The DSM Files: Investigating the Incoherence of Psychiatry’s Bible
Sometime during the spring of 2021, I decided to read the Diagnostic and Statistical Manual of Mental Disorders, the DSM, the so-called “bible” of psychiatry. I had a couple of things in mind for this project: first of all, I teach a class about the intersection of mental health and literature, and while I had the literature part down well, and lived experience plus some peer specialist training for the mental health part, the class has been taken by quite a few psychology and social work majors over the years. I needed to up my game.
Second, I was interested for quasi-personal and quasi-philosophical reasons. My own mental health history involved what I interpreted as severe depression brought on by a profound spiritual crisis. I sought help for this in the early ‘90s, when anti-depressants targeting the serotonin system were starting to dominate the scene. Prozac and Zoloft were the “go-to” meds, promising a revolution, the end of unhappiness as we knew it. Within 15 minutes of my appointment with a locally prominent and well-respected psychiatrist, and after having taken what I later found was a modified version of the Hamilton Scale for assessing depression, I was prescribed Prozac and told that I had a “brain disease” that would require medication for life.
This was partially a relief: medical science was validating my feelings! I had a thing called depression; officialdom had signed off on the problems that made me a shitty college student and a terrible romantic partner.
But I was also troubled: my depression was a feeling, sure, but it also arose, in my experience, from a sense that the world had no meaning, that the progressive Mennonite world in which I had grown up did not square with a cosmology I was beginning to believe was better informed by astrophysics than theology. I couldn’t believe, but I also couldn’t disbelieve, worried about the state of my immortal soul—if, that is, I even had one.
Were these concerns, concerns common throughout the past two centuries of philosophical inquiry, merely bad brain chemistry? Could they—and, importantly, should they—be “cured” by a simple pill? And why had the psychiatrist, supposedly the brightest and the best, never even asked about these things? Were my thoughts irrelevant to my feelings?
The question about whether or not to fill the prescription (for Prozac) was also complicated by the fact that a friend of mine had taken it and gone precipitously from depressed to suicidal. This was years before any SSRI had received a black box warning about potential suicidality. Not that it would have mattered: all of my cohort of friends were college-age at the time, and the black-box warning only applies to children on the drug. We would all have aged out; any suicide attempts made after the drug was given would have been (and still would be) attributed to the depression, not the drug.
But it scared me, and I felt that I was not getting my needs met, my spiritual crisis addressed. I felt, in a word, dismissed.
So, being a 20-year-old male, I dismissed psychiatry as well and didn’t fill the prescription. I never went back.
I remained conflicted about this for years, still repeating the bromides that all mental health problems were chemical imbalances, genetic in origin; that modern medicine cured them with medications; and that people so afflicted would be afflicted for life. That did not mean that I wanted treatment, but it did mean that I planned not to ever have children, for who would want to pass on this internal turmoil to another generation? Take me and my flawed genes out of the gene pool, I reasoned. There were still plenty of non-depressed people to fill up the Earth, and anyway, it was, even then, becoming increasingly clear that more people just meant more of a burden on a collapsing ecosystem, more carbon spewing into a warming atmosphere.
This did not mean that I was happy. Indeed, the issues that led to my depression, more complex than I had realized, manifested in various ways over the years, and, while I eventually became a decent college student, I was still a terrible romantic partner, an uneven writer, and and erratic employee. I did, eventually, become a decent self-advocate, though, which I had to be in order to actually find support for my mental health in a landscape that was (and still is) primarily focused on psychiatric drugs. It took 20 years and a lot of work, but I eventually did find someone who worked for me—someone who respected my choice to end our therapeutic relationship when I had met my goals, someone, notably, who helped me articulate therapeutic goals in the first place.
But after all of this, I had only read specific parts of the DSM, such as the entry on depression, and a few others of interest along the way. (The entry on borderline personality disorder is interesting if you’re studying feminism, by the way.) By the time the fifth version of the DSM came out, DSM-5, I knew I had to read it. This one was more controversial than the previous ones, notably for eliminating the “bereavement exclusion” that in previous versions had excluded grief as a form of clinical depression.
