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The Crack-Up Book

I tell my students, if you want to learn about depression, don't read the DSM. Read. If you want to understand grief, read Joan Didion's.
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"In a real dark night of the soul, it is always three o'clock in the morning, day after day."

That is how F. Scott Fitzgerald described his mental state in a series of essays called
The Crack-Up, published in 1936, a few years before he died. The Crack-Up was Fitzgerald's description of his own experience with depression and alcoholism, and obliquely, his wife Zelda's bipolar disorder.

Yet nowhere in the essays are such psychiatric terms used. Instead, Fitzgerald uses metaphor and poetry. He writes that he "cracked like an old plate," and lived in a state of emotional bankruptcy in a world of "dangerous mist" and "villainous feeling." He sums up the last, lost decade of his life: there had been "too much anger and too many tears."

Thankfully Fitzgerald was writing before the publication of the American Psychiatric Association's diagnostic manuals, the fifth edition of which, the DSM-5, was recently published. Had the DSMs existed, even a writer of Fitzgerald's stature would have been tempted to draw from symptom lists to describe his inner torment in The Crack-Up.

The DSMs have become victims of their own success. To be sure, the DSM-3, published in 1980, was a necessary step forward for the psychiatric world. Earlier manuals were steeped in unclear Freudianisms with little consistency in the language of even basic psychiatric diagnoses. Doctors, and perhaps more importantly, insurance companies, had no way to talk to one another. DSM-3 became quite unexpectedly a runaway success, a best seller. (The last version made $100 million for the APA.) But each successive edition seems to have gone haywire, adding over time, hundreds of new diagnoses. Which in turn has led to mass over-diagnosing and over-medicating.

A central problem is that the DSM's diagnoses are categorical, rather than dimensional. That is, to qualify for one of the 400 or so diagnoses in today's manual, one has to meet sharply drawn criteria. The DSMs have set up diagnosis as a light switch that is either on or off. But psychiatric conditions are not absolute and differ wildly in intensity from person to person. A dimensional perspective -- like that of a dimmer switch, as psychologist Simone Hoermann has put it -- more accurately reflects the realities of psychiatric suffering.

The result is a mass confusion between severe and persistent mental illness -- the truly mentally ill -- and the worried well. Millions of Americans are mistakenly walking around thinking they have a mental illness. One in ten of us in on antidepressants. Since the mass impact of the DSMs, psychiatry has been all off or on (mainly on), with no dimmers.

There are two ways out of this mess. The first is to ignore the DSM-5 entirely and wait until biological psychiatry can be used as a basis for a truly scientific diagnostic system. Thomas Insel, director of the National Institute of Mental Health, did as much recently when he said that NIMH would no longer use the DSM to guide research, favoring instead new categories based on neural circuits and cognitive functioning.

The second approach is to actually listen to patients as they tell their stories and describe what they are feeling. As William Osler, Canadian physician and a pioneer of modern medicine, said a century ago, "Listen to your patient. He is telling you the diagnosis." Besides, listening is good treatment. Research shows unequivocally that the more patients feel understood, the better their satisfaction with treatment. The better their satisfaction with care, the better their compliance and clinical outcomes.

I tell my students, if you want to learn about depression, don't read the DSM. Read The Crack-Up. If you want to understand grief, read Joan Didion's The Year of Magical Thinking. If you want to know about Post-Traumatic Stress Disorder, read Wilfred Owen's poetry about World War I. This is how Owen described shell-shocked soldiers (he was one himself) in "Mental Cases":

These are men whose minds the Dead have ravished
... their eyeballs shrink tormented
Back into their brains, because on their sense
Sunlight becomes a bloodsmear; night becomes blood-black ...

Until the biology catches up, we would do well to heed the lessons of the literary and, yes, psychiatric experts -- Fitzgerald and Owen: no categories, all dimension.