get "homosexuality" out, now "transgendered" want to be kept in.Greenberg lays out the history of the DSM, it's pioneering characters including its subsequent characters who now say "oops", but to his credit the author exposes the story and the behind the scenes of the story, treats the history in a respectful but direct way using humor; making them into people, not gurus who have the holy seeing as to who you are based on a checklist.I didn't know until reading Greenberg's book that out of the history of slavery came one of the first sort of DSM labels. That slaves running away was a mental disorder. If that doesn't say it all about so-called mental illness. If you don't accept the horrible conditions of your life you are mentally ill! "Now take these drugs!" In the new DSM book, in the DSM-5 if you grieve longer than two weeks for a loved one's death you are officially mentally ill.Greenberg lays out the money issue as to why now? Why now revamp the DSM? Why now? Because the American Psychiatric Association (APA) is in need of money. With all the criticism they were getting for drug money flowing into their coffers as well as the drug companies doing trainings for the APA, for drugging the hell out of our kids, the APA greatly reduced the drug money connection. The DSM is their best selling book. They need the money but as the reviews on the DSM-5 show anyone can get the "diagnosis" and "code numbers" on line, free from which to do their insurance billing. DSM-5 not needed.Greenberg's description of the "committee work" I found hilarious and sad for it is exactly the same process I witnessed of the government re-writing the health, safety and well-being of children in day care regulations. It went on forever and the main folks advocating for no safety rules were some of the day care providers with the poor histories of providing care to children. Then like the DSM committee work it all went on line for public comment. The committee work Greenberg watched in action and the committee I watched in action were the similar dynamic although because a couple of us die hard advocates were on the committee the government did at least on paper a better job of keeping safety regulations. And yes, like Greenberg witnessed with his committee, the day care regulation committee also tried to keep their meetings secret and attempted to take away the first amendment rights of us advocates who spoke to the media.Where did this phenomenon start coalescing from in history? Once again it looks like from the Germans and a guy named Emil Kraepelin in the mid 1800s (which is where and when the whole public education system started) and by the end of the 1800s started the classification system, his "neat categories of mental illness".But it was really war that jumped the gun into providing a warm petri dish in which psychiatrists were grown and thrust out into the world to try to stop soldiers returning from war from having emotional reactions about their experiences, well maybe not stop the emotional reactions but to deny they had anything to do with war. 1952 the year the DSM first got published was the year that Dr. Ewan Cameron was the president of the APA. Working out of Canada for the C.I.A. he headed up the MKULTRA program up there Where they experimented on children (see "The Franklin Cover Up"). 1952 was the year the USA got schizophrenia. Out of war sprang our modern mental health (cover up) systems.Lloyd de Mause and Alice Miller probably had the most direct diagnosis for our modern era in that "all war is about child abuse" but I don't think the author reviewed that aspect of our modern mental illness. Maybe his next book?A great read, a fun read, many laughing out loud moments. Laughing takes power and control away from those insisting that their way makes sense, only makes sense, it's the only way if you will only obey them. Please read and enjoy this book.

It's very rare that I can claim to have read a book of this size in two days - owing to a visual impairment it takes me longer than average to read, despite enthusiasm and state-of-the-art reading aids - but honestly, I couldn't put it down. Not only do I find the subject intrinsically interesting - and relevant - but the way Gary Greenberg writes about it has all the tension and drama of a gripping thriller. Even if you're completely out of sympathy with his views, you must admit it's quite a feat to make a page-turner out of psychiatric nosology. As it happens, I don't need much persuading that the DSM is a deeply flawed attempt to "carve nature at its joints", though I don't think the motivations for compiling it are all bad; and neither does Greenberg. While being trenchantly critical of the combination of conspiracy and cock-up that seems to have bedevilled the enterprise, and produces colourful portraits of the main players, he does acknowledge that the sometimes tawdry, risible and misguided attempt to squeeze the square peg of psychiatry into the round hole of medicine rests on a fundamentally good intention: to provide a language with which to speak about and understand the mind in distress. The DSM may indeed be an uneasy compromise between science, industry, politics and the human condition, and some of the means to secure the ends are very hard to justify, but I never got the impression that he was dissing the whole profession of psychiatry or the enterprise of mental health treatment in general, just pointing out some of the absurdities and dangers that ensue when a professional elite loses touch with those it seeks to help and those who do the helping.

A good expose of the psychiatric medicalisation of mental health, and the turmoil involved in producing the DSM. The DSM does nothing to help mental health at all.

Great

A must read if you're in the world of psychological therapies - facts about the DSM you need to know.

What a writer.