In “Mind Field,” a sharp review of four new books on American psychiatry, Talitha Stevenson pauses midstream to note:
Only 3 per cent of DSM disorders have any known biological causes. The causes of the remaining 97 per cent—and this includes depression, anxiety, schizophrenia, attention deficit hyperactivity disorder (ADHD), bipolar and all personality disorders—are not known. The theory that chemical imbalances cause mental illness—that a serotonin deficiency causes depression, for example—is unproven. Billions of research dollars have been spent on trying to establish a link between neurotransmitters and mental disorder, and the attempts have failed. For all the scientific terminology, psychiatric diagnoses are based on subjective judgments.
This aside in Stevenson’s review article in the Financial Times appears just after she quotes DSM-III architect Robert Spitzer telling author Gary Greenberg, with startling honesty, the DSM “looks very scientific ... it looks like they must know something.”
Stevenson’s appraisal of The Book of Woe, Greenberg’s compelling account of the making of DSM-5, includes cogent reviews as well of Saving Normal by Allen Frances; Cracked: Why Psychiatry Is Doing More Harm Than Good by James Davies; and Our Necessary Shadow: The Nature and Meaning of Psychiatry by Tom Burns—books that take as their central focus the reliability and unreliability of the DSM as a scientific manual.
“Last month,” she notes, “Thomas Insel, the director of the American National Institute of Mental Health (NIMH), observed that the DSM was ‘at best, a dictionary’ and that ‘symptoms alone rarely indicate the best choice of treatment.’ A later statement, issued jointly with the NIMH’s president-elect, stressed that the manual remained ‘the key resource’ but still insisted on the need for a diagnostic system ‘that more directly reflects modern brain science.’ ”
Appearing as they did just days before DSM-5 was published, Dr. Insel’s efforts at playing down the effect of his earlier remarks doubtless gave the APA limited cover, even if the NIMH’s support for the manual remains tepid at best. Remember: Insel had described the DSM as suffering from a “lack of validity.” But fundamental questions remain, including about the reliability of biomarkers the NIMH hopes to assign the remaining 97 percent of mental disorders, whose precise biological causes are not known and may never be. Recall Stevenson, cited above: “Billions of research dollars have been spent on trying to establish a link between neurotransmitters and mental disorder, and the attempts have failed.”
If you switch to the New York Times magazine this weekend, however, you’ll find an article on sex, the DSM, and pharmacology entitled “Unexcited? There May Be a Pill for That.” Author Daniel Bergner picks up the story of Hypoactive Sexual Desire Disorder (HSDD), a carry-over from DSM-IV, which the updated manual continues to define as "persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity for a minimum duration of approximately 6 months." Entirely relatedly, he also tells of the well-funded drive to form and get approved a new drug called “Lybrido,” which, he says, has been “created to stoke sexual desire in women.” Lybrido, libido: the marketing may make them sound interchangeable, but the neurobiology of desire is far from clear and likely to remain so.
“‘Female Viagra,’” notes Bergner, “is the way drugs like Lybrido and Lybridos tend to be discussed. But this is a misconception. Viagra meddles with the arteries; it causes physical shifts that allow the penis to rise. A female-desire drug would be something else. It would adjust the primal and executive regions of the brain. It would reach into the psyche.”
“The neural networks of eros,” he adds of the current state of the research, “are only vaguely known. Tiny subregions and crucial pathways in the brain have been identified — blurrily, speculatively. Some progress has been made by looking at what sites in the brain light up when people watch slide shows of pornography while lying in magnetic-resonance-imaging cylinders. But the images just aren’t exact enough. The brain’s interwoven networks are too intricate for the technology to properly view them.”
In short, and however unhappily for many, “desire resists comprehension.” “Whether it is mainly a raw drive or a complex emotion is a question that has bedeviled psychiatry for decades," he notes. "And the fading of desire can seem impossibly intricate. Is it a result of a lack of intimacy or its cause?”
Bergner’s article barely touches on the controversy surrounding the approval and settings of HSDD, whose principal criterion he sees as sufficiently open-ended to include “lack of lust, when it creates emotional distress." But he usefully cautions of both the blindspots in biological psychiatry and the ongoing bid to medicate female desire: “Millions of American women are on SSRI” antidepressants, one of whose known side effects is, quite unambiguously, the “chemical dulling” of their libido.
Such is our cultural fixation on medication that the subject—and science—of natural aphrodisiacs isn't even mentioned in the article. Nor are alternative ways of increasing libido, including by physical exercise. Bergner is more astute in predicting the likely psychological consequences on couples if the new drug is approved:
Chemically enhancing a woman's desire might play out in all kinds of ways within a relationship. Some couples might feel closer, others might feel desolate because, despite more sex, their bond isn’t stronger. Wives might yearn for the old seductive efforts of their husbands, even if those gestures stopped working long ago. Women might feel yet more pressure to perform: Why not get that prescription? their partners might ask; why not take that pill? And men, if they are willing to confront the truth, might not be so happy about the reminder, as their partners reach for the pill bottle, that their women need chemical assistance to want them.
Bergner closes by focusing on one of the participants in the trials, a “44-year-old part-time elementary-school teacher," who “seemed untroubled by … the paradox that one of the problems this medication might be addressing is the desire-killing side effect of yet another type of psychotropic chemical, the S.S.R.I.’s.”
“She said that if this drug didn’t work, she would sign up for the next experimental medication that came along.… For her, the existence of the antidepressants that so many others take was proof that her problem would be solved.”