Cracked E-Book

James Davies

• Herausgeber: Icon Books
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2013

Seitenzahl: 445

Beschreibung

Why is psychiatry such big business? Why are so many psychiatric drugs prescribed – 47 million antidepressant prescriptions in the UK alone last year – and why, without solid scientific justification, has the number of mental disorders risen from 106 in 1952 to 374 today? The everyday sufferings and setbacks of life are now 'medicalised' into illnesses that require treatment – usually with highly profitable drugs. Psychological therapist James Davies uses his insider knowledge to illustrate for a general readership how psychiatry has put riches and medical status above patients' well-being. The charge sheet is damning: negative drug trials routinely buried; antidepressants that work no better than placebos; research regularly manipulated to produce positive results; doctors, seduced by huge pharmaceutical rewards, creating more disorders and prescribing more pills; and ethical, scientific and treatment flaws unscrupulously concealed by mass-marketing. Cracked reveals for the first time the true human cost of an industry that, in the name of helping others, has actually been helping itself.

Leseprobe

Praise for Cracked

‘[Cracked] should be read by every doctor … by everyone in politics and the media, not to mention any concerned citizen.’

Peter Hitchens, Mail on Sunday

‘Chilling reading’

Will Self, Guardian

‘Davies’s book is a potent polemic’

Bryan Appleyard, Sunday Times

‘If, in the world of psychiatry, the DSM is Holy Scripture, Cracked is set to become a heretical text.’

Robert Crampton, The Times Magazine

‘Builds a disturbing picture of a profession that is in thrall to pharmaceutical companies’

Michael Mosley, BBC Focus

‘An eye-opening and persuasive work’

Publishers Weekly

‘[A] diligent study’

Financial Times

‘A well-written book … a positive contribution to the debate about whether psychiatry can become a more open practice.’

Therapy Today

‘Disturbing and uncompromising’

Kirkus Reviews

‘An engrossing book, full of interviews with patients and professionals’

GP Magazine

‘I couldn’t put the book down. It is totally engaging, as controversial as it is compelling, and as erudite as it is enjoyable … The book deserves to be a bestseller and should be read by every mental health professional.’

International Review of Logotherapy and Existential Analysis

‘This is an excellent book … [it] careens, almost literally, from one psychiatric outrage to the next … I strongly recommend this book.’

Dr Phil Hickey, Behaviourism and Mental Health

‘This thought-provoking book will make people think twice before sitting on a psychiatrist’s couch or filling a prescription.’

Booklist

‘This is a very well-written book – intellectually sound, but written in an accessible way … It should be read by all mental health professionals, by all politicians and policy makers charged with shaping future mental health provision.’

Dr Neil Thompson, Social Justice Solutions

‘You will be illuminated and often shocked and certainly made to think more about how you view the children in your care. Every teacher should read it.’

International School Magazine

Printed edition published in the UK in 2013 by

Icon Books Ltd, Omnibus Business Centre,

39–41 North Road, London N7 9DP

email: [email protected]

www.iconbooks.net

This electronic edition published in 2013 by Icon Books Ltd

ISBN: 978-184831-557-0 (ePub format)

ISBN: 978-184831-558-7 (Adobe ebook format)

Text copyright © 2013, 2014 James Davies

The author has asserted his moral rights.

No part of this book may be reproduced in any form, or by any means, without prior permission in writing from the publisher.

Typesetting by Marie Doherty

Contents

Endorsements

Title page

Copyright information

About the author

Dedication

Author’s note

Preface

1. Psychiatry’s early breakdown and the rise of the DSM

2. The DSM – a great work of fiction?

3. The medicalisation of misery

4. The depressing truth about happy pills

5. Dummy pills and the healing power of belief

6. Mental oddities and the pills that cause them

7. Bio-babble?

8. Money and power ruling head and heart

9. But they make us rich

10. When science fails, marketing works

11. The psychiatric myth

12. Psychiatric imperialism

13. How to fix the cracks?

Appendix: Antipsychotics (neuroleptics) – breaking the brain?

Acknowledgements

Notes

Index

About the author

James Davies obtained his PhD in medical and social anthropology from the University of Oxford. He is also a qualified psychotherapist (having worked in the NHS), and a senior lecturer in social anthropology and psychology at the University of Roehampton, London. He has delivered lectures at many universities, including Harvard, Brown, Columbia, Oxford and UCL, and has written articles about psychiatry for The Times, The Guardian, the New Scientist, Salon and the Harvard Divinity Bulletin. He is author of the recent book The Importance of Suffering: the value and meaning of emotional discontent (Routledge, 2011). He lives with his wife and daughter in London.

For my daughter, Rose

Author’s note

I have concealed all identities and altered all real names in case-study material to protect individuals’ anonymity.

Preface

The figures are startling. At least one in four of you in the UK and US will suffer from a mental disorder in a given year.* And if you are one of those lucky ones with a constant spring in your step, the odds are high that you are close to someone less fortunate. That is what the psychiatric industry tells us – we are a population on the brink. And that is why it asserts that its services are more essential than ever before. Psychiatry is a science, after all, and has the tools and knowledge at its disposal to help us when our lives break down. This is the official story we hear, the one gaining airtime in the media, the ear of National Health Service (NHS) policy-makers, and widespread dissemination through celebrity chat-shows and popular magazines. But what if the actual truth about psychiatry were not so sanguine or clear-cut as we have been led to believe? What if there is another more insidious story to be told, one that threatens all of our preconceptions? Well, an alternative story certainly does exist, a deeper and far more maddening story. And in this book I intend to tell it.

