Shrink Wrapped

February 11, 2012

“Grief is the agony of an instant, the indulgence of grief the blunder of a life.”

Thus spake Disraeli, British Prime Minister under Queen Victoria and apparently a prophet of modern ennui. The New York Times ran a story recently about proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders, or DSM, invariably described as “the bible of mental health treatment,” which wants to include grief – good, old, normal bereavement — as a new category of depression in the next edition of the book. This has sneaky implications: The DSM is the go-to reference for psychiatrists and, more critically, health insurers, who follow its recommendations when deciding to cover — or not cover – treatment for what ails ya.

In other words, if your complaint has a name and a diagnostic number in the DSM, someone’s more likely to pay for your pills. Adding a “disorder” like grief to the mix widens the margin for mistaken diagnoses and will benefit Big Pharma more than anyone else. “Current efforts to revise the manual,” says the Times, “are shaping up as the most contentious ever.”

Of course grief – acute sorrow from the death of a loved one – has been medicated forever, usually with alcohol, and in some cases, obviously, it can persist indefinitely and morph into mental illness. But up till now, taken alone, grief has been excluded from the DSM as a marketable ailment. It’s one of a host of conditions, ranging from shyness to schizophrenia, that by their absence make depression apparent in a given case. Other possibilities need to be excluded before they hand out the Prozac.

Currently, the DSM requires that patients exhibit at least five symptoms of major depression before a correct diagnosis can be made – trouble sleeping, feelings of worthlessness, “suicidal ideation,” etc. These must persist for at least two weeks and not be caused by external factors. A depressed grief-stricken person, you’d think, would present symptoms above and beyond, or anyway different from … well, grief.

But no: Under the new rules, if your husband dies suddenly and you’re still weeping about it two weeks later, you can put away the sherry and head to the pharmacy for relief.

In fairness to the industry, a lot of psychiatrists are frowning on this. “There is the potential for considerable false-positive diagnoses and unnecessary treatment of grief-stricken persons,” the Times reports, words that would cheer the heart if the experts weren’t so concerned with externals: “Drugs for depression can have side effects, including low sex drive” (as if that were the best reason for avoiding them!). Americans are already the most medicated people on earth – the pathologizing of “negative emotion” has hit epidemic levels in this country.

Take “attenuated psychosis syndrome” (A.P.S.), my current favorite for inclusion in the revised DSM. This is a label to be stuck on people – mainly young people – “who experience delusional thinking and hallucinations and sometimes say things that do not make sense.” As a predictor of insanity it’s almost useless, however, since “seventy percent to 80 percent of young people who report these strange experiences do not ever qualify for a full-blown diagnosis” of psychosis or schizophrenia, per the Times’ report.

The key word here is attenuated — as in, “We’re stretching all this a bit thin.” It’s like “generalized anxiety disorder” (G.A.D.), a fair description of the human condition and the diagnosis you’re likely to get if you turn up in a therapist’s office for anything from fidgets to a busted romance. The purpose of the label is to pay for the treatment. Ditto with “binge eating disorder” (B.E.D.), “premenstrual dysphoric disorder” (P.D.D.), “intermittent explosive disorder” (I.E.D.) or “pervasive developmental disorder — not otherwise specified” (P.D.D.-N.O.S.) – a label I’m jonesing to get for myself, since it contains the seed of all possible explanations. (“See him? He’s got P.D.D.-N.O.S. Such a waste!”)

“The world has changed,” says Dr. James H. Scully, Jr., chief executive of the American Psychiatric Association, whose job it is to approve final revisions to the DSM. “We’ve got electronic media around the clock, and we’ve made drafts of the proposed changes public online, for one thing. So anybody and everybody can comment on them, at any time, without any editors.”

That sounds right – very democratic. Meantime millions of children are medicated for “attention-deficit disorder” – a twenty-fold increase in prescriptions in just thirty years, says the Times – despite the fact that “no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems,” the very things it’s meant to improve.

Did you know that? Treatment for A.D.D. is basically a band-aid. It seems that amphetamines work equally well – in fact, identically — on children without A.D.D., Ritalin, Adderall and other drugs being designed to improve and make bearable the performance of “boring, repetitive tasks.” Their social utility is paramount, far more important than the subtle needs of any one kid. And the message from the experts is perfectly clear: Snap out of it! There is to be no trouble in any of our lives! Dope ‘em up, move ‘em out!

