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

man who has crunched the numbers and seen the results, and concluded that “we just don’t have good thresholds for identifying what we would consider mental disorders.” Having eliminated any account of the origin or nature of mental illness in favor of pure observation, the DSM-III had also eliminated the thresholds, vague as they might be, provided by Freud’s insistence that mental illness was distinguished by its origins in intrapsychic conflict. The resulting symptom-based diagnosis is binary; if you have five of the nine symptoms of depression, you have the same disorder as a person with all nine, just as if you have a small stage 1 tumor in your lung, you have the same disease as someone with the same kind of tumor who is about to die. With those five symptoms, as with the first appearance of the tumor, you have crossed the line from health to illness, and the rest is only a question of severity.
    But, as those prevalence numbers made clear, doctors using DSM checklists were all too likely to find disease everywhere. There was no governor, no way to say this person was sick and that one was simply unhappy, nothing like the CT scan that confirms that the patient with the persistent cough and fatigue has a tumor in his lung. A doctor who diagnosed strep entirely on the basis of symptoms was practicing bad medicine, while a doctor who diagnosed depression only on the basis of symptoms was practicing standard psychiatry. It seemed that in his attempt to make psychiatry look more like the rest of medicine, Spitzer had actually fashioned a book that only highlighted the differences.
    The comorbidity rates—the frequency with which people qualified for more than one diagnosis—were another embarrassment. Here again, Regier said, the ECA studies pointed not so much to a sick population as to a flawed manual. Spitzer had anticipated the possibility of multiple diagnoses, and in the introduction to DSM-III he suggested that there was a hierarchy of mental illness, that some disorders only had a narrow range of symptoms while others contained multitudes. Schizophrenia, for instance, was far more encompassing than major depression, so clinicians confronted with a patient presenting symptoms of both were advised to render only a schizophrenia diagnosis on the assumption that the low mood was part of the more comprehensive disorder. Regier pointed out that this amounts to a claim that the depression itself is “just noise,” of no inherent interest or value in understanding the patient or their disorders. But the ECA team found that people with symptoms of both schizophrenia and depression were different from people with only schizophrenia in many ways. Ignoring their depression meant failing to get a complete diagnostic picture and losing “an enormous amount of data” about mental health. “The ECA blew the hierarchy out of the water,” Regier said proudly. “It just didn’t make any sense when we started looking at the data.”
    Concerns like this led the APA to abandon the hierarchy in the DSM-III-R, but the real problem, Regier told me, was not the approach but something much more basic: the idea that DSM disorders are discrete diseases that exist in nature in the same way as cancer and diabetes. This, to Regier, is the fundamental flaw of the DSM, the one that accounts for the high rates of both prevalence and comorbidity. “It makes it seem like an anxiety disorder doesn’t have any mood symptoms and a mood disorder doesn’t have any anxiety symptoms. But it isn’t that simple. It’s just not the way people present.”
    But it is the way the DSM presents mental illness; indeed, that neat separation is the signal innovation of the DSM-III. Fortunately for Mirin and Regier, by the time of their fateful meeting with the
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editors, they’d turned their skepticism into a strategy. “We walked them through how we understood mental illness, and what our thoughts were about diagnosis and the DSM,” Mirin