Once upon a time, psychiatry was reserved for only the most distressed members of society. This was always a small minority: people who were often removed to asylums, usually against their will, and subjected to esoteric treatments. Today, the few have become the many. Not because psychiatric wards have increased in number, but because psychiatric treatments and beliefs about mental distress have now crashed through the walls of the hospital and surged into every corner of contemporary life, affecting how we understand and manage our emotional lives. Just consider the facts. According to recent NHS figures, in 2012 alone, over 50 million prescriptions for antidepressants were dispensed to the English public. And the vast majority of these pills were not prescribed to the stereotypically ‘mad’ characters depicted in Hollywood movies. No, most of their recipients were just like you or me. Average people simply trying to make their way. Perhaps you are one of them. Perhaps someone you love is one of them.

Today, psychiatry’s power and influence is far from abating – it’s growing at a remarkable rate. And in this book I will show you why this is, paradoxically, a very bad thing for our mental health. To substantiate this claim, my method will be simple. I will investigate three medical mysteries: why has psychiatry become the fastest-growing medical specialism when it still has the poorest curative success? Why are psychiatric drugs now more widely prescribed than almost any other medical drugs in history, despite their dubious efficacy? And why does psychiatry, without solid scientific justification, keep expanding the number of mental disorders it believes to exist – from 106 in 1952 to 374 today? What is going on?

To answer these mysteries, I will leave no aspect of the industry unexamined. Each chapter will focus on a different part of the story: how the process of creating new diagnostic categories regularly strays from scientifically accepted standards; how antidepressants actually work no better than placebo (sugar) pills for most people; how negative drug trials are routinely buried and research is regularly manipulated to convey positive results; how numerous doctors have been enticed by huge rewards from pharmaceutical companies into creating more disorders and prescribing more pills; and how mass-marketing has been unscrupulously employed to conceal from doctors, patients and the wider public the ethical, scientific and treatment flaws of a profession now in serious crisis.

I have written this book to seduce a new generation away from the escalating craze for psychiatric drugs and diagnoses. I reveal through governmental, academic and interview sources that the unhappy truth about psychiatry can be explained by one startling fact: in recent decades many areas of psychiatry have become so lured by power and money that they are in danger of putting the pursuit of pharmaceutical riches and medical status above their patients’ well-being. My aim is not to shock anyone gratuitously, just to report what the inconvenient facts suggest: that psychiatry, in the name of helping others, is now in serious peril of better helping itself.

During my journey researching and writing this book I have amassed a vast number of air miles criss-crossing the Atlantic, interviewing some of the leading lights of the psychiatric world. I have consulted the people who have put the profession on the map – the heads of the premier psychiatry schools, the creators of new diagnostic categories, the presidents of national psychiatric associations: the people with long and glowing entries on Wikipedia, the real movers and shakers of the profession. My aim has not been to incriminate anyone personally, merely to get at the truth. And as my eyes have gradually been opened by discoveries more worrying than I could have anticipated, I have checked and double-checked what I have heard to ensure I’ve got the story correct. Now that my investigations are complete, it’s time to make what I have discovered more freely available. As you follow me in the coming pages, you won’t always find the ride comfortable; you will encounter facts and confessions that will shock, baffle and dismay you. But there is no point sugar-coating the facts. For if things are ever to be put right, then what is required above all are people, just like you, understanding and spreading the word that a profession purporting to help us is now seriously, disconcertingly – and in both senses of the term – cracked.

* This is clearly not just an American and British problem. It’s estimated that approximately 450 million people worldwide have a mental health problem – people throughout the developed and developing world. (World Health Organisation, 2001)

1

Psychiatry’s early breakdown and the rise of the DSM

On a chilly Wednesday morning in late January, I pass through the gates of my university after a fraught drive through London’s rush hour. With two minutes left on the clock, I make my way hurriedly to the ground floor of the lecture theatre. Today I am expected to deliver my first lecture on critical psychiatry. As I enter the room it feels more close and cramped than usual, as nearly every student on the course has decided to attend (which, I must add, doesn’t always happen on cold January mornings). The students are preoccupied as I approached the lectern and start quietly ordering my notes. Many of them are chatting intently, some are tapping on laptops or mobiles, while a few eager souls (in the front row, of course) quietly sit waiting for me to begin.

‘Right everyone, settle down, I have a great piece of research I want you to consider. You’ll like this one, trust me, so please listen closely.’ I clear my throat and begin.

Some years ago during a balmy April, a group of eight academics conducted a dramatic experiment, months in preparation. As part of the experiment they individually presented themselves at different psychiatric hospitals dotted around the United States. Each academic then told the psychiatrist on duty they were hearing a voice in their head that said the word ‘thud’. That was the only lie they would tell; otherwise, from that point on they would behave and respond completely normally. All of them were admitted into their respective hospitals. And all were diagnosed with serious mental disorders and given powerful antipsychotic pills. All the while they acted completely normally. The experimenters thought they would be in for a couple of days and then be discharged, but they were wrong. Most were held for weeks, and some in excess of two months. They could not convince the doctors they were sane. And telling the doctors about the experiment only compounded the problem. So it quickly became clear that the only way out was to agree that they were insane, and then pretend to be getting better.

Once the leader of the experiment, Dr David Rosenhan, got out and reported what had happened, there was uproar in the psychiatric establishment. Rosenhan and his colleagues were accused of deceit. One major hospital challenged Rosenhan to send some more fake patients to them, guaranteeing that they would spot them this time. Rosenhan agreed, and after a month the hospital proudly announced to the national media that they had discovered 41 fakes. Rosenhan then revealed that he had sent no one to the hospital at all.*

For a moment there is stunned silence in the lecture room, quickly followed by some chuckling and surprised chatter. I now have their full attention. Three or four hands shoot up.

