Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine (review)

In the immediate aftermath of the earthquake in Haiti, Time asserted that "Haitians who survive the horrific earthquake will be at risk of developing post-traumatic stress disorder (PTSD)."¹ Grob and Horwitz would almost certainly take issue with this knee-jerk assertion and the inevitable calls for mental health professionals to intervene. "Victims of natural disasters," they observe, "might benefit more from economic and social assistance that helps them overcome the genuine devastation in their circumstances than from individual therapy" (p. 189). The history of PTSD, they argue, like that of the other case studies they present (peptic ulcers, tonsillectomy, coronary heart disease and cancer, anxiety disorder, and depression), is littered with unsubstantiated claims about disease specificity, the efficacy of prevention and treatment, and the state of our etiological understanding.

Both authors are experienced and confident observers of the social construction of psychiatric and other diagnoses and the medicalization of everyday life. The case studies cover a lot of interesting developments without overwhelming the reader with unimportant details. The chapters on anxiety, depression, and PTSD are particularly skillful syntheses and do more than compile the gaps in the medical evidence and the messy compromises that resulted in DSM and other classificatory schemes. The authors give a rich description of the antipsychoanalytic animus behind DSM-III. They add to existing historical accounts by emphasizing the role played by psychiatrist Vietnam War veterans in advocating for PTSD. Their description of the ever-expanding trauma industry is troubling.

At the same time, the authors' criticism of modern psychiatry for not basing classificatory schemes on specific etiologies, genes, or response to treatment is itself open to some skepticism. Beside mechanism envy, why expect that most or all "mental" suffering should follow the idealized mechanistic model of infectious disease and metabolic disorders?

Grob and Horwitz document important but underappreciated continuities between current diagnostic controversies and questions raised by nineteenth-century alienists and others. What type of suffering should be understood as part of the normal human condition? What represents somatic pathology? They point out that while some DSM promoters self-consciously aimed to recapture the clinical, symptom-oriented, mind-set of prepsychoanalytic thinkers like Emil Kraepelin, they paid little attention to the primacy Kraepelin and others gave to the longitudinal study of disease. Instead, modern nosologists promoted misleading and simplistic cross-sectional snapshots.

Grob and Hurwitz observe the essential fungability of anxiety and depression diagnoses and their treatments. As also documented by David Healy and others, the selective serotonin reuptake inhibitors, the blockbuster drugs of the past decades, were refashioned by psychiatrists and drug manufacturers as antidepressants rather than anxiolytics because of the "hostile cultural climate toward anti-anxiety drugs in the 1980s" (p. 137). Overall, "the configuration of these groups at any particular time shapes the extent to which symptoms will be defined as natural or as pathological" (p. 31).

Grob and Horwitz highlight the arrogance and self-interest of modern medicalizers as well as the duplicity of the American public. We learn a lot about the gap between "rhetoric and reality in modern American medicine." Their analysis is detailed and sound and opens up for others further study of the factors beside economic self-interest and ignorance that produce this gap. For example, beside unwarranted faith in claims of better medical outcomes, what assumptions and calculations led parents and doctors to opt for tonsillectomy and adenoidectomy in their heyday? A contemporary actor whom the authors cite noted that these surgeries were "ritualistic" and satisfied "parental need" (p. 74). Was surgery understood as the engine driving the palpable decline in death from infectious disease and thus highly valued? Were more extreme treatments understood as an insurance policy against the feared long-term complications of acute streptococcal infections? Our historical understanding of medical efficacy still needs...