Inside the Battle to Define Mental Illness

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Happy New Year everyone!! Jim

http://www.wired.com/magazine/2010/12/ff_dsmv/all/1

Inside the Battle to Define Mental Illness

By Greenberg

December 27, 2010 |

12:00 pm |

Wired January

2011

Every so often Al Frances says something that

seems to surprise even him. Just now, for instance, in the predawn

darkness of his comfortable, rambling home in Carmel, California,

he has broken off his exercise routine to declare that “there is

no definition of a mental disorder. It’s bullshit. I mean, you

just can’t define it.” Then an odd, reflective look crosses his

face, as if he’s taking in the strangeness of this scene:

Frances, lead editor of the fourth edition of the American

Psychiatric Association’s Diagnostic and Statistical Manual

of Mental Disorders (universally known as the DSM-IV),

the guy who wrote the book on mental illness, confessing that

“these concepts are virtually impossible to define precisely with

bright lines at the boundaries.” For the first time in two days,

the conversation comes to an awkward halt.

But he recovers quickly, and back in the living room he finishes

explaining why he came out of a seemingly contented retirement to

launch a bitter and protracted battle with the people, some of

them friends, who are creating the next edition of the DSM.

And to criticize them not just once, and not in professional mumbo

jumbo that would keep the fight inside the professional family,

but repeatedly and in plain English, in newspapers and magazines

and blogs. And to accuse his colleagues not just of bad science

but of bad faith, hubris, and blindness, of making diseases out of

everyday suffering and, as a result, padding the bottom lines of

drug companies. These aren’t new accusations to level at

psychiatry, but Frances used to be their target, not their source.

He’s hurling grenades into the bunker where he spent his entire

career.

As a practicing psychotherapist myself, I can attest that this is

a startling turn. But when Frances tries to explain it, he resists

the kinds of reasons that mental health professionals usually give

each other, the ones about character traits or personality quirks

formed in childhood. He says he doesn’t want to give ammunition to

his enemies, who have already shown their willingness to “shoot

the messenger.” It’s not an unfounded concern. In its first

official response to Frances, the APA diagnosed him with “pride of

authorship” and pointed out that his royalty payments would end

once the new edition was published—a fact that “should be

considered when evaluating his critique and its timing.”

Frances, who claims he doesn’t care about the royalties (which

amount, he says, to just 10 grand a year), also claims not to mind

if the APA cites his faults. He just wishes they’d go after the

right ones—the serious errors in the DSM-IV. “We

made mistakes that had terrible consequences,” he says. Diagnoses

of autism,

attention-deficit hyperactivity disorder, and bipolar disorder

skyrocketed, and Frances thinks his manual inadvertently

facilitated these epidemics—and, in the bargain, fostered an

increasing tendency to chalk up life’s difficulties to mental

illness and then treat them with psychiatric drugs.

The insurgency against the DSM-5 (the APA has

decided to shed the Roman numerals) has now spread far beyond just

Frances. Psychiatrists at the top of their specialties,

clinicians at prominent hospitals, and even some contributors to

the new edition have expressed deep reservations about it.

Dissidents complain that the revision process is in disarray and

that the preliminary results, made public for the first time in

February 2010, are filled with potential clinical and public

relations nightmares. Although most of the dissenters are

squeamish about making their concerns public—especially because of

a surprisingly restrictive nondisclosure agreement that all

insiders were required to sign—they are becoming increasingly

restive, and some are beginning to agree with Frances that public

pressure may be the only way to derail a train that he fears will

“take psychiatry off a cliff.”