‘Hold your questions for now everyone. I’ve another series of experiments to tell you about first. These occurred around the same time as Rosenhan’s experiment, and were equally devastating for psychiatry.’

These experiments explored the following question: ‘Would two different psychiatrists diagnose the same patient in the same way?’ To answer this, the researchers presented the same set of patients to different psychiatrists in different places, to see whether their diagnoses would match up. When the results came in, the situation did not look good. Taken en masse, they revealed that two psychiatrists would give different diagnoses to the same patient between 32 and 42 per cent of the time.1 And this troubling result was confirmed by another series of studies showing that psychiatrists in the United States and in Russia were twice as likely to diagnose their patients as schizophrenic as their colleagues in Britain and Europe.2 This meant that the diagnosis you could be assigned not only often depended on who your psychiatrist was, but on where your psychiatrist was located. How could you therefore trust your diagnosis, when a different psychiatrist was likely to diagnose you with something else?

I told my students about these experiments, because in the history of psychiatry they were considered game-changers. They plunged psychiatry into severe crisis in the 1970s by exposing that there was something terribly wrong with the diagnostic system. Psychiatrists were not only defining sane people as insane, but when two psychiatrists at any given time were faced with the same patient, they would assign different diagnoses nearly half the time. So why were these critical mistakes being made? The profession was desperate for an answer. And when one finally emerged, the course of psychiatry would be altered for good. It turned out there was a serious problem with the centrepiece of the entire profession, the psychiatrist’s bible – the DSM.

•

So what, you may ask, is the DSM? To answer this question, please follow me into the office of Dr Herbert Pardes, one of America’s leading psychiatrists. To give you some idea of his professional standing, just consider his CV. He was former chair of Columbia University’s Department of Psychiatry (the most powerful psychiatry department on the globe); former president of the American Psychiatric Association (the more glitzy US equivalent of the Royal College of Psychiatrists), and finally, former director of the largest psychiatric research organisation internationally (the National Institute of Mental Health). In short, if there were a CEO of psychiatry, then Herbert Pardes was probably it.

Pardes welcomed me into his office with an easy smile and a warm handshake, ‘I’m glad we’ve finally managed to make this meeting happen’, said Pardes kindly. ‘Come on over, take a seat.’

Once Pardes and I had settled comfortably in his unexpectedly grand office, the first topic I pressed him on was the DSM. ‘If you don’t understand the history of the DSM’, insisted Pardes, ‘you cannot hope to understand modern psychiatry.’ The DSM is shorthand for the Diagnostic and Statistical Manual of Mental Disorders and is the book listing all the psychiatric disorders that psychiatrists believe to exist. ‘So the DSM contains every mental disorder with which you or I could be potentially diagnosed’, said Pardes, ‘and that’s its significance.’

Pardes then briefly recalled the DSM’s journey from its modest 130 pages in 1952 to the 886 pages it boasts today. In short, the first edition of the DSM was written in order to solve a problem that had plagued the profession for decades. Until the 1950s, psychiatrists working in different places possessed no shared dictionary in which all the disorders were clearly defined and that carefully listed each disorder’s core symptoms. Without this dictionary, the behaviour that one psychiatrist called ‘melancholic’ or ‘depressive’ another psychiatrist was likely to call something else. So this made communication between psychiatrists in different places almost impossible.3 ‘If I say to another psychiatrist that I have tried the drug Thorazine on 250 people with paranoid schizophrenia’, explained Pardes, ‘what happens if this other psychiatrist’s definition of paranoid schizophrenia is not the same as mine? Well, our discussion becomes meaningless. So the DSM was developed to try to identify and standardise the symptoms characteristic of any given mental illness – anxiety disorder, phobia, mood disorder and so on.’ Every psychiatrist was then expected to learn this list so that different psychiatrists in different places would all be working from the same page.

Once the first DSM arrived in the 1950s, psychiatrists were expected to use the dictionary in the same standardised way still in operation today. For instance, if you go and visit a psychiatrist tomorrow because you’re feeling down, the psychiatrist will ask you to describe your symptoms. The purpose of this is to try to work out from your symptoms what diagnosis from the dictionary you should be assigned. For example, if you report feeling tense, irritable and panicky, and that you have been feeling this way for over two weeks, then you are likely to be diagnosed with one of the anxiety disorders. Whereas if you mention that you’re feeling sad, teary and lethargic and are experiencing disrupted sleep, then you are more likely to be diagnosed with one of the depressive disorders. Of course, sometimes your symptoms will not fall neatly into any single category, but rather span two or three. In this case your problem will be considered ‘comorbid’ – namely, that you are suffering from a disorder that is occurring simultaneously with another (perhaps you suffer from major depression as well as panic disorder). But whether your condition is comorbid or not, the diagnostic process is the same – your psychiatrist attempts to match your symptoms as closely as possible to one of the diagnostic labels listed in the book.

Now here comes the problem. And it’s a problem that still afflicts psychiatry today. How does your psychiatrist know if he or she has assigned the correct diagnosis? Is there a safe and reliable way that he or she can test, objectively speaking, whether the diagnosis given is the right one? I put this question to Pardes: ‘Well, one way to test whether the diagnosis is correct is to apply a scientific or biological test [such as a blood, urine or saliva test] or some other form of physical examination to assess, firstly, whether a patient has a mental disorder, and, if so, precisely what disorder they suffer from. But the crucial problem for psychiatry is that we still have no such objective biological tests.’

