Free The Book of Woe: The DSM and the Unmaking of Psychiatry by Gary Greenberg

side of Mirin’s suburban swimming pool when Mirin asked Hyman if NIMH would give the APA money to get the next revision of the DSM up and running.
    Mirin’s request for taxpayer money to kick-start a project from which a private organization would reap huge profits was not as untoward as it might seem. After all, the DSM is indispensable to public health, and NIMH had helped fund the DSM-IV. Nonetheless, and despite their friendship, Hyman said no. He told Mirin that a revision was premature, not only because the ink was barely dry on the DSM-IV, but more important, because psychiatrists had yet to come up with a better way to carve up the landscape of mental illness. All they could do, Hyman thought, was continue to create and refine concepts that would then be mistaken for real disease entities, and further trap psychiatry in its epistemic prison. Until someone figured out how to fashion a key, Hyman didn’t think there was much point to another revision, and he wasn’t going to provide any public money for one. After all, you don’t remodel a house when the foundation is infested with termites.
    Mirin didn’t fight back—mostly, he says, because he didn’t disagree. “The DSM was a system based on descriptive criteria influenced by experts in the field,” Mirin told me. “They had lots of opinions, but these couldn’t necessarily be validated.” The uncertainty out of which the diagnoses were fashioned could not help but show up in the clinic.
    “It’s one thing to guess and another to biopsy a tumor or to measure an enzyme,” Mirin said. And both he and Hyman knew which method the DSM had saddled them with. Spitzer may have freed them from Freudian metaphysics, but still, as Mirin put it, “we were stuck with making diagnoses based on scripture.”
    Even so, America’s leading psychiatrists weren’t about to renounce the only scriptures they had—mostly because, as much as they knew the DSM was flawed, they didn’t have anything with which to replace it. “I realized that it got me nowhere 9 to criticize the DSM because that did not offer a constructive alternative,” Hyman told me. “In fact, given the way the DSM had controlled the imagination of scientists, there was little information with which to see beyond it.”
    Hyman may have been anguishing about psychiatry’s predicament, but Mirin wasn’t losing any sleep over the fact that his profession was stuck guessing about categories that didn’t really exist. “I don’t recall feeling particularly tortured about it. The DSM was essential to being paid for treatment. Without its methodology, payors would see mental illnesses as figments of a provider’s imagination.” It was also essential to the APA’s finances. After all, Mirin told me, “coming down the mountain with the Ten Commandments sure sells a lot of books.”
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    Of all his accomplishments during his tenure in Washington, Steve Mirin seems proudest of the time he persuaded
The Washington
Post
to support legislation requiring insurers to pay for mental health care at the same level as other medical services. So far,
parity
, as this mandate was called,
had only been implemented in a few states, and often only for mental disorders considered by insurers to be biological in origin. In 2002, there was a bill pending in Congress that would make it binding everywhere and for the entire range of DSM-IV diagnoses. President George W. Bush had endorsed it, but the bill seemed likely to sink into the mud of the legislative process, in part, Mirin thought, becausethe
Post
10 —“the hometown paper of every member of Congress,” as he put it—had twice come out against parity. So he arranged to meet on September 3 with an editorial page editor to see if he could sway the paper’s opinion.
    Mirin arrived expecting an hour with a single editor, so he was surprised and pleased when six editors and a reporter filed into the conference room and talked with him for