By the time I actually got around to reading the DSM-5, 8 years after its debut, I had another reason for doing so: due to work that I had done in the mental health field and my own approach as a writer, I was interested in the DSM as the story psychiatry says about itself, as part of a long-term narrative about how we should think about mental health, as a marketing device displaying the product psychiatry has to offer the world—and, indeed, as a world view, the story psychiatry articulates about how we should think about what is going on inside our heads.
Nothing here should be read as a denial of internal suffering, turmoil, and pain—again, I have gone through these myself. Rather, it takes a critical view of the way the DSM categorizes internal suffering and makes sense (or sometimes nonsense) of it. It is about a story that is full of loose ends, inconsistencies, and bad logic. This is a retelling of a story of a field that has gone astray, a paradigm ready for a shift, an industry we have come to depend on to explain everything from personal pain to population-level suffering but that is ill-equipped for the task. It is told from the perspective of lived experience, from a personal place, but also from the place of a writer and a literary critic, from the place of an advocate for my peers who have experienced internal turmoil and extreme states of mind.
We want, and we deserve, better.
Others have observed that our lives are increasingly medicalized. TV, radio, and credible text sources exhort us to consult our family doctors when taking on such risky tasks as eating, exercise, or having sex. The opinion of an MD is recommended as a way of mitigating the perils or working, aging, youthfulness, childhood, and giving birth. Psychiatry has followed suit. Over the past 60 years, the DSM has expanded from 106 diagnoses to 365 today. There is scarcely a part of one’s thoughts or feelings the DSM does not potentially cover, from one’s beliefs about the world to one’s sadness, happiness, or lack of feeling at all. Both optimism and pessimism are noted, as well as worry, carelessness, anger, and joy. Thoughts impossible to follow are mentioned as well as thoughts and actions that are too tightly ordered, as well as the lack of thought. The DSM rarely wades into what normal is, but it certainly implies it.
Critics of the DSM point out that few medical conditions are declared diseases only at the judgment of the patient, except for purely cosmetic issues, but this does bring up a serious issue: at what point is psychiatry, as with the rest of medicine, expanding past the point of providing relief from pain or repair of damage and into the messy and highly individualized realm of everyday life? If I know the DSM’s definition of depression, will I spend my days worried that every down mood is the start of a dangerous psychiatric pathology? When I read that anxiety is “comorbid” with depression, will I begin to worry about worrying about being depressed?
The level of diagnosis and treatment has also been on the rise, with concomitant increases in disability designations for many of those so diagnosed. According to statistics from the National Institutes of Mental health, cited in a recent TED Talk by Phil Borges, disability due to mental health diagnoses almost quadrupled between 1988 and 2008, from 1.24 million to 4 million, with 1100 people added to the rolls each day. Are we really sicker now, or are we just more often, or more readily, diagnosed? As the number of diagnoses available in the DSM increase, are more of us who would once have been considered normal now nuts?
It is, of course, likely that we are, indeed, sicker now: jobs are less stable, work is more stressful, workplaces and schools more competitive. It is harder to build wealth, harder to enjoy leisure. Access to public services and spaces have decreased as the private sector has expanded; tax revenue has declined, and confidence in public institutions has eroded. There is a good life out there to be had, but it costs too much for most of us to enjoy. By all measures except the access to technology, such as smart phones and social media, life has gotten worse; over the same 40 years that the DSM has blossomed, our lives have gotten harder economically and more hopeless compared to the relative heyday between the end of WW2 and the mid-1970s. Perhaps the DSM has simply expanded to meet the need. Or perhaps both things have happened: as there are now more things making us crazy, so, too, there are more ways to be crazy.
But this creates problems for the DSM’s current model—or, rather, implied model. Absent from the DSM is an over-arching notion of what “mental” actually means: the only references to “theory of mind” have to do with a potential patient’s ability or inability to recognize the thought patterns of others. The very field that will deem you disordered for the lack of a theory of mind does not actually have one in the most serious, scientific or philosophical senses.
