The authority of any doctor depends on their ability to name a
patient's suffering. For patients to accept a diagnosis, they must
believe that doctors know--in the same way that physicists know about
gravity or biologists about mitosis--that their disease exists and that
they have it. But this kind of certainty has eluded psychiatry, and
every fight over nomenclature threatens to undermine the legitimacy of
the profession by revealing its dirty secret: that for all their
confident pronouncements, psychiatrists can't rigorously differentiate
illness from everyday suffering. This is why, as one psychiatrist wrote
after the APA voted homosexuality out of the DSM, "there
is a terrible sense of shame among psychiatrists, always wanting to
show that our diagnoses are as good as the scientific ones used in real
Since 1980, when the DSM-III was published, psychiatrists
have tried to solve this problem by using what is called descriptive
diagnosis: a checklist approach, whereby illnesses are defined wholly
by the symptoms patients present. The main virtue of descriptive
psychiatry is that it doesn't rely on unprovable notions about the
nature and causes of mental illness, as the Freudian theories behind all those "neuroses" had done. Two doctors who observe a patient carefully and consult the DSM's
criteria lists usually won't disagree on the diagnosis--something that
was embarrassingly common before 1980. But descriptive psychiatry also
has a major problem: Its diagnoses are nothing more than groupings of
symptoms. If, during a two-week period, you have five of the nine
symptoms of depression listed in the DSM, then you have "major depression," no matter your circumstances or your own perception of your troubles.
2. Rent-seeking run amok. Al Frances, lead editor of the last edition of the DSM, shares one of his "keenest regrets" about the book:
as he perceives it, in the epidemic of bipolar diagnoses in children
over the past decade. Shortly after the book came out, doctors began to
declare children bipolar even if they had never had a manic episode and
were too young to have shown the pattern of mood change associated with
the disease. Within a dozen years, bipolar diagnoses among children had
increased 40-fold. Many of these kids were put on antipsychotic drugs,
whose effects on the developing brain are poorly understood but which
are known to cause obesity and diabetes. In 2007, a series of
investigative reports revealed that an influential advocate for
diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph
Biederman, failed to disclose money he'd received from Johnson &
Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times
reported that Biederman told the company his proposed trial of
Risperdal in young children "will support the safety and effectiveness
of risperidone in this age group.") Frances believes this bipolar "fad"
would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.
More to the point:
I recently asked a former president of the APA how he used the DSM
in his daily work. He told me his secretary had just asked him for a
diagnosis on a patient he'd been seeing for a couple of months so that
she could bill the insurance company. "I hadn't really formulated it,"
he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.
"Did it change the way you treated her?" I asked, noting that he'd
worked with her for quite a while without naming what she had.
"So what would you say was the value of the diagnosis?"
The fact that diseases can be invented (or, as with homosexuality,
uninvented) and their criteria tweaked in response to social conditions
is exactly what worries critics like Frances about some of the
disorders proposed for the DSM-5--not only attenuated
psychotic symptoms syndrome but also binge eating disorder, temper
dysregulation disorder, and other "sub-threshold" diagnoses. To harness
the power of medicine in service of kids with hallucinations, or
compulsive overeaters, or 8-year-olds who throw frequent tantrums, is
to command attention and resources for suffering that is undeniable.
But it is also to increase psychiatry's intrusion into everyday life,
even as it gives us tidy names for our eternally messy problems.