On May 22, the American Psychiatric Association will release the fifth version of the Diagnostic and Statistical Manual of Mental Disorders—the DSM-5. The last version, the DSM IV, was published in 1994 and has provided the clinical terms for diagnoses that allow for insurance payments, treatment costs, and public support for such afflictions as Asperger's and grief—all of which, among a host of established disorders, are set to be altered by the new version.
Last week, Blue Rider Press published Gary Greenberg's The Book of Woe: The DSM and the Unmaking of Psychiatry, a powerful critique of the entire DSM methodology. Greenberg is a practicing psychotherapist who also authored Manufacturing Depression: The Secret History of an American Disease and The Noble Lie. He has been referred to as "The Dante of our Psychiatric age," by Errol Morris, and blogs about the DSM for the New Yorker. With The Book of Woe, written during and after his own participation in the revision process of the DSM-5, Greenberg doesn't just paint the DSM as irrelevant, but as an arbitrary and totalitarian influence in the treatment of mental and emotional distress. Greenberg makes an unsparing case against the DSM’s hold on the naming rights to our psychic suffering.
What is the most disturbing aspect of the DSM-5 to you?
The most disturbing aspect is not unique to the DSM-5, but intrinsic to any DSM: that a private guild—the American Psychiatric Association (APA)—owns such an important public trust. The DSM plays a significant role in determining who gets treatment, what drugs get approved, what research gets funded, who gets special education services, and the disposition of criminal cases. The APA represents only one of many mental health professions, is rife with conflicts of interest with the pharmaceutical industry, has its own, scientifically questionable approach to treatment, it also stands to make hundreds of millions of dollars from the manual and associated products. That's unseemly. But even worse, it leaves the public at the mercy of people who are not accountable to anyone except their own organization. It's the worst kind of privatization.
What effect do you see the DSM-5 having on treatment for drug and alcohol addiction?
I'm not sure the DSM-5 will have any direct effect on treatment; the DSM-5 is not a treatment manual. But any DSM has a major indirect effect on treatment: It provides the diagnoses that are the tickets to treatment resources. To put it more concisely: money. The DSM-5 will most likely eliminate the categories of Substance Abuse and Substance Dependence in favor of a new super-category of Substance Use Disorder. Qualifying for this diagnosis may be easier than for the DSM-IV diagnoses, largely because the number of criteria a patient has to meet has been reduced. Some studies indicate that this will result in a large increase in prevalence. If General Motors comes out with a new car, that doesn't change the number of drivers, and if the APA comes out with a new diagnosis, that doesn't change the number of people who will qualify for a mental disorder diagnosis. Whether this happens, and if it does, whether it's a bad thing (treatment resources are overburdened by an influx of new patients) or a good thing (more people get treatment), or whether it will have any effect at all, remains to be seen.
You say that psychiatry should not have a monopoly on the diagnoses and treatment of human suffering, such as addiction. Who else should be involved? Based on what “expertise” or “interests”?
Diagnosis and treatment are really two separate issues. I don't think psychiatry claims to have a monopoly on treatment, although it does have (mostly) a monopoly among mental health providers on drug treatments. On this, I think I agree with the psychiatrists. I'm not sure that anyone else besides people who have been to medical school should be prescribing drugs. As for diagnosis, I don't think psychiatric diagnosis is necessary, at least not until psychiatry has the knowledge to render diagnoses on the same basis as other medical specialties. Psychiatrists don't treat mental disorders. They treat symptoms. So they don't really need diagnoses to do their job. But if there has to be psychiatric diagnosis, then it should be in the hands of a public agency, one that doesn't have a profit motive in fashioning a manual, one that is not wedded to its own professional interests, and one that is not fooling around with the drug industry.
"I tell my patients the truth: that if they want to use their insurance, I have to diagnose them with a mental disorder, and that this diagnosis will stay with them for the rest of their lives."
Addiction is increasingly being recognized as a brain disease. One aim of the DSM-5 is said to be to bring diagnoses of substance use disorders into line with the burgeoning neuroscience about addiction. Does the DSM-5 meet its goal?
