Our Tragic Flaw

I just read with fascination an article from Sunday's New York Times Magazine entitled, "Women Who Want to Want." The article profiles Lori Brotto of the British Columbia Center for Sexual Medicine in Vancouver, who leads a panel that will define what is currently called Hypoactive Sexual Desire Disorder (HSDD) for the upcoming new version of the Diagnostic and Statistical Manual (DSM-V) to be released by the American Psychiatric Association in 2012 or 2013.

The DSM tries to be the definitive diagnostic tool for any kind of mental health problem. Perhaps more importantly, health insurers will not cover mental health services that are not coded according to DSM criteria. As a result, every clinician who accepts insurance must interact with the DSM whether they agree with its criteria or underlying philosophy or not.

The research agenda that undergirds the DSM assumes that all mental health disorders have a distinct biolgical basis, and distinct and unique symptomatic traces. Part of the process of identifying specific disorders involves a normative evaluation of collections of symptoms. When certain collections of symptoms appear with some measurable frequency, researchers assume they have identified a specific disorder.

All of the disorders within DSM are defined as involving clinically significant "distress or impairment" of the individual, and/or, in some cases, others. (For example, individuals with antisocial personality disorder rarely feel distressed or impaired, but those off of whom they prey often do.)

All of the DSM's criteria are ultimately normative: that is, what is considered abnormal distress or abnormal impairment defines a disorder--there is no absolutely objective scale.

If it were not for the enormous investment of research energies, dollars, and infrastructure that supports the ongoing institution of the DSM, I think it would be perfectly clear to all that its research agenda has failed miserably. The definition of disorder in general has come under repeated attack for all sorts of good reasons; whole sections of the DSM are questionable and quite controversial (not least of which are the sexual disorders discussed in the aforementioned magazine article); and all the disorders are beset by staggering patterns of comorbidity (which means multiple diagnoses in the same person).

One can catch of glimpse of these difficulties from this short passage from the cited article:

One criterion Brotto advocates adding is a dim or missing sense of excitement during sex itself. This is one of her ways of including Basson’s thinking — that desire often arises during, not before. But it leads to a troubling question. What if the lack of excitement is due to a partner’s ineptitude? What if it’s caused by a lover’s emotional disconnection? Suddenly the realm of mental disorder, which is supposed to be delineated, as the introduction to the D.S.M. puts it, by “dysfunction in the individual,” is being distorted by the role of others. Is it the patient who has the condition, or the partner, or the couple? In building on Basson’s “responsive desire,” Brotto’s criteria run repeatedly into this fundamental problem. A partner’s involvement is more or less inescapable.

Brotto stares squarely at this conundrum, knowing, she told me, that it can’t be resolved, knowing that the best she can do is acknowledge it in some sort of introductory passage and continue on the path she thinks right. Meanwhile, the usual waning of erotic urgency over the course of long relationships, a decline that, according to many clinicians and one study, may beset women more steeply than men, could mean that proposed criteria like “absent/reduced sexual excitement/pleasure during sexual activity” are met by nearly everyone — another muddle of diagnostic logic. To address this problem, the disorder’s current language encouraging clinicians to take the context of their patients’ lives into account may need more emphasis in the D.S.M.-V.

Brotto knows too that there are sexologists who maintain that desire by any definition — whether the sheer lust Basson minimizes or the responsive variety she trumpets — is almost entirely a cultural invention rather than a biological reality; that it has been made to seem essential by the sex scenes in movies and the advice columns in magazines; and that it is best deleted from the D.S.M. Leonore Tiefer, a professor in the psychiatry department at New York University and the author of a collection of essays titled “Sex Is Not a Natural Act,” argues that the contrivance is compounded by the pharmaceutical industry, which offers research money to sexologists who find ways, no matter if unconsciously, to inflate hugely the numbers of women suffering from an already-fictive condition — a disorder that the drug companies intend to cure. High numbers help to increase awareness, which stokes demand. To what extent this theory represents truth, as opposed to being merely plausible, is hard to sort out. When I spoke recently with officials at Boehringer-Ingelheim, which just announced the auspicious, if not overwhelming, results of large-scale trials of its desire-enhancing medication, Flibanserin, the officials were careful to cite only conservative figures on the women who might want such a pill. (Though the exact mechanisms of the drug are unclear, it seems to act on the brain’s serotonin and dopamine receptors.) Brotto, like all the specialists in all areas working on the new D.S.M., is allowed to receive no more than $10,000 per year from any source connected to the pharmaceutical industry. This is an A.P.A. rule. But Tiefer’s is hardly the only voice warning that, despite A.P.A. protections, drug-company influence can shape, indirectly as well as directly, the decisions of D.S.M. panelists.

Brotto is surrounded by skepticism. And she herself told me that it might take till the publication of the D.S.M.-VI, probably two decades from now, for science to establish sound norms for women’s desire.

In fact, Brotto may be far too optimistic in this estimate. So far, no clear biological basis has been found for any mental health disorder whatsoever.

The real issue here is that the DSM lacks a coherent and articulated philosophical basis. No amount of science can save it; indeed, such science can only further expose the DSM's deficiencies. In this blog post I can hardly clear things up very much: such would be (may be) the task of a second book. But I would like to float two extremely important components of what could prove a more coherent approach.

The first involves making a clear distinction between medical and psychological realms of concern. Modern psychology, after all, was begun by a medical doctor, Freud, who clearly regarded mental health as a medical domain. Most of the subsequent course of the field has been in the hands of psychiatrists, also medical doctors. It's no coincidence that the DSM is published by the American Psychiatric Association.

