For reasons that mostly escape me, I am once again sticking my nose in psychiatry’s business. Really its business—the Diagnostic and Statistical Manual that is one of the American Psychiatric Association’s major sources of income. Every so often, the APA renews its franchise on the terminology of mental illness by revamping the DSM. The DSM-III came out in 1980, the DSM-IV came out in 1994 and was minorly revised in 2000, and planning began immediately for DSM-V. That book was scheduled for release in 2011, moved up to 2012, and then recently delayed another year.

That’s an indication that all is not well in the revision process. Psychiatrists are once again fighting about which of our foibles are mental illnesses, which forms of suffering are the symptoms of what diseases, and, of course, the granddaddy of all these worries, what a mental illness is in the first place. Does a man who prefers teenage girls as his sexual partners (but who does not coerce them sexually) have pedohebephilic disorder, or is he just a creep (or for that matter responding in an unfortunate manner to a society that bombards us with images of tarted up teenagers and holds them up as the epitome of desire)? Is an adolescent who is socially maladjusted and sometimes hearing voices, but nowhere near psychotic, suffering from attenuated psychotic symptoms syndrome and in need of Abilify, and its devastating effect on metabolism, as a preventive, or is he just a weird kid? If someone you love dies and you experience in your grief five or more of the nine symptoms of major depressive disorder, are you mentally ill or just mourning your loss?

I don’t know the answers either. I do know that the most decisive thing the APA has done so far is to rename the DSM-V. It’s now the DSM-5, the better to name subsequent editions in keeping with modern naming conventions—you know, DSM 5.1, DSM 5.2 and so on. I also know that when you start to ask psychiatrists to tell you about their view of the process, they can get mighty touchy, especially if they think you are the Enemy. Which is the occasion for this post—an email response I got from a psychiatrist who had written what I thought was an interesting article suggesting that maybe the DSM was no longer necessary, that psychiatry didn’t really need its own diagnostic manual, costing 75 or 100 dollars a pop, since the United Nations’ World Health Organization supplies the International Classification of Diseases, a list of all our afflictions, physical and mental, for exactly free. (I’d link to the article, but for reasons that will become clear in a minute, I don’t want to reveal this doctor’s identity.) I wrote him to see if I could interview him further on this subject. Here is his response, unedited.

I most likely won’t be able to help you. After reading the reviews of you book on Amazon it appears to be another psychiatry bashing book. Depression is a medical illness, in fact in industrial nations it is the leading cause of disability. Doubting the reality of depression is in the same ballpark as doubting evolution. Therefore I believe your book is rather irresponsible and a disservice to people who are suffering. Depression is different in that it effects the self and everyone’s experience is different, but it is not fair to generalize your own or a few patient’s experience to everyone.

Regarding the debate about the DSM-V, one of my fears it that it will be yet another tool used against mental health. However I believe both sides in the debate are interested in making psychiatry more scientific in its diagnoses. My guess is your paper is going to suggest the debate on the DSM-V supports your own view that mental illness is someone a construct. I would urge you to think take a different approach to the debate and if you are interested in learning about the actual concerns in the scientific community about moving the nosology in psychiatry further then I can provide you with some useful info. If on the other hand you are going to repeat the same old theme about psychiatrists and how we construct mental illness then I will not be a part of that.

Now, I’ll admit to having gone a little hard on psychiatrists in my book. But I have to say that I haven’t seen the ill effects of it on them or their grasp on the mental health franchise. Nor would it be fair to say that I didn’t back up everything I said, including my contention that mental illness is at least partly constructed by psychiatrists, with scientific evidence. Speaking of evidence, it’s not my fault that there simply isn’t any to support their idea that depression is a simple biochemical imbalance. And when you consider that day in and day out they keep telling people this, and that people end up taking drugs with known side effects, not to mention start to think of themselves as biochemically defective and their depressions as personally meaningless, you really have to wonder who is more irresponsible here.

Not that I would want to diagnose disagreement as pathology, but you really have to wonder about this kind of thin-skinnedness. I mean, this doctor is a smart guy who wrote a pretty decent little paper, and he has to know that it is a fundamental violation of intellectual integrity to make conclusions about what a book says based on its reviews, let alone its Amazon reviews. He’s got to know that he only undercuts himself by doing that, that he’d be better off politely declining than going off half-cocked like this, especially if his interlocutor is an irresponsible hothead who wants people to suffer and kill themselves, and is also writing for a national magazine with a big circulation. Why would he provoke such a person, who, after all, might post his name and other particulars along with his intemperate and grammar-challenged outburst ? (Which I won’t. In fact, in my response to him, in which I reminded him that there is a difference between criticism and bashing, I repeated my admiration for his paper, so I wouldn’t want to help him torpedo his own credibility.)

So why would an otherwise intelligent man do something so dumb?

That, by the way, is a very common question in therapy. People come in, and you’re impressed by their grasp on themselves, their articulacy, their common sense, and they tell you about something they did that they know was dumb. What was the blind spot? More often than not, the answer has something to do with anxiety. Nobody’s at their best when they’re anxious. The urgency of that upwelling feeling leads us to do stupid shit.

Here’s what I think. I think the psychiatric profession suffers from an unresolved inferiority complex. I think they’re so worried about whether or not they really belong in medicine that when someone points out some of the stresses in the relationship between psychiatry and the rest of medicine, they get worried. I think Dr X is sick and tired of people pointing it out, and has not yet learned to sort out the bashers from the criticizers. He feels bashed by all of them/us. More important, my doubts (and really that’s what I am about psychiatry, including psychotherapy—doubtful) awaken his own, and he can’t tolerate that. So he lashes out.

Too bad. Because I have, to my great surprise and delight, met psychiatrists recently, important psychiatrists, who can indeed tolerate their doubts, who don’t insist that people who oppose them are creationists or dangerous, and who have the mark of intelligence described so well by Scott Fitzgerald: the ability to hold two opposing thoughts in their minds at the same time.  This guy just isn’t one of them. I suppose he suffers from doubt-deficit syndrome.

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