At stake in the fight between Frances and the APA is more than

professional turf, more than careers and reputations, more than

the $6.5 million in sales that the DSM averages each

year. The book is the basis of psychiatrists’ authority to

pronounce upon our mental health, to command health care dollars

from insurance companies for treatment and from government

agencies for research. It is as important to psychiatrists as the

Constitution is to the US government or the Bible is to

Christians. Outside the profession, too, the DSM

rules, serving as the authoritative text for psychologists, social

workers, and other mental health workers; it is invoked by lawyers

in arguing over the culpability of criminal defendants and by

parents seeking school services for their children. If, as Frances

warns, the new volume is an “absolute disaster,” it could cause a

seismic shift in the way mental health care is practiced in this

country. It could cause the APA to lose its franchise on our

psychic suffering, the naming rights to our pain.

This is hardly the first time that defining

mental illness has led to rancor within the profession. It

happened in 1993, when feminists denounced Frances for considering

the inclusion of “late luteal phase dysphoric disorder” (formerly

known as premenstrual syndrome) as a possible diagnosis for DSM-IV.

It happened in 1980, when psychoanalysts objected to the removal

of the word neurosis—their

bread and butter—from the DSM-III.

It happened in 1973, when gay psychiatrists, after years of loud

protest, finally forced a reluctant APA to acknowledge that

homosexuality was not and never had been an illness. Indeed, it’s

been happening since at least 1922, when two prominent

psychiatrists warned that a planned change to the nomenclature

would be tantamount to declaring that “the whole world is, or has

been, insane.”

Some of this disputatiousness is the hazard of any professional

specialty. But when psychiatrists say, as they have during each of

these fights, that the success or failure of their efforts could

sink the whole profession, they aren’t just scoring rhetorical

points. The authority of any doctor depends on their ability to

name a patient’s suffering. For patients to accept a diagnosis,

they must believe that doctors know—in the same way that

physicists know about gravity or biologists about mitosis—that

their disease exists and that they have it. But this kind of

certainty has eluded psychiatry, and every fight over nomenclature

threatens to undermine the legitimacy of the profession by

revealing its dirty secret: that for all their confident

pronouncements, psychiatrists can’t rigorously differentiate

illness from everyday suffering. This is why, as one psychiatrist

wrote after the APA voted homosexuality out of the DSM,

“there is a terrible sense of shame among psychiatrists, always

wanting to show that our diagnoses are as good as the scientific

ones used in real medicine.”

If bad tests are sanctioned in the DSM,

insurance companies might use them to cut off coverage for patients deemed

not sick enough. It could be a disaster.

Since 1980, when the DSM-III was published,

psychiatrists have tried to solve this problem by using what is

called descriptive diagnosis: a checklist approach, whereby

illnesses are defined wholly by the symptoms patients present. The

main virtue of descriptive psychiatry is that it doesn’t rely on

unprovable notions about the nature and causes of mental illness,

as the Freudian

theories behind all those “neuroses” had done. Two doctors

who observe a patient carefully and consult the DSM’s

criteria lists usually won’t disagree on the diagnosis—something

that was embarrassingly common before 1980. But descriptive

psychiatry also has a major problem: Its diagnoses are nothing

more than groupings of symptoms. If, during a two-week period, you

have five of the nine symptoms of depression

listed in the DSM, then you have “major depression,”

no matter your circumstances or your own perception of your

troubles. “No one should be proud that we have a descriptive

system,” Frances tells me. “The fact that we do only reveals our

limitations.” Instead of curing the profession’s own malady,

descriptive psychiatry has just covered it up.

The DSM-5 battle comes at a time when psychiatry’s

authority seems more tenuous than ever. In terms of both research

dollars and public attention, molecular biology—neuroscience and

genetics—has come to dominate inquiries into what makes us tick.

And indeed, a few tantalizing results from these disciplines have

cast serious doubt on long-held psychiatric ideas. Take

schizophrenia and bipolar disorder: For more than a century, those

two illnesses have occupied separate branches of the psychiatric

taxonomy. But research suggests that the same genetic factors

predispose people to both illnesses, a discovery that casts doubt

on whether this fundamental division exists in nature or only in

the minds of psychiatrists. Other results suggest new diagnostic

criteria for diseases: Depressed patients, for example, tend to

have cell loss in the hippocampal regions, areas normally rich in

serotonin. Certain mental illnesses are alleviated by brain

therapies, such as transcranial magnetic stimulation, even as the

reasons why are not entirely understood.