That said, as with normal, while nothing is stated, much is implied. The DSM frequently refers to “genetic and physiological” “factors” in mental disorders, often without citing specific studies that determine these. The DSM, in certain cases, ties genetic “factors” to the prevalence of the disorder (or its symptoms, barring definite diagnosis) in “first-order relatives,” somehow forgetting the obvious, that a trait can run in a family without being genetic: mannerisms, a taste for Victorian furniture, wealth. As often, so-called “twin studies,” studies of identical twins reared in separate households, are cited as showing genetic “factors,” studies that are problematic at best, presenting circular logic, methodological inconsistencies, and false assumptions, even as they have been widely cited.
And sometimes, the notations of physiological or genetic “factors” are simple asserted with no citations at all. The listing for generalized anxiety disorder is a case in point. The DSM-5 states: “One-third of the risk of experiencing generalized anxiety disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are shared with other anxiety and mood disorders, particularly major depressive disorder.” Who says? The DSM doesn’t tell us. And what are these “genetic factors”? The DSM cites no genetic tests that will determine whether or not any given individual has these factors, which you’d think treating psychiatrists, and certainly their patients, would like to know.
Other “risk and prognostic factors” include “temperamental” and “environmental” factors. Temperament, then, and by implication, is not genetic or physiological, but the DSM also does not tell us how temperament comes about, just that, in the case of generalized anxiety, it includes “neuroticism,” “negative affectivity,” and “harm avoidance.” From the point of view of this writer, all of these terms are merely recapitulations or descriptions of what a person who is anxious is like. I suppose that has value in that it helps show a treating mental health provider a picture of the generally anxious, but it lacks an etiology, an origin story; it answers the question of what makes up an anxious person, but it does not answer the question of what makes a person anxious.
Maybe it comes from a person’s individual story. That makes intuitive sense: you’re generally anxious because things in your life have made you so (at least the two-thirds that are not genetic). Environmental factors for generalized anxiety disorder, though, are described thus: “Although childhood adversities and parental over protection have been associated with generalized anxiety disorder, no environmental factors have been identified as specific to generalized anxiety disorder or necessary or sufficient for making a diagnosis.”
So, no, then?
That would be news to those suffering from anxiety. My work in the mental health field brought me into contact with many people with this diagnosis, and, importantly, with their stories. If you listen, they can almost all tell you what makes them anxious, but you have to be listening for that, and you have to ask them to share their stories.
To be fair, the DSM does take care here to separate “associations” (correlation) from “factors” (presumably causation), but it does not weigh in on why the correlation exists, and, as noted, does not show us the causative link between the “factors” and the disorder—and, in the case of the “temperamental” factors, does not provide anything plausibly causative at all, merely descriptions.
And so the language here presents the facade of precision with the substance of confusion. As a writer, this is fascinating: are the authors of the DSM really trying to make sense of what they know here, or what they think they know? Is the material just too slippery for precision of thought? Or is this flim-flam, an attempt to convince those reading, and maybe those writing, that things are better settled than they really are?
Implied is that mind arises from the genetic and the physiological, that it is influenced by the temperamental, or perhaps expressed through the temperamental, which, presumably, is a set of fixed qualities that every human has. All other associations are just that, associations, and we mustn’t put too much stock in what people say about being anxious because they’ve been abused, traumatized, or because they have bad bosses or terrible partners. Or, at least, people are not generally anxious because of these things. If you’re looking for something specific, just flip to the back of the chapter, and there you’ll find specific anxiety disorder or unspecified anxiety disorder, both with much more vague descriptions and much lower thresholds for application. No matter what you say about your anxiety, your psychiatrist can find a disorder to fit it without bothering with the problematic “factors” and “associations” found in the description of GAD.
Notably, in this diagnosis and others, the DSM lists temperament, genetics, and physiology as “factors,” but culture and gender as “issues.” The DSM is not kind enough to tell us the difference between a factor and an issue, not even in its glossary. But, again, they are implied. Back to generalized anxiety disorder: “There is considerable cultural variation in the expression of generalized anxiety disorder,” and “generalized anxiety disorder is diagnosed somewhat more frequently in females.” Presumably, then, a “factor” is causal or etiological, and an “issue” is a matter of expression or frequency of diagnosis.