In other words, unlike in other areas of medicine where a doctor can conduct a blood or urine test to determine whether they have reached the correct diagnosis, in psychiatry no such methods exist. And they don’t exist, as Pardes also intimated, because psychiatry has yet to identify any clear biological causes for most of the disorders in the DSM (this is a pivotal point that I’ll talk about more fully in coming chapters). So the only method available to psychiatrists is what we could call the ‘matching method’: match the symptoms the patient reports to the relevant diagnosis in the book.

These facts, although at first glance appearing innocuous, are crucial for understanding why psychiatry, in the 1970s, fell into serious crisis. They help us explain why psychiatrists were not only guilty of branding sane people as insane (as the Rosenhan experiment revealed), but also guilty of regularly failing to agree on what diagnosis to assign a given patient (as the ‘diagnostic reliability’ experiments showed). Psychiatry was making these errors because it possessed no objective way of testing whether a person was mentally disordered, and if so, precisely what disorder they were suffering from. Without such objective tests, the diagnosis that a psychiatrist would assign could be influenced by their subjective preferences, and as different psychiatrists were swayed by different subjective factors, it was understandable that they regularly disagreed about what diagnosis to give. This is why these early experiments were so dramatic for the profession: they produced for the first time clear evidence that psychiatric diagnosis was at best imprecise, and at worst a kind of professional guesswork. And so without any objective way of testing the validity of a diagnosis, psychiatry was in peril of falling far behind the diagnostic achievements of other branches of medicine.

A solution was needed, and fast.

•

Under the leadership of the American Psychiatric Association (APA), the profession in the 1970s plumped for a radical solution. It decided to tear up the existing edition of the DSM (then called DSM-II) and start again. The bold idea was to write an entirely new manual that would solve all the problems beleaguering DSM-II. This new manual would be called DSM-III, and its central aim would be to improve the reliability of psychiatric diagnosis and thereby answer the mounting criticisms that were threatening to shatter the profession’s legitimacy.†

The first step the APA took was to set about finding someone to lead the writing of DSM-III. The APA needed a person highly competent, energetic and daring, but also someone who had experience with psychiatric classification. After sifting through countless candidates and enduring many frustrations, the APA finally settled on a man called Dr Robert Spitzer, who was based at Columbia University’s medical school. Spitzer had been a young and up-coming psychiatrist when the earlier DSM-II had been written, and he had also been minimally involved in that project. But most importantly, he appeared to have the drive and vigour needed to get the job done. The APA was sufficiently impressed with his qualities, so they hired him in 1974 to start work on DSM-III. Little did Spitzer know at the time that his appointment as Chair of DSM-III would ultimately make him the most influential psychiatrist of the 20th century.

The first thing Spitzer did to reform the DSM was to assemble a team of fifteen psychiatrists to help him write the new manual. This team was called the DSM Taskforce, and Spitzer was its outright leader. So in the mid-1970s the Taskforce set about writing a kind of New Testament for psychiatry: a book that aspired to improve the uniformity and reliability of psychiatric diagnosis in the wake of all its previous failings. If this sounds all very intrepid, well, that’s pretty much what it was. Spitzer’s Taskforce promised a new deal for psychiatry, and there was a lot of pressure on them to deliver.

So what precisely did Spitzer do to try to set things right? How was he going to make psychiatric diagnosis more reliable and scientific? His answer was simple. The DSM needed to be altered in three major ways:

Many existing disorders would be deleted from DSM-II.The definitions of each disorder in the old DSM would be expanded and made more specific for DSM-III.A new checklist would be developed for DSM-III to improve the reliability of diagnosis.

Let’s briefly look at each of these alterations more closely. The first involved Spitzer deleting some of the more unpopular and controversial mental disorders. These included some of the disorders introduced into psychiatry by psychoanalysis, a discipline with important differences from psychiatry (see footnote below).‡ In the 1970s psychoanalysis had fallen out of vogue in psychiatry, along with many disorders it had introduced to the previous DSM. One of the most controversial of these was homosexuality. Indeed, in the DSM-II homosexuality was listed as a mental disease. It was described as a ‘sexual deviation’ and was located in the same category as paedophilia.4 While some psychiatrists felt it was wrong to brand homosexuality an illness, the main push to remove the disorder largely came from outside pressure groups including the gay rights movement. These groups asked why a normal and natural human sexual preference had been included in the DSM as a mental disease, especially when there was no scientific evidence to justify its inclusion. Surely it was prejudice rather than science that had placed homosexuality on the list?

Many psychiatrists were not so sure, but the APA, perhaps sensing the change in public mood, decided to consult the wider psychiatric community for their views. So at the APA convention in 1973 all the attending members were asked to vote on what they believed: was homosexuality a mental disorder or not? The vote was closer than expected: 5,854 psychiatrists voted to take homosexuality out of the DSM, while 3,810 voted to keep it in. And because the ‘outers’ were in the majority, homosexuality ceased to be a mental disorder in 1974 and was therefore not included in Spitzer’s DSM-III. It was politics and not science that had removed the disorder from this list. As we continue, it’s worth holding that thought in mind.