The only way in which DSM-5's addictive disorders section reflects neuroscience is in its reliance on "craving" as one of the two diagnostic criteria for substance use disorder. This change reflects the belief that craving is a single phenomenon with a particular brain chemistry. While there are some indications that this is the case, it is far from proven. 50 or 100 years from now, I am sure our understanding of the brain will seem as laughable as phrenology seems to us. So for the moment, popping people into PET scanners or MRI machines strikes me as wishful thinking multiplied by greed. The fact that addiction is increasingly being recognized as a brain disease does not mean that addiction is—or is best understood as—a brain disease. I don't doubt that is the direction in which research is moving, but I'm not sure this means we are approaching the truth about addiction, or about the brain and its relationship to the mind.
What is your opinion on the effect of 12-step based programs on recovery—the spiritual solution rather than the medical?
I think the 12-step program is useful for many people, and I have both friends and patients who benefit from it. I also think it is only one of many ways that people can stop using the drugs they are addicted to, and is surely not the only "spiritual" approach. Nor is it necessarily correct to think of it in contradistinction to the medical approach. After all, the 12-step program owes much of its success to a concerted effort on the part of doctors, including psychiatrists, to popularize the disease model of addiction, which Alcoholics Anonymous in many respects originated.
The DSM-5 includes the first “behavioral disorder”—compulsive gambling—in the Addiction section. Proponents say that compulsive behaviors have very similar effects on the brain as substances do. Critics say this is opening the door to the medicalization of more and more of everyday life. What do you think?
I think that long before the behavioral disorders opened the door to medicalization of daily life, that goal had been accomplished. The struggle of psychiatry since 1980 has not been to fashion more and more illnesses, but rather to convince us that when we are unhappy, anxious, compulsive, etc., we have a mental illness. In this they have been successful, at least to judge from the vast increase in numbers of people seeking treatment. It's a predictable outcome of the DSM approach to mental suffering.
Do you think 12-step culture might be overreaching with its own set of expanding diagnoses (shopping, varieties of sex addiction) or do you find them valid?
The idea that any compulsive behavior marked by craving is an addiction, and that addiction is a disease, is a very powerful one. It speaks to confusions deep in our culture about desire and satisfaction, about consumption and regret, about having and not-having. So I don't think it's fair to blame this tendency on 12-step culture. It's obviously an idea whose time has come. But is it valid? Not if that means that sex addiction or Internet use disorder are diseases in the same way that cancer or diabetes are diseases. Addiction will remain poorly understood so long as we stay wedded to a strictly medical model (and I include in that the 12-step model, which, as I said, is also a disease model).
You write about the "magic bullet" effect of medication, an easy option for those addicts with a psychiatric diagnosis who could just do 12-step work.
I'm not sure it is useful to set up a polarity between "taking drugs" on the one hand and "doing the work" on the other. While drugs can be an "easy way out," they are not always. Even Bill Wilson thought there was some value to LSD, and sometimes the absolute abstinence from all drugs, not just the drug to which a person has become addicted, that is required in some 12-step programs is counterproductive.
Some critics of the revision say that the expansion of diagnoses is a big boon for the drug industry, since there will be more people to medicate. Psychiatry is the darling of the drug industry. Do you believe that the DSM-5 was guided by this same self-interest?
Yes, of course. Psychiatry long ago hitched its wagon to the medical star, and increasingly that means to the neuroscience star. The failure of DSM-5 to develop a brain-based nosology is only the latest embarrassment that has resulted from this dogged determination to prove that psychiatry is just like the rest of medicine—real doctors treating real diseases. Too bad the profession has turned its' back on what once made it unique and valuable: its focus on the mind.
As a psychotherapist, do you use the DSM-5?
In my practice, it has virtually no clinical value. Its primary value is its ability to help patients use their insurance to pay for therapy. I tend to discourage patients from doing this. I'd rather make less money than participate in a practice I don't believe in. So I tell them the truth: that if they want to use their insurance, I have to diagnose them with a mental disorder, and that this diagnosis will stay with them for the rest of their lives. If they want to go ahead with it anyway, then we talk about the diagnosis I am going to use to make sure that they fully understand the implications of diagnosis, including the fact that DSM diagnoses are not real diseases, but rather constructs.