Alan V. Horowitz and Jerome C. Wakefield, The Loss of Sadness (Oxford University Press, 2007)
When Arthur Miller’s Death of a Salesman came back to Broadway in 1999, the director, looking for insight into the character of Willy Loman, sent the script to two psychiatrists, asking them to diagnose him. They independently agreed that he suffered from bi-polar depression. Miller retorted: “Willy Loman is not a depressive. He is weighed down by life. There are social reasons for why he is where he is.’’ This incident opens The Loss of Sadness by Alan V. Horowitz and Jerome C. Wakefield and illustrates their thesis quite nicely: America has decided that sadness is an illness.
Leaving aside the myriad forces driving the trend, this book focuses on the realm of medical diagnosis. Horowitz and Wakefield trace the diagnosis of depression, and its distinction from sadness, back as far as Hippocrates, through Robert Burton, and on to the modern day. Throughout this 2,500 year sweep of history, the criterion whichseparated depression from intense, normal sadness, was that it was without cause, or obviously disproportionate.
In a bizarre cleavage of the formal from the actual, this changed in 1980 with the release of the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder. This document, usually referred to as the “bible” of psychiatry by science journalists, defines the various mental disorders. This revision switched from narrative, rooted in the psychodynamic tradition, to a series of diagnostic algorithms—essentially checklists. Now, when professionals refer to a disorder, they know they are talking about the same thing. The problem, the authors argue, is that the standard definition for depression is invalid. The symptoms of sadness, both psychological and somatic, meet the guidelines for Major Depressive Disorder even though they are clearly normal. The DSM provides no exceptions for context.
The authors’ idea of disorder relies on Wakefield’s concept of evolutionary function. If the heart, whose purpose is to pump blood, ceases to pump blood adequately, we say that there is a cardiovascular disorder. The authors argue that states of intense and unpleasant sadness are universal, serve plausible evolutionary ends, and therefore are not disordered. What is disordered are extreme sadness responses that do not respond to anything.
This confusion is a minor issue in clinical practice since depression, semantic similarity aside, is unique and a patient is unlikely to seek treatment unless they feel abnormal. The problem arises most clearly in research. A drug trial could characterize a population of non-disordered people, muddying the results (and contributing to the fact that placebos appear to be as effective as drugs). More problematic, though, is that the myriad insults of modern life—poverty, social isolation, war, interpersonal strife—are perfectly capable of causing intense (and normal) sadness and malaise. Consequently, medication threatens to take the place of personal and social change, which might alleviate the disheartening conditions in which we live.
Far from being a sweeping piece of cultural criticism, illuminating the social control which is the medicalization of negative moods, The Loss of Sadness is a focused (and devastating) critique of the specific DSM criteria. A more pervasive problem in The Loss of Sadness is conceptual—Horowitz and Wakefield repeatedly equate normal sadness with depressive disorder experientially. Though the words we use to describe both are the same, this is an obtuse analogy—depression is qualitatively separate from sadness but because of its unshared nature there are no adequate words in the language for it. “Depression,” as William Styron writes in Darkness Visible, “is so mysteriously painful and elusive...as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it.” The authors, and anyone else interested in this experience, would do well to re-visit Styron’s masterful memoir.
The sciences of the mind are, to be generous, in their infancy. Biological reductionism rules the popular culture, though the biology is more or less undiscovered. Indeed, if the DSM is the “bible” of psychiatry, it is equivalent to only a fifth of the books of Leviticus and Deuteronomy recovered from parchment scraps at the Dead Sea. Nonetheless, how we view our experiences, of sadness, pain, malaise, and even happiness, and how we respond to them, have changed radically, with staggering implications for art, politics and the culture at large. The Loss of Sadness is an important salvo in the war to define the concept of mental illness. Coming from insiders like Horowitz and Wakefield, at such an opportune time, it is likely to have a powerful impact, and perhaps bring us a step closer to a science of the mind that is thoughtful and accurate.
Ben Gore is a novelist and essayist who is between homes. He is currently at work on a book about bicycles and their meaning.