More on Grief

When it comes to criticism of the DSM-5, the loudest and most trenchant voices belong to those who think it’s going to extend the reach of psychiatry further into everyday life. Allen Frances is leading this charge, but he’s joined by Christopher Lane, Paula Caplan, and just about every other sentient being who’s not on the DSM-5 committees. (That would include me; I’m sure if I searched the phrase “extend the reach” in the searchable pdf file of my book that my publisher made the mistake of providing me with, I would find it often enough to make me cringe. But I won’t.) And when they lodge this charge, the case in point is often the soon to be defunct bereavement exclusion, that little diagnostic codicil that currently prohibits doctors from diagnosing people in mourning from being diagnosed with depression for the first two months after their loss. Bereft of the bereavement exclusion, the criticism goes, the DSM-5 will result in more people diagnosed with depression, more antidepressant prescriptions, and more diseasing of America.

The wisdom of crowds is a beautiful thing, unless you’ve ever actually been in one. Having spent way too much of my pre-1995 life at Grateful Dead shows, I have had the opportunity to do just that. Even when it’s pretty, it’s scary, and if you don’t believe me, just watch Triumph of the Will.

Anyway, I digress. (I can’t help it. I haven’t been in a synagogue more than five times in thirty years, but still the Jew lies deep in me.) Point is, when so many people are saying the same thing, even when that thing is quite plausible, even (or especially) when you agree with it, it’s time to wonder about it, or maybe about yourself. So to the question: Will removing the bereavement exclusion really lead to more psychiatric diagnosis?

In a way, it’s hard to imagine psychiatry extending its reach any further. I mean, it’s already reaching so far you can feel it palpating your prostate (or, I suppose, your ovaries, if you are lucky enough¬† not to be of the gender that possesses those walnut-sized cancer factories embedded deep in its collective groin). The DSM-IV, like the DSM-III, has a psychiatric diagnosis to suit just about any complaint you might have about the life of your psyche. That’s not an accident. Diagnostic expansion was part of the mission of the DSM-III, the one that has been the template for diagnosis since 1980: not only to provide the criteria for discerning a particular psychiatric disorder, but to provide psychiatric disorders for everything that ailed us. Bob Spitzer, the Khalid Sheik-Mohammed of the DSM-III, was a nosological diplomat, and he recognized that if he stuck with only the 21 criterion-based diagnoses (of really severe mental illnesses like schizophrenia and manic depression) that had been developed when he started the revision, he’d lose the support of the rank and file, who needed their depressive neuroses and their anxiety reactions¬†if they were to stay in business.

Now that’s not to say that psychiatrists weren’t already reaching deep into our psyches. Of course they were, but they weren’t doing it by declaring us mentally ill. They were doing it by providing psychoanalysis to the walking wounded, transforming the language of the self in the process, but without diagnosing any of that population with what could plausibly be thought of as a medical illness. That’s what changed with the DSM-III. Psychiatrists, for mostly parochial reasons (like saving their profession from charges of pseudoscience), started to give quasi-medical names to our pain. When the drug companies got interested in psychiatric drugs, those names became extremely useful. And the two industries have been doing the tango ever since.

But none of this would have worked without a market. There is a demand side to the economy of mental disorder. In the three decades since the DSM-III was introduced, the impetus to declare ourselves sick gathered the force of a constant windstorm. So long as you’re willing to join the ranks of the diseased, it blows at your back. To say, “I am clinically depressed” is to stake a claim to many goods: sympathy, tolerance, time off from work, the right to take mind-altering drugs on the insurance companies’ tab every day without being accused of being a stoner. To say, “I have Asperger’s” opens other doors (which the APA is going to shut; that one worked too well). And so on. There’s a premium on illness; it’s increasingly how we define ourselves, how we demand resources from society, how we understand our lives. And not just mental illness. There’s a reason health care is gobbling up more and more dollars every year, and it ain’t all the fault of greedy doctors and drug companies. It’s also because, as Peter Sedgwick said in 1972, and as i never get tired of quoting, “The future belongs to illness.” Forty years later, the future is here.

Or, to put it another way, the market may have reached saturation. I mean, how much more saturated can it get? Already, bereavement exclusion or not, the DSM provides criteria and labels by which half of us will suffer a mental illness in our lifetimes. That may be because the DSM is an evil disease-generating book. But it may also be because consumers know what they want and psychiatrists know how to give it to them. Removing the bereavement exclusion may not increase the market but only reapportion the share from other diagnoses, in the same way that opening a Lowe’s next to a Home Depot does not necessarily create more DIY home improvers, but only gives them a better choice of where to go to buy faucets.

So here’s my prediction: the removal of the bereavement exclusion (and the DSM-5 in general) won’t put the fingers of psychiatry further up our collective rectum. (or is it recta?) It will only give it a new orifice to probe.

One Response to “More on Grief”

  1. Secuti says:

    Rectum, an abbreviation for Rectun Intestinum or ‘Straight intestine’ derives from the latin for straight ‘Rectus’ and the plural form is indeed ‘Recta’. Incidently that also appears to be where the DSM-5 revision members took their new amendments out of.

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