In The Book of Woe: the DSM and the Unmaking of Psychiatry, psychoanalyst and journalist Gary Greenberg examines the history of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), revealing the “deeply flawed process by which mental disorders are invented and uninvented.”
Like the book it sets out to critique, The Book of Woe is frustratingly long, and rich on detail at the expense of elucidation. For those who are not interested in the particular rows that took place at conferences and seminars, behind closed doors, over the phone or in email exchanges during the various revisions of DSM, it can at times be an irritating read. But Greenberg does make many important and thought-provoking points.
One of Greenberg’s arguments is that none of the disorders in any of the editions of the DSM are real. Psychiatric diagnoses are constructs which group people according to a range of common symptoms. The counting and naming of everything from personality traits to mental disorders “are all reifications” Greenberg argues. We categorise and name things, but that does not mean they exist. For instance, “there really is no such thing as extroversion, even if you know it when you see it, any more than there is such a thing as Major Depressive Disorder.”
Reification is a problem not only in psychiatry but in psychology. Numerous academics talk about ‘authoritative,’ ‘authoritarian’ and ‘permissive’ parenting styles as if they are real categories rather than means by which some psychologists—based on superficial information— have categorised complex human relationships.
Nor is reification a novel phenomenon. The renowned philosopher and political economist, John Stuart Mill, wrote nearly 150 years ago “The tendency is always strong to believe that whatever receives a name must be an entity or being, having an independent existence of its own.” But, as Greenberg rightly argues, recognising the problem with reification is not necessarily an argument against trying to put a name to aspects of our inner lives. Is there any case for trying to categorise human suffering into distinct disorders? Greenberg’s answer is yes and no.
The impulse to categorise and diagnose may reflect “our desire to understand ourselves and one another” and ”to use knowledge to relieve suffering,” Greenberg writes. Take Naomi. She was diagnosed with Asperger’s Syndrome in her teens (a diagnosis introduced two decades ago in DSM-IV and removed this year in DSM-5). On receiving the diagnosis she was horrified: for a start, “it sounded like ass burger” which “is bad enough”, she told Greenberg, but it also seemed to say she had “this cluster of selective stupidity—social stupidity and practical stupidity.” But over time, Greenberg argues, the Asperger’s label changed Naomi’s sense of herself and helped her forge a more coherent identity.
A diagnosis may help some to cope better with life. But a diagnosis may also result in “a kind of reductionism that insults our sense of ourselves as unfathomably complex or even transcendental creatures” Greenberg writes. A doctor who tells a widower that his grief is an illness “is potentially not only labelling, stigmatising, and medicating him, but also shaping the patient’s understanding of loss, of himself, of the meaning of life”.
There is also the danger of a diagnosis being used as an instrument of control. Individuals can be sectioned and have medical procedures imposed on them against their will—as happened in the UK to an Italian woman diagnosed with bipolar disorder, whose plight hit the headlines last week.
Who should have the authority to decide when someone’s autonomy can be undermined in this way? Greenberg argues that psychiatrists have acquired this authority because of the idea that “the mind can be treated like the body, that it is no more or less than what the brain does, that it can be carved at the joints like a diseased liver.”
Back in the 1920s the father of psychoanalysis, Sigmund Freud, warned against bringing medicine into an understanding of psychical phenomena. Analysts need to learn from “the mental sciences, from psychology, the history of civilization and sociology” rather than “anatomy, biology and the study of evolution,” Freud wrote.
Using medicine and biology to understand our inner selves will inevitably fail. Psychiatry has therefore gone through a series of crises. Each edition of the DSM comes in response to one of these crises, not new scientific breakthroughs, Greenberg argues. And rather than psychiatry becoming more modest in its claims, each revision of the DSM has extended the reach of psychiatry - with more and more aspects of our inner lives being medicalised. The most recent revisions of DSM “have caused diagnosis rates of autism, attention-deficit hyperactivity disorder, and bipolar disorder to skyrocket,” Greenberg writes.
The weakness in Greenberg’s argument lies in looking to crises within psychiatry to explain the hyperinflation of diagnostic categories and diagnoses. We need to look beyond psychiatry to broader social and cultural developments, such as the rise in determinism—where humanity is seen less as the master of its fate and more as powerless in the face of difficulties—in order to understand how problems with living have been redefined as medical illnesses. When humans are seen as weak and vulnerable—victims of circumstances rather than active agents who can overcome difficulties—psychiatric diagnoses are likely to flourish.
Greenberg does ask himself whether his book may serve to undermine “the already shaky foundations of a profession that offers the last and only hope for some patients…that has succeeded, at least in some cases, at quelling their hallucinations, modulating their mood swings, allaying their anxiety, and restoring them to some semblance of normal functioning.” But he believes that psychiatry will ultimately be responsible for its own downfall if it carries on selling the fiction of psychiatric diagnosis as fact.
“By no longer insisting it is just like the rest of medicine, and by renouncing its noble lies about the scientific status of psychiatric diagnosis, the profession might become a more honest one than it is now… But there is no doubt that an honest psychiatry would be a smaller profession. It would have fewer patients, more modest claims about what it treats, less clout with insurers, and reduced authority to turn our troubles into medical problems,” he writes.
I agree. But in the context of the social forces that have allowed for the never-ending expansion of psychiatric diagnoses, this may be wishful thinking.