Grief is a new psychic territory. You cross into an altered land, and meet the residents, who greet you as if inviting you into their tribe. They are kindred. You may have only known them glancingly before, across tables at a dinner party, or down the hall, but now you know them, for this passage that you and they have made.Sometimes, several years slip by with us attired in the proverbial widow's black. Poetry and music resonate in new ways. Joy is sweeter; sorrow deeper. Sobbing helps. Time, eventually, heals, although we are never the same. Some change utterly.
The experience is so profound that the American Psychiatric Association's proposal to recast grief as mental illness in the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which will be released next month for use around the world, has jarred a great many people, both lay and professional. So have several other revisions, to definitions of anxiety, behavioural addictions, even how we navigate physical pain.
It is a peculiar and reductive logic about the nature of being human, this idea that grief – or stress, or bingeing on pie – merits medical intervention. And it is a logic that pervades the DSM revisions, which is why the manual is proving wildly controversial on the eve of its unveiling.
Psychiatrists have resigned from the revision working groups to protest against various criteria; open letters have been penned by the British Psychological Society, and the American Society for Humanistic Psychology; petitions have been signed by thousands of mental-health practitioners; boycotts are being planned in both North America and Europe. "I will not buy DSM-5. I will not use it. I will not teach it," psychiatrist Patrick Landman, of Université de Paris VII, declared in Psychology Today, where several professionals have taken to voicing their fierce opposition with ongoing blogs.
The original edition was published in 1952 in order to standardize diagnostic criteria, reflecting at the outset the optimistic notion that our social and emotional lives might be tidily catalogued. Subsequent revisions have manifest the fashions of the times. Homosexuality was in at one point. Then that came out, and shyness went in. What is fashionable now, it seemsfor all intents and purposes, is expanded catchment.
This is the overriding concern of mental health professionals who oppose the DSM-5. As the manual grows (the original had 95 mental disorders; the last edition, 283), they argue that it lowers so many thresholds for being diagnosed with minor mental illnesses that life, itself, becomes treatable as disease.
The proposed revisions to Generalized Anxiety Disorder, for instance, drop the bar practically to the level of being worried about your job and having muscle tension. You need to have one of four symptoms, according to psychiatrists who have seen the draft, and be worrying "excessively" about at least two areas of your life. Your job and your finances, say. How worried is too worried? What is wrong with waves of dread when your bank account dwindles to zero?
Allen Frances, a U.S. psychiatrist and professor emeritus at Duke University who oversaw the previous DSM revisions in 1994, calls this "a travesty of careless suggestions that will likely turn our current diagnostic inflation into hyperinflation."
One of the most decried DSM revisions involves the introduction of "Somatic Symptom Disorder," which will be diagnosed in a patient who displays "excessive and disproportionate thoughts, feelings and behaviours" in relation to an illness. It doesn't have to be an imagined illness, or a medically unexplained illness. It can be cancer, or gout. If you are plagued by chronic pain, let us say, and fret about it a lot, then your physician can decide that you are being unreasonable, and thus declare you disordered.
Of course, clinicians do not have to make such diagnoses. For example, there's no imperative to diagnose people with "Major Depressive Disorder" if they are grieving. But in the DSM-5, the APA removes the exemption of mourning from a diagnosis of mental illness because there are no biological markers to distinguish the two states. You cannot rule out one or the other on the basis of a blood test, or a brain scan. Therefore, members of the APA have argued, the bereaved deserve access to the same treatment as everyone else.
The operative assumption behind many of these revisions is that clinicians will use their best judgment when considering treatment. "Mental disorders are beyond most people's everyday experiences," insists David Kupfer, chair of the DSM-5 Task Force. "Clinical training is required in order to make a diagnosis using DSM." They won't really label you mentally ill due to cancer pain; they won't try to solve your financial and marital anxieties by prescribing an atypical anti-psychotic. Stop worrying excessively about the DSM revisions.
In fact, however, it has become common for people to receive medication rather than concerted counsel from busy doctors and psychiatrists, and that is why loosening these criteria is so problematic. "Psychiatry wants to be just like the rest of medicine, and a lot of its practitioners have stopped listening to people," says Joel Paris, chair of McGill University's department of psychiatry and author of An Intelligent Clinician's Guide to the DSM-5. "The problem lies not with this particular edition [of the DSM] but with the ideology behind it, which is that mental illness is neurobiological, and that psychosocial factors are not that important. This is the position that has taken over academic and clinical psychiatry over recent decades, and it has led to a serious overprescription of medications."
Here, I think of a friend who went to see a psychiatrist during his divorce, and emerged from his first session with a diagnosis for "soft bipolar" disorder and an prescription for anti-psychotics. Love, loss, guilt, thwarted dreams, sudden shocks, mounting pressures, these are slings and arrows, not chronic disease.
Dr. Frances frequently points out that even modest changes in diagnostic criteria lead to outbreaks of mental illness because of the power and ingenuity of pharmaceutical marketing. The incidence rates of attention deficit disorder, he offers by way of example, have tripled in the United States since a small amendment was made for DSM-IV.
