The Book of Woe: The DSM and the Unmaking of Psychiatry by Gary Greenberg - review by Irving Kirsch

Irving Kirsch

Mad & Madder

The Book of Woe: The DSM and the Unmaking of Psychiatry

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How would you feel two weeks after a loved one – perhaps a son or daughter or mother or father – had died? Might you still feel sad or empty most of each day? Would you have lost interest in most activities? Could the loss affect your appetite or your sleep? If so, you could be officially diagnosed as mentally ill under the criteria adopted in the newly released fifth version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – or DSM as it is commonly known. Older versions of this psychiatric bible contained a bereavement exclusion. You would not be considered to be suffering from a major depressive disorder if the depression were due to the loss of a loved one. The new version drops this exclusion. One could well argue that any parent who has recovered after the loss of a child in just two weeks is mentally ill, but DSM-5 makes you mentally ill if you have not. 

Dropping the bereavement exclusion is one of the more controversial changes in the new DSM; like many of my friends and colleagues, I could make no sense of it. It seemed barbaric, idiotic and senseless. In The Book of Woe, Gary Greenberg explains the logic of the decision. You see, the loss of a loved one is only one of a variety of life’s catastrophes that can make you depressed. People may get depressed after a divorce or a financial disaster and, as it turns out, researchers find no difference between the symptoms of depression following the loss of a loved one and those following other stressful life events. Why, then, should bereavement be singled out for special treatment?

Perhaps, one could argue, the compilers of DSM-5 should have expanded the exclusion, rather than dropped it. Maybe anyone who is depressed because they have suffered a severe loss of any kind should be spared the stigmatising label of a mental illness. As Greenberg points out, this is exactly the argument made by the researchers who first established the essential similarity between depression following the loss of a loved one and depression triggered by other losses.

The bereavement exclusion illustrates a more basic problem on which Greenberg focuses: the notion that psychological disorders are medical illness, diseases of the brain associated with faulty neurotransmission. Mental illnesses are enshrined in DSM on the basis of considerations that would have no place in other branches of medicine. These include whether the person is distressed by the presence of the symptoms and the effect of the condition’s definition on insurance reimbursement. Imagine deciding that cancer is not cancer if the patient is not upset by its presence or that it is a disease because the person might otherwise not be given appropriate care.

You may have thought that mental illnesses are real diseases of the brain that can be diagnosed reliably by psychiatrists. In The Book of Woe, Greenberg argues persuasively that they are not. But one need not take Greenberg’s word for it. An acknowledgement that diagnosed mental illnesses are not real diseases can be found in DSM itself. It states that ‘there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder’. In other words, depression, schizophrenia, bipolar disorder and the other conditions listed in the book are simply invented categories, not discovered illnesses.

Categories are necessary for many purposes – research, for example. But to serve their purpose, they have to be reliable. Greenberg, who served as a field tester for the DSM categories, reveals just how unreliable they actually are. Whether you are suffering from depression, anxiety or a personality disorder depends on which psychiatrist is making the diagnosis. So it should come as no surprise that the National Institute of Mental Health, which funds more mental health research than any other organisation in the world, has rejected DSM-5 and has announced that it will be ‘re-orienting its research away from DSM categories’.

Gary Greenberg’s well-written book is explosive in its revelations. Although I have concentrated on its disturbing implications, Greenberg’s own focus is more on the process by which this travesty came into being. He seems to have interviewed every major figure in the development of DSM-5, as well as many of the prominent developers of its predecessors. His writing is as entertaining as the topic is serious, and he reports his conversations with experts with an often scathing wit. Greenberg once interviewed me for a magazine article. Having read The Book of Woe, I am thankful to have been treated so kindly.

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