To turn now to Spitzer’s second alteration, this involved making the definitions of each mental disorder more specific and detailed. The idea was that if each disorder could be defined more precisely, psychiatrists would be less likely to misunderstand the disorders and therefore misapply them to patients. The problem with the earlier DSM-II, Spitzer had argued, was that its definitions of disorders were too open to interpretation. So, for example, in DSM-II ‘depressive neurosis’ was defined in a single sentence: ‘This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession.’5 Spitzer believed that such vague definitions explained why psychiatrists regularly gave different diagnoses to the same patient. If a word in the dictionary were poorly defined, people would not know how to use it properly. The same was the case with psychiatric diagnoses. This imprecision was why, as Spitzer said, for DSM-II, ‘there are no diagnostic categories for which reliability [is] uniformly high … [and why] the level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories.’6 Spitzer’s hope was that by sharpening the definitions there would be less scope for personal interpretation, which in turn would mean diagnostic reliability would rise.

Finally, to help improve diagnostic reliability further, Spitzer’s team created criteria for each disorder that a patient had to meet in order to warrant the diagnosis. So while, for example, there are multiple symptoms associated with depression, it was somehow decided that a patient would need to have at least five of them for a period of at least two weeks to qualify for receiving the diagnosis of depression. The only problem was: on what grounds did Spitzer’s team decide that if you have five symptoms for two weeks you suffered from a depressive disorder? Why didn’t they choose six symptoms for three weeks or three symptoms for five weeks? What was the science that justified putting the line where Spitzer’s team chose to draw it? In an interview in 2010, the psychiatrist Daniel Carlat asked Spitzer this very question:

Carlat: How did you decide on five criteria as being your minimum threshold for depression?

Spitzer: It was just consensus. We would ask clinicians and researchers, ‘How many symptoms do you think patients ought to have before you would give them the diagnosis of depression?’, and we came up with the arbitrary number of five.

Carlat: But why did you choose five and not four? Or why didn’t you choose six?

Spitzer: Because four just seemed like not enough. And six seemed like too much [Spitzer smiles mischievously].

Carlat: But weren’t there any studies done to establish the threshold?

Spitzer: We did reviews of the literature, and in some cases we received funding from NIMH to do field trials … [However] when you do field trials in depression and other disorders, there is no sharp dividing line where you can confidently say, ‘This is the perfect number of symptoms needed to make a diagnosis’ … It would be nice if we had a biological gold standard, but that doesn’t exist, because we don’t understand the neurobiology of depression.7

I expect that by now some of you may be scratching your heads. Wasn’t the whole point of Spitzer’s reform to make psychiatric diagnosis a little more scientifically rigorous? But what, you may ask, is rigorous about a committee drawing arbitrary lines between mental disorder and normality? And what is scientific about asking the psychiatric community to vote on whether existing disorders should be removed from the DSM? In other words, in the name of making psychiatric diagnosis more scientific, had Spitzer’s team continued to make use of the unscientific procedures that had dogged the construction of earlier manuals?

As important as this question is, I’ll refrain from answering it right now, because there is a more crucial question to be addressed first: did Spitzer’s reforms actually work? Did they solve the reliability problem? I mean, if you went to see two different psychiatrists independently today, would they be likely to both assign you the same diagnosis?

In an interview for TheNew Yorker in 2005, a journalist called Alix Spiegel asked Spitzer that very question. His answer was unequivocal: ‘To say that we’ve solved the reliability problem is just not true’, said Spitzer. ‘It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem.’8 Here Spitzer admits something that many within the profession agree with: diagnostic reliability, despite the reforms, is still woefully low.

According to a study published in the journal Psychiatry in 2007, for instance, which asked a group of psychiatrists whether they thought psychiatric diagnosis was now reliable, a full 86 per cent said that reliability was still poor.9 It was not only their clinical experience that led them to this conclusion, but also presumably their familiarity with existing research, including work undertaken by Spitzer himself to find out whether his reforms had worked. Its conclusions were not reassuring. For example, you’ll remember that I said before Spitzer’s DSM-III two psychiatrists would give different diagnoses to the same patient 32 per cent to 42 per cent of the time. Well, Spitzer found that after his reforms psychiatrists were now disagreeing around 33 to 46 per cent of the time – results indicating the very opposite of diagnostic improvement.§ And these disappointing figures are consistent with other more recent studies also implying that reliability is still poor. For example, another study published in 2006 showed that reliability actually has not improved in 30 years.10

•

An obvious question for the British reader is whether poor diagnostic reliability is a problem in the UK? After all, in the UK we have alongside the DSM the International Classification of Diseases (the ICD). Perhaps the ICD leads to greater reliability than the DSM? Although this is a reasonable question to ask, when we take the research en masse, it actually shows that using the ICD leads to no greater diagnostic reliability than using the DSM.11 This may partly explain why in countries like Britain where the ICD is used along with the DSM, many mental health researchers and professionals often prefer the DSM.12 In fact, the National Institute for Clinical Excellence (the body that sets the clinical guidelines for the NHS) now recommends the use of the DSM over the ICD for disorders including depression.13 Also, in my own experience of working in the NHS, the DSM is a very influential manual. But even if you wanted to dispute its precise impact, and as an article in the British Journal of Psychiatry put it: ‘we’d still not avoid all the problems that beset the DSM [here in Britain]. Both manuals were developed and classify mental disorders in pretty much the same way. As the DSM writes: “the many consultations between the developers of the DSM-IV and the ICD-10 … were enormously useful in increasing the congruence and reducing meaningless differences in working between the two systems”.’14 Herbert Pardes also confirmed this to me when recounting that ‘the DSM worked very closely with the ICD to get worldwide cooperation between diagnostic categories’. In other words, diagnostic reliability is a problem for international psychiatry – whichever manual you employ, the reliability rates are broadly the same.