I believe this has all been an enormous and disastrous philosophical mistake. The field as a whole (though certainly not all of its participants) continues to conflate medical and psychological concerns. I would propose, instead, that we have in fact two distinct fields of interest here that overlap, to be sure, but must be regarded distinctly.

In this post I can only suggest the distinction (I will try at some later date to flesh it out adequately), but hopefully it will be enough to give you a sense of where I am going with this. The domain of the psyche (which in the original Greek means soul) involves the mind; the domain of medicine involves the body (including its most complex organ, the brain). I am not a dualist; I know perfectly well that the mind is a function of the body. But I believe that psychological issues arise in the experience of the person and reflect the experience of the person in ways that are certainly represented in the biochemistry of the brain, and are causally dependent upon the brain, but that are most directly approached through experience, not biology. (For a fuller, but quite accessible, philosophical discussion of this orientation toward the mind/body problem, see John Searle's Mind: A Brief Introduction.)

Among the DSM's disorders we may construct a spectrum from the medical to the psychological. On the medical extreme we find conditions that may be defined entirely by biological factors, such as Down syndrome, which can be attributed wholly to a chromosomal anomaly. On the psychological extreme we may find conditions that are defined entirely by experiential factors, such as Post Traumatic Stress disorder.

Now, let us be clear: a person with Downs will likely experience unique difficulties as a result of his chromosomal irregularity, and these would count as psychological difficulties; and a person with PTSD likely has some kind of biological pre-disposition toward a disabling response to stress. So, the biological and psychological intermingle complexly--probably in every case. But the relevant question concerns treatment: at one end of the spectrum a medical treatment (if any be available) is indicated; at the other, a psychological treatment. Medicine intervenes in the biological function of the person. Psychological therapy intervenes in the experience of the person. Medicine treats the body; psychotherapy treats the mind.

As we move toward the middle of the spectrum, a mixture of approaches may be indicated: some medical treatment in addition to psychotherapy. In fact, it may be that most conditions referenced by the DSM call for such a mixture. Even so, it behooves us, I think, to remain clear on the extent and limits of each treatment modality.

Secondly, now that we can set to one side the medical aspects of various mental health conditions, a close reading of the DSM suggests that there is, in fact, only one properly psychological diagnosis. Further, a philosophical interpretation of the DSM leads one to the very same conclusion. I will begin with the philosophical argument.

Every diagnosis in the DSM makes some reference to clinically significant "distress or impairment." In most cases, these concerns are initiated and reported by the complainant. To be clear: in order to be diagnosed for the vast majority of DSM disorders, a person must report severe distress or impairment. (The exceptions involve a minority of cases, like antisocial personality disorder, where the patient is unaware of, or unconcerned with, such matters.) Any number of factors may contribute to a person's distress, and a sense of being impaired is one of them. Impairment, then, is privileged by the DSM as a special case of distress.

Cynically, one can see the rationale for the privilege of impairment. If a person is missing work, or unable to attend to family obligations, that is a kind of impairment that is recognized by our culture as requiring treatment. Implicit in impairment is a plea to insurance companies to provide relief for a major disability that affects the person's productivity in society. Simultaneously, and along similar lines, severe distress implies impairment: that is, a person who is severely distressed will (by definition?) be impaired in her ability to function productively. Here we see the ominous undercarriage of the whole (mental) health system, as a means to re-instate economic units into active production.

The experience of distress, including the particular case of distress about being impaired, is called anxiety. Accordingly, all conditions referenced in the DSM are definitionally anxiety conditions (with the possible exception of conditions where distress or impairment are reported by third parties). So goes, in brief, the philosophical argument for anxiety as the one over-arching psychological concern.

A close reading of the DSM, and particularly the pattern of comorbidity that has been established among DSM diagnoses, supports the notion that all psychological concerns are rooted in anxiety. Depression and anxiety are closely linked, suggesting a theory that anxiety expresses itself in two contrasting forms: hyper-arousal (such as panic, or manic phases), and hypo-arousal (such as major depression, or dissociation).

Without fleshing out this theory any further, allow me to suggest how this approach might grossly simplify the research project of Ms. Brotto who, as you remember, was concerned particularly with female hypoactive sexual desire disorder (HSDD). She uses mindfulness techniques to work with "undersexed" women, with some success--which makes sense if what she is dealing with is essentially an anxiety issue. The patriarchal problem here--the cultural assumption that women should be sexually active and available to their (presumably) male partners throughout all phases of adult life--poses no difficulty if we see a person's anxious concern as being, in part, about reconciling her sexual rhythms with cultural expectations. Brotto has a fundamental problem at least in part because low libido is culturally forbidden, and yet this has nothing to do with science or biology. Nevertheless, it produces an experience of anxiety that psychotherapy can fruitfully address.

So, now in microcosm, we can see the rub. If a woman seeks therapy because of anxiety about a low libido, insurers will not cover her without some biological argument, and a concrete "impairment." So, well-intentioned researchers such as Brotto spend a career trying to ferret out such a rationale. Undoubtedly, this frenzy of research will find nuggets of truth that we might not have discovered otherwise. But, at the same time, it works to obscure an obvious and painful truth that keeps people--in this case women--in a kind of anxious prison in which they are either defined as "disordered" or their complaints are seen as trivial and their treatment indulgent.

The obvious and painful truth to which I refer is this: in some cases--and perhaps in many--psychological distress is a function of a disordered society. If my analysis is anywhere near the truth, we can begin to see that the DSM itself is what is "disordered," and that many of the people it has put into its various pigeon-holes are made anxious, at least in part, by the conundrum of how to live joyfully in a profoundly dysfunctional world.