It’s entirely understandable that inner states, such as anxiety, would vary in their expression across cultures. Different cultures have different languages, different sets of expected behaviors. Some cultures express anxiety through sleeplessness, a surplus of energy, substance use, and so forth; others with feelings of heat throughout the body, or other somatic symptoms. How, then, do we know that these different expressions are, at their core, the same thing?
And then there is gender. According to the DSM, women are more likely to receive the diagnosis of anxiety. Is this because women are biologically more likely to experience anxiety? The simplest explanation is that women are more likely to be socialized to express their inner turmoil in ways that our society calls “anxiety.” But according to the DSM, this is impossible, since no environmental factors are specific to the diagnosis. Perhaps, then, psychiatrists are simply more likely to diagnose women, for one reason or another (sexism?). Yet the DSM’s authors take pains to assure us of the objectivity of this diagnosis.
As a writer trying to make some sense of the story the DSM tells about what it means to be crazy, what it implies about what it means to be normal, and what it says about itself, the DSM seems more confused than deceptive, more incoherent than infamous.
For a statistical manual, its numbers, at least in the case of generalized anxiety disorder, don’t add up; for a work that uses the term “mental” frequently, it presents no unified notion of what a mental phenomenon or, for that matter, a mind, even is. The average work of science fiction presents a more coherent universe than the worldview presented in the DSM.
And then there is the language. Everything is a disorder. OK, that is an exaggeration: the “manias,” the “philias,” the “phrenics” and so forth get their own designations, but the DSM’s default is to disorder.
The formula works thus: modifier + undesirable state or behavior + “disorder” = diagnosis.
You’re not depressed; you have “major depressive disorder.” You’re not traumatized; you have “posttraumatic stress disorder.” You’re not compulsive or obsessed, you have “obsessive-compulsive disorder.”
Not to be pedantic, but, again, from a writer’s perspective, a good deal of this makes no sense whatsoever.
Given that there are already perfectly good words being used, there is no semantic sense in slapping “disorder” on most of these diagnoses. Why not just call depression depression, anxiety anxiety?
All of this would be somewhat laughable if it weren’t so serious. Not only are people’s lives at stake when the risk of suicide looms, people’s quality of life is at risk when the DSM fails to makes sense of what is really going on. Decisions about a person’s fitness for work, play, family membership, and even ability to walk the streets freely depend on the descriptions in this book. The media and the general public, not to mention those who seek help from mental health service providers, are often uncritical of the diagnoses being meted out and accept prescribed treatment without question.
Having worked in the field, though, in a position that tried to shift the culture from one focused only on diagnosis or treatment to one focused on recovery, I can say that the reality is quite different: some people are helped by the system and go back to work, school, and family life; some are partially helped and still struggle, often on disability, and many for years, if not decades; some are not helped at all, and they drift in and out of the system, often facing homelessness, hopelessness, and incarceration. All are medicated.
The most frequent complaint I heard—and it was part of my job to listen seriously and as a peer to their stories—was “My psychiatrist/therapist/case manager doesn’t listen to me.”
And why should they? If a person’s experience does not comport with the incoherence that is the DSM, the content of which is used by insurance companies and managed care organizations to justify billing and allow for service provision, it is a null set. The provider is inclined by training and forced by financial realities to make the person’s experiences fit the descriptions in the book.
There is a lot in the DSM about how things can go wrong, almost nothing about how they can go right. Normality is relegated to the purgatory of implication, and the one thing every interaction with a service-provider ought to focus on, what a person receiving the service actually wants out of treatment, is nearly absent in the book’s 947 pages.
In the end, the DSM says as much about psychiatry’s fears as it does about its certainties: fears of odd behaviors and thoughts, fears of unpleasant feelings, fears of positing what a mind is. It is an expression of the fear that without disordering everything, people will start to see the sense in what is bothering them, how it has helped them cope or how it is a manifestation of what has happened to them—and then they will look elsewhere for ways to help them help themselves change.