Some mental health researchers are convinced that the DSM

might soon be completely revolutionized or even rendered obsolete.

In recent years, the National Institute of Mental Health has

launched an effort to transform psychiatry into what its director,

Insel, calls clinical neuroscience. This project will focus

on observable ways that brain circuitry affects the functional

aspects of mental illness—symptoms, such as anger or anxiety or

disordered thinking, that figure in our current diagnoses. The

institute says it’s “agnostic” on the subject of whether, or how,

this process would create new definitions of illnesses, but it

seems poised to abandon the reigning DSM approach.

“Our resources are more likely to be invested in a program to

transform diagnosis by 2020,” Insel says, “rather than modifying

the current paradigm.”

Although the APA doesn’t disagree that a revolution might be on

the horizon, the organization doesn’t feel it can wait until 2020,

or beyond, to revise the DSM-IV. Its categories line

up poorly with the ways people actually suffer, leading to high

rates of patients with multiple diagnoses. Neither does the manual

help therapists draw on a body of knowledge, developed largely

since DSM-IV, about how to match treatments to

patients based on the specific features of their disorder. The

profession cannot afford to wait for the science to catch up to

its needs. Which means that the stakes are higher, the current

crisis deeper, and the potential damage to psychiatry greater than

ever before.

Changing Our Minds

From the DSM-I to the DSM-5,

definitions of mental illness have evolved with the

culture. Here’s a sample of the rewrites.

— Biba

Condition

DSM-I (1952)

DSM-II (1968)

DSM-III (1980; revised 1987)

DSM-IV (1994; revised 2000)

DSM-5 (rough draft released 2010)

Autism

Schizophrenic reaction, childhood type

In this first mention of autism, it’s described only in

children, as a symptom of a psychotic reaction.

Schizophrenia, childhood type; schizoid

personality

Now a symptom of two conditions but still just in

children.

Infantile autism

Autism gets its own classification, but still only in

children. The 1987 revision finally extends it to

adults.

Autistic disorder

As in the DSM-III revision, DSM-IV

defines autism through six specific symptoms, including

impairment of social interactions.

Autism spectrum disorder

Now an umbrella term for a whole category of conditions,

including autistic disorder, Asperger’s syndrome, and

more.

Depression

Depressive reaction

Classified as a psychoneurotic disorder characterized by

anxiety.

Depressive neurosis

No longer considered a form of anxiety, it’s now

explained as a reaction to internal conflict or the loss

of a beloved object or person.

Major depression

Now a category of disorder. An exception is created for

bereavement following the loss of a loved one, which is

called a “normal reaction.”

Major depressive episode

The bereavement exception is limited: Only if a

griever’s symptoms last less than two months are they

considered normal.

Major depressive episode

The bereavement exception is removed, since “evidence

does not support” distinguishing grief from other

“stressors.”

Hysteria

Phobic reaction; conversion reaction

The term hysteria appears throughout the

volume.

Hysterical neurosis; hysterical personality

Hysterical neurosis becomes its own category. A second

disorder, hysterical personality, is characterized by

self-dramatization and overreaction.

Histrionic personality disorder

Now more specifically differentiated from the neurosis,

which is renamed conversion disorder.

Histrionic personality disorder

The term hysteria is removed from the index,

but the personality disorder remains, defined as

excessive attention-seeking.

Histrionic personality disorder is removed.

Sexual Interest/Arousal Disorder

Not listed

Not listed

Not listed

Not listed

A new disorder for DSM-5, defined as an

absent or reduced interest in sex. Diagnosed in men if

their “excitement” lags during 75 percent of encounters;

in women, if reduced during all encounters.