This leads me to one final point about the reliability problem that would be perilous to overlook: what would happen if some day reliability rates in psychiatry were to improve dramatically? This question is important because it reveals a more fundamental problem for psychiatry that it has yet to solve: even if every psychiatrist on the globe independently diagnosed the same patient with the same disorder (for example, with ‘social anxiety disorder’), this would still not prove that social anxiety disorder actually exists in nature, that it’s actually a discrete, identifiable biological disease or malfunction of the brain. You require much more than mere agreement to prove that. You need hard evidence. Unless our sciences can test whether what we agree on is objectively the case, agreement counts for nothing from a scientific standpoint. So even if psychiatrists reach high diagnostic agreement at some future point, this would not prove that the mental disorders with which they diagnose patients actually exist as valid disease entities. There need to be other procedures to establish that. So the issue is: are there other procedures? And if so, what exactly are they?

This question is so central to the entire psychiatric enterprise that I decided to ask Robert Spitzer myself.

* Here I paraphrase from Adam Curtis’ brilliant BBC documentary, The Trap (2007).

† I was often told that poor diagnostic reliability was not the only driver for the DSM’s reform. There was also a need to match DSM terminology to that used in the International Classification of Diseases (ICD). However, Robert Spitzer, Melvin Sabshin and other leaders in the APA knew that the reliability issue was paramount and that the DSM must make that issue its priority.

‡ What is the difference between psychoanalysis and psychiatry? Or between psychiatry, psychology and psychotherapy, for that matter? It can be summarised this way: a psychologist researches different aspects of our mental lives – cognition, memory, perception, etc. They are not clinicians, unless they have undertaken a specialist postgraduate training in clinical psychology or psychotherapy (the ‘talking cure’). The psychotherapist or psychoanalyst, on the other hand, has trained at the postgraduate level to treat patients with the ‘talking cure’ – they do not have to be medical doctors (and so do not prescribe medications). Psychiatrists are medical doctors who have later specialised in psychiatry. Some psychiatrists practise one form of psychotherapy or another but most do not, nor do they have to. Today, most psychiatrists diagnose disorders and prescribe and monitor medications.

§ The psychologist Paula J. Caplan argues that one study showed that when different psychiatrists were diagnosing patients from the Axis II group of disorders (basically the personality and developmental disorders) their diagnoses were the same only about two-thirds of the time (66 per cent). Whereas for the remaining disorders they were the same only about half the time (54 per cent). See: Caplan, P.J. (1995), They Say You’re Crazy. New York: Da Capo (pp. 197–200).

2

The DSM – a great work of fiction?

On a sunny May morning in 2012, I catch the train from New York City. As we leave Penn Station the train slowly rattles under the Hudson River before emerging onto the wasteland of industrial New Jersey. After travelling for about 30 minutes through a bleak landscape of largely abandoned warehouses, signs of a more affluent suburbia begin to break through. With each passing mile the houses get bigger, the cars shinier and the landscape lusher, until we finally reach Princeton University.

I’m travelling to Princeton this May morning because three years earlier Dr Robert Spitzer had moved out there from nearby West Chester. His wife had taken a job at a local research laboratory, and Spitzer, now in his late 70s, had decided to embark upon one last adventure. They had chosen a large and comfortable house in the historic leafy suburbs just north-east of the university, and as my taxi pulled up outside it was clear they had chosen well.

‘Come on in’, said Spitzer, dressed in shorts, sandals and a loose sports top, as he led me into the living area. ‘You wanna stay for lunch?’

Still reeling from my mountainous American breakfast, I struggled to say, ‘Sure, that’d be nice.’

‘Before we do that’, said Spitzer, to my great relief, ‘how about we first sit down so I can tell you what you want to know?’

Once we had settled in our chairs, the first question I had for Spitzer concerned one of the other major changes he introduced into the DSM. What I didn’t mention in the last chapter is that while he created a new checklist system and sharpened the definitions for each disorder, he also introduced over 80 new disorders, effectively expanding the DSM from 182 disorders (DSM-II) to 265 (DSM-III). ‘So what’, I asked Spitzer, ‘was the rationale for this huge expansion?’

‘The disorders we included weren’t really new to the field’, answered Spitzer confidently. ‘They were mainly diagnoses that clinicians used in practice but which weren’t recognised by the DSM or the ICD. There were many examples: borderline personality disorder was one, and so was post-traumatic stress disorder. There were no categories for these disorders prior to DSM-III. So by including them we gave them professional recognition.’

‘So presumably’, I asked, ‘these disorders had been discovered in a biological sense? That’s why they were included, right?’

‘No – not at all’, Spitzer said matter-of-factly. ‘There are only a handful of mental disorders in the DSM known to have a clear biological cause. These are known as the organic disorders [things like epilepsy, Alzheimer’s and Huntington’s disease]. These are few and far between.’

‘So, let me get this clear’, I pressed, ‘there are no discovered biological causes for many of the remaining mental disorders in the DSM?’

‘It’s not for many, it’s for any! No biological markers have been identified.’

‘Well, it’s important to hear you say this, because this is something most people simply don’t know. I didn’t know it when I started out training as a psychotherapist. Most of my patients don’t know it today. And I suspect for many people reading this interview it will come as a surprise too.* ‘So if there are no known biological causes’, I continued, ‘on what grounds do mental disorders make it into the DSM? What other evidence supports their inclusion?’

‘Well, psychiatry is unable to depend on biological markers to justify including disorders in the DSM. So we look for other things – behavioural, psychological; we have other procedures.’

