As World Mental Health Day approaches, has the drive to identify all illnesses created a ‘fiction’ of psychiatry?
In his riveting tale of how psychiatrists “medicalise” human suffering, Gary Greenberg recounts that, in 1850, a physician called Samuel Cartwright reported a new disease in the highly respected New Orleans Medical and Surgical Journal. Cartwright named it drapetomania, from the ancient Greek drapetes for a runaway slave; in other words, here was a disease that “caused Negroes to run away”. It had one primary diagnostic symptom – “absconding from service” – and a few secondary ones, including “sulkiness and dissatisfaction just prior to flight”.
Drapetomania was, of course, consigned to the dustbin of medical history. It never made it into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the leading authority on mental health diagnosis and research. But, Greenberg suggests in his scathing critique of the DSM, it might well have done – had the manual existed at the time.
After all, he notes, homosexuality was listed as a “sociopathic personality disorder” when the DSM was first published in 1952, and remained so until 1973. “Doctors were paid to treat it, scientists to search for its causes and cures,” he writes in The Book of Woe: The DSM and the Unmaking of Psychiatry. “Gay people themselves underwent countless therapies including electric shocks, years on the couch, behaviour modification and surrogate sex.”
Greenberg, 56, is a US psychotherapist of 30 years’ experience and a prolific writer on mental illness (including his own depression after the collapse of his first marriage). But the target of his latest book is the DSM itself, the so-called “psychiatrist’s bible”, which aims to provide a definitive list of all mental health conditions, along with their diagnostic criteria.
Updated at regular intervals – DSM-5, the fifth edition, was published in May – it has considerable influence worldwide, including in the UK, where it underpins several clinical guidelines on mental health. Yet Greenberg holds that by imposing a pseudoscientific model on our “hopelessly complex” inner world, it creates a “charade” of non-existent disorders.
As World Mental Health Day approaches this week, he argues that, thanks to the DSM, “countless millions” are hooked on powerful antidepressants to cure a mythical “chemical imbalance”, while rates of mental disorders in children, including autism, bipolar illness and ADHD, have rocketed. The DSM is, he says, a “fiction” which medicalises human experience and allows psychiatrists “dominion over the landscape of mental suffering”.
Greenberg’s language may at times sound overblown but he isn’t alone. DSM-5, 14 years in the writing, has been criticised by many for the unhealthy influence of the pharmaceutical industry and its tendency to medicalise behaviours and moods that many would argue fall within the normal range.
“Few professionals are happy with the DSM,” Greenberg says on the phone from his home in Connecticut, where he lives with his wife, teenage son, cat, dog and “a dozen or so” hens. “We are forced to engage with a charade of diagnostic disorders that we don’t believe our patients have for the crassest of reasons – money.” (In the US, people have to have their diagnosis confirmed by the DSM to access insurance funds for treatment.) “It’s not just psychotherapists – even psychiatrists admit this is a deeply flawed document.”
The rot set in during the 19th century, he says, when expectations of medicine changed dramatically after the discovery of micro-organisms. “It created a desire for all mental suffering to be understood in the same way as physical suffering, such as smallpox or cholera. To consider craziness as another treatable disease which originates in biology had tremendous appeal.”
Playing into this is another factor, the influence of the pharmaceutical industry. Despite an attempted clean-up in recent years by the American Psychiatric Association, 67 per cent of the “task force” members responsible for DSM-5 are reported to have industry links.
Yet Greenberg believes that many psychiatrists – and even drug reps – are well-meaning. “It is intellectual rather than financial corruption. The idea that human suffering can be reduced to a biochemical imbalance – this is about ideology rather than money.”
Greenberg’s book tracks in painstaking detail how the DSM’s decisions have created “false epidemics” of over-diagnosis and over-treatment. In 1994, for example, the diagnostic threshold for bipolar disorder was lowered to cover people without full-blown mania (instead, they have elevated moods that doctors call hypomania, but which Greenberg describes as exuberance). As a result, bipolar diagnoses soared, as did prescriptions for mood stabilisers and antipsychotic drugs, which in the US were for the first time being advertised directly to the public. “Suddenly, everyone and his brother was bipolar,” says Greenberg. About six million people are now diagnosed as bipolar in the US, and in the UK, it’s one in 100.
He also describes how a loophole in the DSM criteria was exploited “by one of the few real bad guys in psychiatry” to establish a juvenile version of the disorder, without any solid evidence. This was at a time, coincidentally, when powerful antipsychotics were being rebranded as mood stabilisers. As a result, diagnoses of child bipolar illness increased 40-fold over a decade. “In 2007 alone half a million children, 20,000 of them under six, were prescribed drugs that a decade before would have been prescribed only in the most dire circumstances,” says Greenberg.
The side effects of some of the drug cocktails children were prescribed included obesity, diabetes and suicidal thoughts.
In an attempt to reduce bipolar diagnoses in children, DSM-5 has introduced a new illness, called Disruptive Mood Dysregulation Disorder (DMDD), to cover intensive temper tantrums. But this too is proving controversial, with fears that it may capture some children who may be volatile, but who are not ill. “Clinical trials of treatments for DMDD are probably already under way and may well lead to another treatment epidemic,” he says.
A different tale concerns Asperger’s syndrome, which was first included by the DSM in 1994. Greenberg explains that this had some beneficial effects. “It may not have been a disease but calling it one gave a hitherto neglected group of children access to support and educational services, as well as a sense of identity and community.” The result though, was that from a worldwide prevalence of four in 10,000 for autism disorders (including Asperger’s) in 1988, 20 years later this was one in 88. Alarmed at diagnostic rates “getting out of hand”, DSM-5 has removed Asperger’s, replacing it with the umbrella term Autistic Spectrum Disorders. This means a “higher threshold for diagnosis”, according to Greenberg, and possibly less access to educational benefits for future generations.
He is unimpressed with the DSM-5’s new Hoarding Disorder – “Is an eccentric old man living amid his junk sicker than a billionaire who is always thinking of the next way to make a buck?” – and argues that anyone over the age of 50, including himself, would qualify for another new entry: Mild Cognitive Disorder.
Greenberg is particularly dismissive about DSM-5’s changes to the criteria for Major Depressive Disorder. Until now, this diagnosis was specifically excluded in cases of recent bereavement, on the grounds that grief is normal. That exemption has been removed in DSM-5, leading critics to argue that grief has been medicalised.
“The exemption clause was an embarrassment because it challenged the idea that depression is caused by biology and led critics to demand that other external factors, such as divorce and redundancy, be exempt too,” he says. “So they got rid of it, which means that if you are depressed while bereaved you can be classified as mentally ill.” Not that bereaved people who are depressed shouldn’t be helped, he adds. “But is it really a medical problem?”
So what needs to happen? Psychiatrists, he believes, must narrow their scope – to make a “reasonable claim” for certain mental illnesses falling within their domain. “When the DSM was published there were 14 mental disorders and now there are 250 – it needs to scale back.”
There is a place for drug treatments, he says, although “you only have to look at the clinical trials to see they help some people but not all.”
Above all, psychiatrists need to be more honest with their patients, he believes. “They shouldn’t tell people their illness is caused by a chemical imbalance when there is no evidence this exists. Psychiatry has little knowledge of the underlying processes governing mental health and it should not pretend otherwise.”