I wrote on this same theme 20 years ago, reviewing Dr. Peter Kramer’s landmark Listening to Prozac for “The New York Observer.” Text below.



LISTENING TO PROZAC (New York Observer, June 1993)

Does anyone remember that old “Twilight Zone” episode where the citizens of some future society are all required to look and sound alike? On reaching adulthood, everyone is given a choice of body type A or B, blond or brunette, amounting in either case to a blandly attractive, surgically perfected, absolute sameness of appearance? The plot revolved around a couple of misfits, who thought they might be happier being drab and maladjusted than flawless and not themselves.  But in the end they changed their minds, or were made to change their minds, and in those virtuous days of the 1960s, when Rod Serling was alive and the psychologists hadn’t done much more than IQ us into corners, loss of individuality was regarded as a tragedy, pure and simple.  We were against it, the way we were against Communism, atheism and fluoride in the water.

But not anymore, or not on the evidence of the books that keep pouring out of the psychotherapy industry.  The harder we’re urged these days to follow our bliss and run with the wolves the more determined are the experts, in their oily little hearts, that we stay on the straight and narrow.  No real eccentricity is permitted in the fix-it-all culture; no quirk of character or twist of sentiment is allowed to exist without reference to “pain,” “abuse” and the duty of our citizens to “grow” at all costs.  Growth for the sake of growth is the primary feature of a cancer cell, but never mind.  You are not OK the way you are, and if you don’t believe me, pick up a copy of Listening to Prozac, Dr. Peter Kramer’s riveting account of the history and future of anti-depressant drugs in America.  If and when your brain manages to absorb the dispiriting message of Dr. Kramer’s book, you might recommend it to your friends.  If, on the other hand, your hair stands up from now till Christmas, take heart:  there’s a pill out there with your name on it.

Before I make it entirely clear how disturbed I am about the imminent triumph of chemistry and psychiatry over self-awareness, depth of feeling, creativity, spirituality, subtlety, humility, discernment, intuition, experience, significance and the dignity  of the human race, I ought to say a few kind words about Dr. Kramer and his book.  I mean them sincerely.  Listening to Prozac is a fascinating, well crafted, sometimes ironic and possibly momentous contribution to our understanding of personality and the future of psychopharmacology (a fancy word for drugging the population when it gets upset).  Dr. Kramer is smart as hell, and he writes awfully well for someone named Dr. Kramer.  I have to admit, too, that I prefer the sound of an M.D.’s voice to the earnest kazooing of the psychobabblers.  Listening to Prozac is filled with “aggressive fathers” and “passive mothers,” and there’s a whole chapter devoted to formes frustes, or “low self-esteem.”  But deep down, I think, Dr. Kramer isn’t sold on the lingo.  He calls it “insulting,” and he’s right:  it is.

It’s also next to meaningless.  Pick a problem (any problem) and call it what you want.  Adult children of alcoholics, outer-directed husbands’ love-addicted wives, frenzied sisters’ younger brothers — all of them, nowadays, suffer from what Dr. Kramer describes as a “chronic condition:  heightened awareness of the needs of others, sensitivity to conflict, residual damage to self-esteem.”  Come at this from another angle and you’ve got “co-dependency.”  Fifteen years ago you had Erroneous Zones and the When-I-Say-No-I-Feel-Guilty crowd.

These rock-ordinary human attributes have been with us since the dawn of time; they are “odd indications for medication,” Dr. Kramer thinks, but I don’t.  I honestly believe we’ve been so badly damaged by a parade of shifting, pseudo-caring labels that the only cure for what ails us would be an anti-depressant, the psychologists showing no sign of pulling up stakes anytime soon and moving on, say, to poetry.  Prozac, as everyone knows, popped out of the labs in the late 1980s, and, following some trendy analysis in the newsmagazines (and on Oprah, Geraldo, “60 Minutes,” and so on), it emerged as the fanciest thing on the therapeutic circuit, the equalizing, all-embracing, all-fulfilling drug of choice for the occasionally-to-somewhat-bothered-by-lifers.

