The Book of Woe: The DSM and the Unmaking of Psychiatry by Gary Greenberg Page A

enough to expect them to be real.
    •   •   •
    First is right about at least one thing. Most clinicians don’t care what the DSM’s rules are. I know I don’t. I rarely take it down off my shelf. I use only a handful of the codes and by now I know them by heart.
    At the top of my favorites list is 309.28, which stands for Adjustment Disorder with Mixed Anxiety and Depressed Mood. Here’s how the DSM-IV defines it:
    A.The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)
    B.These symptoms or behaviors are clinically significant as evidenced by either of the following
    1.marked distress that is in excess of what would be expected from exposure to the stressor
    2.significant impairment in social or occupational (academic) functioning
    C.The stress-related disturbance does not meet the criteria for another disorder
    D.The symptoms do not represent Bereavement
    E.Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months
    I’m sure you can see why 309.28 is popular with clinicians, and why insurance company claims examiners probably see it all the time. It sounds innocuous, which makes it go down easy with patients (if, as I do, you tell your patients which mental illness you are now adding to their medical dossier) and with employers or insurers or others who might have occasion to scrutinize a patient’s medical history and be put off by a more serious-sounding diagnosis. It offers all kinds of diagnostic flexibility. Take Criterion B1, for instance. It is easy to meet; it is easy enough to use the fact that the patient made an appointment as evidence of “marked distress.” And that lovely parenthetical in Criterion E makes it possible to re-up the patient even after the six months have elapsed.
    But Adjustment Disorder also has a special place in my heart because it was my own first diagnosis, or at least the first one I knew about. I got it sometime in the early 1980s, when I was in my early twenties and the DSM was in its third edition. I don’t remember why I wanted to be in therapy or very much of what I talked about with my therapist. I do remember that my father was paying for it. He was probably hoping I would discover that my self-chosen circumstances—living alone in a cabin in the woods without the modern conveniences—were a symptom of something that could be cured. What I was being treated for, however, was not “Back to the Land Disorder” or “Why Don’t You Grow Up Already Disorder,” but rather, as I discovered one day when I glanced down at my statement on the receptionist’s desk, Adjustment Disorder.
    I guess the tag seemed about right. I definitely wasn’t adjusting; and if it occurred to me that by calling my lifestyle an illness (if indeed that’s what he meant to do, as opposed to just rendering the most innocuous-sounding diagnosis possible), my therapist had passed judgment on exactly where the problem resided, I didn’t think much of it at the time. But I do remember that I noticed, for the first time, that I’d been going to these weekly appointments in a
doctor’s office
. It happened to be in a building adjacent to the office of my childhood pediatrician, but it did not smell like alcohol or have a white-shoed woman bustling about, nor did its business seem a bit related to the shots and probes I’d suffered next door, so the discord stood out. But still the fact of that diagnosis, right there in black-and-white, was undeniable. I was a mental patient.
    I was eventually cured of my maladjustment—not by therapy, but by a family coup that resulted in my grandfather’s being relieved of the farm he’d inherited from his mother. That happened to be the land on which I’d built my home, and so I was evicted, my cabin eventually bulldozed and the land converted to McMansions, and it became necessary for me to