Frances’ revolt against the DSM-5

was spurred by another unlikely revolutionary:

Spitzer, lead editor of the DSM-III and a

man believed by many to have saved the profession by

spearheading the shift to descriptive psychiatry. As the DSM-5

task force began its work, Spitzer was “dumbfounded” when Darrel

Regier, the APA’s director of research and vice chair of

the task force, refused his request to see the minutes of its

meetings. Soon thereafter, he was appalled, he says, to discover

that the APA had required psychiatrists involved with the

revision to sign a paper promising they would never talk about

what they were doing, except when necessary for their jobs. “The

intent seemed to be not to let anyone know what the hell was

going on,” Spitzer says.

In July 2008, Spitzer wrote a letter to Psychiatric News,

an APA newsletter, complaining that the secrecy was at odds with

scientific process, which “benefits from the very exchange of

information that is prohibited by the confidentiality

agreement.” He asked Frances to sign onto his letter, but

Frances declined; a decade into his retirement from Duke

University Medical School, he had mostly stayed on the sidelines

since planning for the DSM-5 began in 1999, and he

intended to keep it that way. “I told him I completely agreed

that this was a disastrous way for DSM-5 to start,

but I didn’t want to get involved at all. I wished him luck and

went back to the beach.”

But that was before Frances found out about a new illness

proposed for the DSM-5. In May 2009, during a

party at the APA’s annual convention in San Francisco, he struck

up a conversation with Will Carpenter, a psychiatrist at the

University of land. Carpenter is chair of the Psychotic

Disorders work group, one of 13 DSM-5 panels that

have been holding meetings since 2008 to consider revisions.

These panels, each comprising 10 or so psychiatrists and other

mental health professionals, report to the supervising task

force, which consists of the work-group chairs and a dozen other

experts. The task force will turn the work groups’ proposals

into a rough draft to be field-tested, revised, and then

ratified—first by the APA’s trustees and then by its 39,000

members.

At the party, Frances and Carpenter began to talk about “psychosis

risk syndrome,” a diagnosis that Carpenter’s group was

considering for the new edition. It would apply mostly to

adolescents who occasionally have jumbled thoughts, hear voices,

or experience delusions. Since these kids never fully lose

contact with reality, they don’t qualify for any of the existing

psychotic disorders. But “throughout medicine, there’s a

presumption that early identification and intervention is better

than late,” Carpenter says, citing the monitoring of cholesterol

as an example. If adolescents on the brink of psychosis can be

treated before a full-blown psychosis develops, he adds, “it

could make a huge difference in their life story.”

This new disease reminded Frances of one of his keenest regrets

about the DSM-IV: its role, as he perceives it, in

the epidemic of bipolar diagnoses in children over the past

decade. Shortly after the book came out, doctors began to

declare children bipolar even if they had never had a manic

episode and were too young to have shown the pattern of mood

change associated with the disease. Within a dozen years,

bipolar diagnoses among children had increased 40-fold. Many of

these kids were put on antipsychotic drugs, whose effects on the

developing brain are poorly understood but which are known to

cause obesity and diabetes. In 2007, a series of investigative

reports revealed that an influential advocate for diagnosing

bipolar disorder in kids, the Harvard psychiatrist ph

Biederman, failed to disclose money he’d received from

& , makers of the bipolar drug Risperdal,

or risperidone. (The New York Times reported that

Biederman told the company his proposed trial of Risperdal in

young children “will support the safety and effectiveness of

risperidone in this age group.”) Frances believes this bipolar

“fad” would not have occurred had the DSM-IV

committee not rejected a move to limit the diagnosis to adults.

Frances found psychosis risk syndrome particularly troubling in

light of research suggesting that only about a quarter of its

sufferers would go on to develop full-blown psychoses. He

worried that those numbers would not stop drug companies from

seizing on the new diagnosis and sparking a new treatment fad—a

danger that Frances thought Carpenter was grievously

underestimating. He already regretted having remained silent

when, in the 1980s, he watched the pharmaceutical industry

insinuate itself into the APA’s training programs. (Annual drug

company contributions to those programs reached as much as $3

million before the organization decided, in 2008, to phase out

industry-supported education.) Frances didn’t want to be “a

crusader for the world,” he says. But the idea of more “kids

getting unneeded antipsychotics that would make them gain 12

pounds in 12 weeks hit me in the gut. It was uniquely my job and

my duty to protect them. If not me to correct it, who? I was

stuck without an excuse to convince myself.”