Please don’t think I’m being flippant when I say that.  Listening to Prozac isn’t concerned with the treatment of insanity or even of mental illness (where drugs to stabilize the mind and emotions obviously play a needed and charitable role).  Dr. Kramer is a practicing psychiatrist who was moved to examine the “moral” and “ethical” implications of Prozac when he observed its transforming effect, not on schizophrenics or the severely disturbed, but on the most insipidly unhappy people:  the discontented, the oversensitive, the sullen and the dull. Traits of character, the doctor says — but your grandmother knew this already — are ingrained in our nervous systems and genetic codes.  Our weaknesses and vulnerabilities have a life of their own, regardless of their “childhood” origin.  At first “psychological,” they become biological, “autonomous,” chemically rooted and malleable; Prozac wipes them out in a “substantial minority” of cases.  It actually “fixes” the personality, rendering the shy outgoing, the angry calm, the lonely and tongue-tied convivial and (by the sound of it) hot to trot.

Deadbeats, on Prozac, are “socially attractive” for the first time in their lives.  Shirkers at work become positively Japanese in their eagerness to produce.  Wallflowers blossom, losers win.  Nobody comes home without a prize except those unlucky few who, for reasons no one has yet figured out, are driven to the brink of suicide by Prozac’s mucking around with their serotonin levels.  (There is already such a thing as a “Prozac Survivor’s Support Group.”)

Try as he might, Dr. Kramer can’t escape the feeling that something doesn’t “sit right” with self-improvement on a chemical basis.  Could it be, he wonders, that “diminishing pain can dull the soul?”  The studies he provides of “successful” cases all concern people whom society rewards in their Prozaced condition:  teenagers who’ve stopped moping, wives who’ve stopped yelling, men who’ve stopped screwing around.  Dr. Kramer wants to know if the world is ready for “cosmetic psychopharmacology” and “the medicalization of personality.”

“What are the implications,” he asks, “of a drug that makes a person better loved, richer, and less constrained — because her personality conforms better to a societal ideal?”  What sort of road are we on when medicine is used, not to cure, but to control, and simultaneously to revise the concept of illness, taking standard traits of human behavior and stripping them down into “symptoms?”  Will we go quiet into that anti-depressant night, allowing “material technology, medications, to define what is health and what is illness?”

Dr. Kramer is too sharp-witted not to realize that we are standing in the shadow of the Brave New World, but in the end, I’m afraid, he’s squarely on the side of the medicators.  Psychotherapy, too, he tells us, was once lambasted “for inducing adaptation to the dominant culture,” and “asking about the virtue of Prozac [is] like asking whether it was a good thing for Freud to have discovered the unconscious.”  There are those, of course, who think it was not.  Dr. Kramer closes his book with a tribute to Woody Allen and his New Age fantasy, Alice, where an edgy Mia Farrow pops downtown to a Chinese doctor and snorts a mixture of mysterious herbs that allows her to dump her insulting husband and put the make on strangers at the zoo.  These aren’t quite the people I’d pick to recommend a vision of the future, on or off drugs, but they keep the shrinks in business, after all.

A word of advice:  if you read the book, you’ll want the dope.  Don’t say I didn’t tell you.


2 Responses to “Shrink Wrapped”

  1. Roy McAlpine Says:

    Hi Peter, I enjoyed your post about the DSM 15 1/2 or whatever edition it is. Lots of disputes about it forever. Some psychiatrists don’t even want one because they think parts of it are so specious. It’s an interesting debate; and paradoxical, too: My understanding is that it was put together during WWII to try to sort things out re: mental illness among combat troops. The paradox, of course, being that the military has been so callous in its disunderstanding of MI and the various forms it takes consequent to combat.
    Re: PDD, Pervasive Developmental Disorder. Don’t jones for it, or anything like it. It’s the new, revised, bland, shiny term for the non-linear “continuum” or “spectrum” of conditions that include autism and asperger’s “syndrome”. You know I work as a chaplain on 4 psychiatric units. The kids that come in with a diagnosis of PDD have hugely varying symptoms, and underneath is the heartbreakingly different way of operating that ranges from downright alienating to out of touch with the common reality to fascinating and sweet. But with the common denominator that connection with others is going to be traumatic, difficult if not impossible, for the rest of their lives. In some ways some may be helped with adaptive strategies, but they’ll have a hard time achieving ease in relationships.
    For some reason the condition fascinates me, but I am no authority. You just struck a familiar chord with your essay and it created an excuse to write to you!
    Always, all the best,

  2. Peter Kurth Says:

    Roy — thanks for comments. Of course I’m being a wiseguy, though the Times also ran an op-ed recently about the persistent misdiagnosis of Aspergers, and they aren’t too keen on “autism” either these days! Check it out:

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