It is, he and others argue, naive to presume that pharmaceutical companies will not make a meal of the new semantics. Eli Lilly already has its antidepressant, Cymbalta, in clinical trials for "bereavement-related depression." In posting information about the trial, principal clinical investigator John Shuster said: "We expect that Cymbalta treatment will be associated with substantial mean reductions in measures of grief and bereavement, with improvements in measures of pain, symptom burden, and functional status."
Is the widow's veil a symptom burden? Does regaining your functional status win out over "death's solemn stillness?"
What is motivating the APA to resist all the criticism is complex. Some point to a hopeless enmeshment with the agendas of drug companies, a phenomenon that has been well documented by journalists and by psychiatrists themselves over the past several years There is also pressure from patient support groups, and "key opinion leaders," which is a euphemism for industry-funded experts.
And there is, ultimately, this obsession with taxonomy, with making the psyche conform to medical measurements. "They want psychiatric diagnoses to have solidity, but the fact is that psychiatry has produced anything but that kind of solidity," says Edward Shorter, an historian of psychiatry at the University of Toronto. Psychiatry remains subjective, conjectural, with one person's "excessive worry" being another person's habit of mind, or cultural bent – something that looks the same but proves adaptive rather than dysfunctional in a different cultural context. It will ever be thus, that the mind eludes the measurement.
Is anxiety disordered? Sometimes, and sometimes not. Sometimes the focus of one's dread is irrational, but only because the dread is displaced. Psychiatrist Aaron Beck, inventor of cognitive-behavioural therapy, wrote about phobias as an act of displacement. A man loses his mother and develops, apparently randomly, an acute fear of flying. It is easier to avoid airplanes than to avoid death. Once, when I was deeply unsettled by certain personal affairs, I unconsciously ignored them and decided, instead, that we were all about to die from the avian flu.
How do you code for and quantify emotional responses that shape-shift?
John Livesley, emeritus professor of psychiatry at the University of British Columbia, resigned last summer from the Personality and Personality Disorders Work Group of DSM-5 because he was so appalled by the vagueness, inconsistency and "stunning disregard for evidence" that characterized the process of revising diagnoses of personality. (This is the category that includes sociopaths, narcissists and borderline personality, among others.)
"Alas," he says, "the DSM is influenced by a large number of factors besides scientific evidence."
Often, those making the decisions are established figures who are settled in their thinking and resist new ideas, not unlike the old psychoanalysts who were unable to incorporate fresh insights questioning female "penis envy," or whatever begged for a double-take. They are Ivory Tower figures, too. "Many members of the Work Group," Dr. Livesley points out, "do not see patients regularly and some have never or only rarely seen patients."
It is easier to ponder how many angels can dance on the head of a pin when no angel is present to argue.
Here is another concern with the trajectory of the DSM: It has been steadily undermining the importance and credibility of the major mental illnesses, which deserve most of medicine's attention and resources. "The DSM evolved as a language of communication between clinicians and researchers," says psychiatrist David Goldbloom, current chair of the Mental Health Commission of Canada, "so that they could be talking about the same observed phenomena when they summarized it with a diagnostic label. I don't think it was conceived of as a biblical embodiment of absolute diagnostic truth of disease, even if people use/see/fear it that way. There are no biological markers for any psychiatric disorder presently. Genes code for proteins, not for the DSM. While I understand the heat about DSM-5 and share the concern about its potential to medicalize normative human experience … it is unlikely to change the severity of who I see as a clinician. The concern about DSM-5 seems to be at its margins."
At its margins, which is where many of us – the bereaved, the heartbroken, the flat-broke – reside, this is about what story we want to tell ourselves about who we are. Our narratives, as we live and ascribe meaning to them, are richer and more nuanced than what is laid out in a set of behavioural criteria, or a shrinking number of physical symptoms. This is why the APA has received such vigorous push-back on the current revisions. Unwittingly, the DSM-5 revisionists are contributing to an impoverishment of meaning, and it may be that the need to generate meaning, to make sense of experience, is more important to our wellness – at these margins – than drugs.
"Psychiatry has entered the new era of the DSM, yet none of the many evaluations carried out in its name in the U.S. and Europe has shown significant or lasting improvement in the mental health of their citizens," wrote Patrick Landman, the French psychiatrist who is part of a movement to boycott the new edition. "To cite just one of many possible examples, between 2000 and 2009, the consumption of antidepressants in the OECD countries increased by an average of 60 per cent. No study has shown a decline in the prevalence of depression. Quite the contrary: The suicide rate in Iceland, a country that consumes the highest amount of antidepressants per capita, has been constant for the past 10 years."
Awkward data, that. Unfortunately, it's also quantifiable.
Editor's Note: An earlier version of this article on psychology incorrectly described Aaron Beck as a psychologist. Dr. Beck, the inventor of cognitive-behavioural therapy is a psychiatrist.