At the party, he found Bob Spitzer’s wife and asked her to tell

her husband (who had been prevented from traveling due to

illness) that he was going to join him in protesting the DSM-5.

Throughout 2009, Spitzer and Frances carried out their assault.

That June, Frances published a broadside on the website of Psychiatric Times,

an independent industry newsletter. Among the numerous alarms

the piece sounded, Frances warned that the new DSM,

with its emphasis on early intervention, would cause a

“wholesale imperial medicalization of normality” and “a bonanza

for the pharmaceutical industry,” for which patients would pay

the “high price [of] adverse effects, dollars, and stigma.” Two

weeks later, the two men wrote a letter to the APA’s trustees,

urging them to consider forming an oversight committee and

postponing publication, in order to avoid an “embarrassing DSM-5.”

Such a committee was convened, and it did recommend a delay,

because—as its chair, a former APA president, later put it—”the

revision process hadn’t begun to coalesce as much as it should

have.” In December 2009, the APA announced a one-year

postponement, pushing publication back to 2013. (The

organization insists that Frances “did not have an impact” on

the rescheduling of the revision.)

Scully, medical director of the APA, fills the

big leather chair in his office overlooking the Potomac River

and the government buildings beyond. He’s a large, ruddy-faced

man with a shock of white hair, and when he leans forward, his

monogrammed cuffs perched on his knees, to deliver his

assessment of Frances, even though it’s only two words—”he’s

wrong”—you can hear his rising gorge and the sense of betrayal

that seems to be swelling behind it.

Of all the things that Frances is wrong about—and there are

many, Scully says, including his position on psychosis risk

syndrome—the confidentiality agreement seems to be the one that

really galls. First of all, it’s simply an intellectual property

agreement “about who owns the product.” Second, he insists, this

is the most open and transparent DSM revision

ever, certainly more open than the process that produced

Spitzer’s and Frances’ manuals, which were written in the

pre-Internet era, before it was possible to field, as the task

force has, 8,000 online comments on the proposed changes.

The agreement may well be mere intellectual property

boilerplate. But, as I explain to Scully and later to APA

research chief Darrel Regier, that hasn’t reassured all the

psychiatrists who’ve had to sign it. They fret privately that

the DSM-5 will create “monumental screwups” that

will turn the field into a “laughingstock.” They accuse the task

force of “not knowing where they’re going” and of “not having

managed this right from the very beginning.” They worry that the

“slipshod nature of the whole process” will lead to a “crappy

product” that alienates clinicians even as it makes psychiatry

“look capricious and silly.” None of them, however, are willing

to go on record, for fear—unfounded or not—of “retaliation” and

“reprisal.”

Regier wants to know who said these things.

Not all the dissidents are insisting on anonymity. E. Jane

Costello, codirector of the Center for Developmental

Epidemiology at Duke Medical School, says she doesn’t mind going

on record because she’s “too small a fish” for them to bother

with. Costello was one of two psychiatrists who resigned from

the Childhood Disorders work group in spring 2009. In her

resignation letter, which she subsequently made public, Costello

excoriated the DSM committee for refusing to wait

for the results of longitudinal studies she was planning and for

failing to underwrite adequate research of its own. The proposed

revisions, she wrote, “seem to have little basis in new

scientific findings or organized clinical or epidemiological

studies.” (In a response, the APA cited “several billions of

dollars” already spent over the past 40 years on research the

revision is drawing upon.)