Before we look at these other procedures, let me explain why you are probably surprised to hear that biological research did not guide the DSM’s expansion. This may sound strange to you because we all expect psychiatry to work much like the rest of modern, mainstream medicine. In mainstream medicine a name will be given to a disease only after its pathological roots have been identified in the body. With few exceptions that is how general medicine operates: once you have discovered the physical origins of a problem, you then give it a name such as cystic fibrosis, cancer or Crohn’s disease. But the surprising truth about psychiatry is that it largely operates in completely the opposite way. Rather, psychiatry first names a so-called mental disorder before it has identified any pathological basis in the body. So even when there’s no biological evidence that a mental disorder exists, that disorder can still enter the DSM and become part of our medical culture.

Of course, the fact that psychiatry operates differently does not mean that its procedures are necessarily wrong. The only way to decide this is to assess whether psychiatry’s alternative methods are scientifically valid. To find out if this is the case, I asked Spitzer to take me through the procedures his Taskforce followed when deciding whether to include a new disorder. For example, if the findings of biology didn’t help the Taskforce to determine what disorders to include in DSM-III, then what on earth did?

‘I guess our general principle’, answered Spitzer candidly, ‘was that if a large enough number of clinicians felt that a diagnostic concept was important in their work, then we were likely to add it as a new category. That was essentially it. It became a question of how much consensus there was to recognise and include a particular disorder.’

‘So it was agreement that determined what went into the DSM’?

‘That was essentially how it went – right.’

What sprung to mind at Spitzer’s revelation was the point I made in the previous chapter about agreement not constituting proof. If a group of respected theologians all agree that God exists, this does not prove that God exists. All it proves is that these theologians believe he does. So in what sense is psychiatric agreement different? Why, when a committee of psychiatrists agree that a collection of behaviours and feelings point to the existence of a mental disorder, should the rest of us accept they’ve got it right? Perhaps, in the absence of biological evidence to convince us, they can produce other kinds of evidence to assure us that their agreements were justified? In other words, what was the evidence leading the Taskforce to agree that a new disorder should be included in the DSM?

•

Before coming back to Spitzer for an answer, let me first put this question to the psychologist Professor Paula J. Caplan, currently a Fellow at Harvard University’s Kennedy School, and former consultant to two DSM committees. I interviewed Paula from my home in London in late April 2012, precisely because she has extensively assessed the evidence that guided many of the decisions the DSM Taskforce made.

One of the disorders she has focused on closely was called ‘masochistic personality disorder’. Spitzer’s Taskforce wanted to include this new disorder in the DSM for people who displayed ‘masochistic traits’ such as those thought to invite harsh treatment from others, or those leading people to seek out pain for enjoyment. Now, a crucial reason why Paula Caplan and other critics objected to these traits being called symptoms of a psychiatric disorder was because these traits were also said to be typical of women who were victims of violence. So it was thought that this diagnosis was very dangerous, not only because it could be used in courts of law to suggest that female victims of violence were in fact bringing it upon themselves (because they had a ‘masochistic personality disorder’), but also because it could be used to let perpetrators of violence off the hook – they were simply doing what these women supposedly wanted.

So after much opposition from Caplan and other psychologists, the committee finally decided to rename masochistic personality disorder as ‘self-defeating personality disorder’ – or the neat SDPD. But the critics then argued that this change in name still implied that there was something ‘self-defeating’ in these victims – something compelling them in some way to invite abuse upon themselves. ‘So the change in name was not really a victory at all’, said Caplan to me energetically, ‘since by renaming the disorder as SDPD nothing really had changed: the renamed disorder could still be used to claim that women victims of abuse, well, kind of asked for it.’

When Caplan made this point to Spitzer, he remained simply unmoved. In fact, his desire to keep SDPD was so strong, it would have been understandable had the critics retreated. But they didn’t. Rather, at the last hour, Caplan devised a simple plan: ‘I decided to scrutinise thoroughly the very research used to justify including SDPD in the DSM.’ And here’s what she found.

Firstly, she discovered only two pieces of research – a remarkably small number by anyone’s standards. But as surprising as this discovery was, when Caplan actually looked at the research she became incredulous. ‘It was so methodologically flawed’, said Caplan animatedly, ‘that it would fail an undergraduate examination. In fact, it was so full of basic errors that I actually decided to use it on an undergraduate exam in which I asked students to point out every conceivable methodological error, because his study had so many.’

For example, in Spitzer’s research a group of psychiatrists at only one university, who already accepted SDPD existed, were shown some old case studies. All then unanimously agreed that the patients in them had SDPD. Caplan pointed out that just because some psychiatrists at one hospital diagnosed their patients with SDPD, that was not proof that the disorder actually exists. As Caplan said: ‘all Spitzer’s research proves is that a group of psychiatrists working in the same institution gave the same label – rightly or wrongly – to a given set of behaviours.’1 It proves nothing more than that.

‘But if you think that first piece of research was weak’, continued Caplan, ‘then consider the second piece. This involved sending out a questionnaire to a selected number of members of the American Psychiatric Association. This asked them whether the diagnosis SDPD should be included in the DSM. If they voted “yes” then they were asked to describe what they thought the characteristics of SDPD were. If they voted “no” then they were asked to return the questionnaire, blank, without any clinical data. This meant that the only data gathered about the characteristics of SDPD was data obtained from people who believed in the existence of SDPD in the first place.’

So how many psychiatrists believed SDPD to exist – how many voted ‘yes’?