To critics, the greatest liability of the DSM-5

process is precisely this disconnect between its ambition on one

hand and the current state of the science on the other. Of

particular concern is a proposal to institute “dimensional

assessment” as part of all diagnostic evaluations. In this

approach, clinicians would use standardized, diagnostic-specific

tests to assign a severity rating to each patient’s illness.

Regier hopes that these ratings, tallied against data about the

course and outcome of illnesses, will eventually lead to

psychiatry’s holy grail: “statistically valid cutpoints between

normal and pathological.” Able to reliably rate the clinical

significance of a disorder, doctors would finally have a

scientific way to separate the sick from the merely suffering.

No one, not even Frances, thinks it’s a bad idea to augment the

current binary approach to diagnosis, in which you either have

the requisite symptoms or you don’t, with a method for

quantifying gradations in illness. Dimensional assessment could

provide what Frances calls a “governor” on absurdly high rates

of diagnosis—by DSM criteria, epidemiologists have

noted, a staggering 30 percent of Americans are mentally ill in

any given year—and thereby solve both a public health problem

and a public relations problem.

But

First, a Columbia University psychiatrist who headed up

the DSM-5’s Prelude Project to

solicit feedback before the revision, believes that implementing

dimensional assessment right now is a tremendous mistake. The

tests, he says, are nowhere near ready for use; while some of

them have a long track record, “it seems that many of them were

made up by the work groups” without any real-world validation.

Bad tests could be disastrous not just for the profession, which

would erect its diagnostic regime on a shaky foundation, but

also for patients: If the tests have been sanctioned in the DSM,

insurance companies could use them to cut off coverage for

patients deemed not sick enough. “If they really want to do

dimensional assessment,” First says, “they should wait the five

or 10 years it would take for the scales to be ready.”

Regier won’t say how many of the tests are usable yet. “I don’t

think it will be useful to get into this level of detail,” he

emails. He acknowledges that dimensional assessment is still

evolving, and he says the DSM-5 field

trials—studies in which doctors will test the rough draft of the

manual with patients—will help refine the tests. But the field

trials, too, are bumping up against formidable deadlines.

Although trials were scheduled to begin in May 2010, as of

October only a pilot study was actually under way—and protocols

for the rest of the trials couldn’t be finalized until that

study was completed. Meanwhile, Regier has pegged May 2013 as a

drop-dead date for publication of the new manual, which means

that two sets of field trials and revisions must be completed by

September 2012.

The time crunch only gives critics more fuel. Frances, on

hearing of the trials’ delay, BlackBerried out a communiqué

about the task force’s “Keystone Kops” missteps—the “Rube

Goldberg design,” the “numerous measures signifying

nothing,” the “criteria sets that are unusable because so poorly

written.” All of which, he wrote, will lead to “a mad dash to

dreck at the end.”

When the rough draft of the DSM-5

was released, in February 2010, the diagnosis that had

galvanized Frances—psychosis risk syndrome—wasn’t included. But

another new proposed illness had taken its place: “attenuated

psychotic symptoms syndrome,” which has essentially the same

symptoms but with a name that no longer implies the patient will

eventually develop a psychosis. In principle, Carpenter says,

that change “eliminates the false-positive problem.” This is not

as cynical as it might sound: Carpenter points out that a kid

having even occasional hallucinations, especially one distressed

enough to land in a psychiatrist’s office, is probably not

entirely well, even if he doesn’t end up psychotic. Currently, a

doctor confronted with such a patient has to resort to a

diagnosis that doesn’t quite fit, often an anxiety or mood

disorder.

But attenuated psychotic symptoms syndrome still creates a

mental illness where there previously was none, giving

drugmakers a new target for their hard sell and doctors, most of

whom see it as part of their job to write prescriptions, more

reason to medicate. Even Carpenter worries about this. “I

wouldn’t bet a lot of money that clinicians will hold off on

antipsychotics until there’s evidence of more severe symptoms,”

he says. Nonetheless, he adds, “a diagnostic manual shouldn’t be

organized to try to adjust to society’s problems.”

His implication is that the rest of medicine, in all its

scientific rigor, doesn’t work that way. But in fact, medicine

makes adjustments all the time. As obesity has become more of a

social problem, for instance, doctors have created a new disease

called metabolic syndrome, and they’re still arguing over the

checklist of its definition: the blood pressure required for

diagnosis, for example, and whether waist circumference should

be a criterion. As Darrel Regier points out, diabetes is defined

by a blood-glucose threshold, one that has changed over time.

Whether physical or mental, a disease is really a statistical

construct, a group of symptoms that afflicts a group of people

similarly. We may think our doctors are like House,

relentlessly stalking the biochemical culprits of our suffering,

but in real medicine they are more like Darrel Regier, trying to

discern the patterns in our distress and quantify them.

The fact that diseases can be invented (or, as with

homosexuality, uninvented) and their criteria tweaked in

response to social conditions is exactly what worries critics

like Frances about some of the disorders proposed for the DSM-5—not

only attenuated psychotic symptoms syndrome but also binge

eating disorder, temper dysregulation disorder, and other

“sub-threshold” diagnoses. To harness the power of medicine in

service of kids with hallucinations, or compulsive overeaters,

or 8-year-olds who throw frequent tantrums, is to command

attention and resources for suffering that is undeniable. But it

is also to increase psychiatry’s intrusion into everyday life,

even as it gives us tidy names for our eternally messy problems.

I recently asked a former president of the APA how he used the

DSM in his daily work. He told me his secretary had

just asked him for a diagnosis on a patient he’d been seeing for

a couple of months so that she could bill the insurance company.

“I hadn’t really formulated it,” he told me. He consulted the DSM-IV

and concluded that the patient had obsessive-compulsive

disorder.

“Did it change the way you treated her?” I asked, noting that

he’d worked with her for quite a while without naming what she

had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain

advances, the APA has found itself caught between paradigms,

forced to revise a manual that everyone agrees needs to be fixed

but with no obvious way forward. Regier says he’s hopeful that

“full understanding of the underlying pathophysiology of mental

disorders” will someday establish an “absolute threshold between

normality and psychopathology.” Realistically, though, a new

manual based entirely on neuroscience—with biomarkers for every

diagnosis, grave or mild—seems decades away, and perhaps

impossible to achieve at all. To account for mental suffering

entirely through neuroscience is probably tantamount to

explaining the brain in toto, a task to which our

scientific tools may never be matched. As Frances points out, a

complete elucidation of the complexities of the brain has so far

proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to

all of us—professional and layman alike—is that psychiatric

diagnosis will probably always be laden with uncertainty, that

the labels doctors give us for our suffering will forever be at

least as much the product of negotiations around a conference

table as investigations at a lab bench. Regier and Scully are

more than willing to acknowledge this. As Scully puts it, “The DSM

will always be provisional; that’s the best we can do.” Regier,

for his part, says, “The DSM is not biblical. It’s

not on stone tablets.” The real problem is that insurers,

juries, and (yes) patients aren’t ready to accept this fact. Nor

are psychiatrists ready to lose the authority they derive from

seeming to possess scientific certainty about the diseases they

treat. After all, the DSM didn’t save the

profession, and become a best seller in the bargain, by claiming

to be only provisional.

It’s a problem that bothers Frances, and it even makes him

wonder about the wisdom of his crusade against the DSM-5.

Diagnosis, he says, is “part of the magic,” part of the power to

heal patients—and to convince them to endure the difficulties of

treatment. The sun is up now, and Frances is working on his

first Diet Coke of the day. “You know those medieval maps?” he

says. “In the places where they didn’t know what was going on,

they wrote ‘Dragons live here.’”

He went on: “We have a dragon’s world here. But you wouldn’t

want to be without that map.”

Greenberg (garygreenbergonline.com)

is the author of Manufacturing Depression: The Secret

History of a Modern Disease.