An official report showed that only 11 per cent of those who returned the questionnaire described what they thought the characteristics of SDPD were.2 So essentially only 11 per cent voted ‘yes’, which is surely not a representative sample of the psychiatric community. But what made matters worse is that the questionnaire was also sent to many psychiatrists who already supported the diagnosis and who were deliberately screened into the study. And these psychiatrists, we can assume, made up a proportion of this 11 per cent.3

Caplan has therefore convincingly argued that neither piece of research justifies creating a new mental disorder. But that didn’t stop Spitzer, as she said, from proudly reporting in the DSM that the nature of SDPD was defined by examining the ‘data’ from a single questionnaire; a questionnaire Spitzer claimed had been ‘distributed to several thousand members of the APA’. ‘Spitzer does not report the methodological flaws in his research’, said Caplan incredulously, ‘and instead leads us to believe the creation of this disorder was based upon widespread scientific consultation and study.’

•

I have discussed at length the case of SDPD because it forces us to ask whether other disorders were included in the DSM on the basis of equally poor scientific evidence. Was this just an isolated example, or is it quite representative? To try to find out, I decided to read to Spitzer the following quotation, which claims that the research backing was not just poor for SDPD but for most of the mental disorders Spitzer’s team included. This verdict comes from one of the leading lights on Spitzer’s Taskforce, Dr Theodore Millon. Here’s what he said about the DSM’s construction:

There was very little systematic research, and much of the research that existed was really a hodgepodge – scattered, inconsistent, and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.4

Once I’d read this quote to Spitzer, I asked him whether he agreed with Millon’s statement. After a short and somewhat uncomfortable silence, Spitzer responded in a way I didn’t expect:

‘Well, it’s true that for many of the disorders that were added, there wasn’t a tremendous amount of research, and certainly there wasn’t research on the particular way that we defined these disorders. In the case of Millon’s quote, I think he is mainly referring to the personality disorders … But again, it is certainly true that the amount of research validating data on most psychiatric disorders is very limited indeed.’

Trying not to look shocked, I continued: ‘So you’re saying that there was little research not only supporting your inclusion of new disorders, but also supporting how these disorders should be defined?’

‘There are very few disorders whose definition was a result of specific research data’, responded Spitzer. ‘For borderline personality disorder there was some research that looked at different ways of defining the disorder. And we chose the definition that seemed to be the most valid. But for the other categories rarely could you say that there was research literature supporting the definition’s validity.’

Spitzer’s admission so surprised me that I decided to check it with other members of his Taskforce. So on a rainy English Monday I called Professor Donald Klein in his New York office to ask whether he agreed with Spitzer’s account of events. Klein had been a leader on the Taskforce, and so was at the heart of everything that went on.

‘Sure, we had very little in the way of data’, Klein confirmed through a crackling phone line, ‘so we were forced to rely on clinical consensus, which, admittedly, is a very poor way to do things. But it was better than anything else we had.’

‘So without data to guide you’, I nudged carefully, ‘how was this consensus reached?’

‘We thrashed it out, basically. We had a three-hour argument. There would be about twelve people sitting down at the table, usually there was a chairperson and there was somebody taking notes. And at the end of each meeting there would be a distribution of events. And at the next meeting some would agree with the inclusion, and the others would continue arguing. If people were still divided, the matter would be eventually decided by a vote.’

‘A vote, really?’ I asked, trying to conceal that I hardly felt reassured.

‘Sure, that is how it went.’

Renee Garfinkel, a psychologist who participated in two DSM advisory committees, also confirmed the unscientific processes by which key decisions were made: ‘You must understand’, said Garfinkel to me bluntly, ‘what I saw happening on these committees wasn’t scientific – it more resembled a group of friends trying to decide where they want to go for dinner. One person says, “I feel like Chinese food”, and another person says, “No, no, I’m really more in the mood for Indian food”, and finally, after some discussion and collaborative give and take, they all decide to go have Italian.’

Garfinkel then gave me a concrete example of how far down the scale of intellectual respectability she felt those meetings could sometimes fall. ‘On one occasion I was sitting in on a Taskforce meeting, and there was a discussion about whether a particular behaviour should be classed as a symptom of a particular disorder. And as the conversation went on, to my great astonishment one Taskforce member suddenly piped up, “Oh no, no, we can’t include that behaviour as a symptom, because I do that!” And so it was decided that that behaviour would not be included because, presumably, if someone on the Taskforce does it, it must be perfectly normal.’

According to other members of the Taskforce, these meetings were often haphazard affairs. ‘Suddenly, these things would happen and there didn’t seem to be much basis for it except that someone just decided all of a sudden to run with it’, said one participant. ‘It seemed’, another member admitted, that ‘the loudest voices usually won out’.5 With no extensive data one could turn to, the outcome of Taskforce decisions often depended on who in the room had the strongest personality. ‘But the problem with relying on consensus’, reiterated Garfinkel, ‘is that in the discussion some voices will just get quieter, either because they don’t want to fight or because they see they’re the minority. And snap, that’s when the decision is made.’

Admittedly, when the Taskforce lacked expertise on a particular disorder, Spitzer would consult the relevant leaders in the field. But this also led to chaotic meetings that members often found difficult to participate in. One of the few British members on the Taskforce, a psychiatrist called David Shaffer, recalled how such meetings often unfolded. ‘[In these] meetings of the so-called experts or advisers, people would be standing and sitting and moving around. People would talk on top of each other. But Bob [Spitzer] would be too busy typing notes to chair the meeting in an orderly way.’6

In an article for TheNew Yorker, Alix Spiegel recounts how two new disorders (‘factitious disorder’ and ‘brief reactive psychosis’) made it into the DSM through such disorderly consultations: