In May, the American Psychiatric Association (APA) issued the latest revision of its official compendium of mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders 5. The DSM, since its debut in 1952, has been the savior and the curse of psychiatry. The oft-revised manual offered a skeptical public the promise of rigorous classification of abnormal behavior and psychological distress into distinct disease entities, proffering science in the place of storytelling. But as with every previous revision, this newest update has thrown the field of psychiatry into turmoil. Clinicians are struggling to master new diagnoses. Researchers are piecing together the new disorders with the old literature. And insurance companies are wondering how much cash newly minted mental disorders will legally require them to dole out for their customers.
Allen Frances, former head of the Duke University School of Medicine’s psychiatry department and a man The New York Times once called “perhaps the most powerful psychiatrist in America,” was chair of the APA task force for DSM-IV (issued in 1994). Frances has become the loudest
and most influential public voice questioning the DSM’s latest revamp. “The fact that we had a descriptive system only revealed our limitations,” he says. “If you believe that labels are only labels, you don’t want to keep changing the language arbitrarily. It just confuses everybody.”
Frances has been warning everyone who will listen that the newest DSM revision will turn even more of human suffering into mental illness and thus into grist for the pharmaceutical mill. I once asked him whether he thought a good definition of a mental disorder would establish a bright boundary line that would definitively sort the sick from the unusual and keep psychiatry in its proper place.
“Here’s the problem,” Frances said. “There is no definition of a mental disorder.”
I mentioned that that hadn’t stopped him from putting one into the DSM-IV. “And it’s bullshit,” he said. “I mean you can’t define it.” Frances came to regret saying this to me after I published it in a January 2011 Wired article. He worried that his offhand comment would give aid and comfort to the enemies of any sort of psychiatric care whatsoever, while all he meant to do was to question the attempt to create airtight definitions of mental illnesses.
Doubts like Frances’, on the part of both respected professionals and confused laypersons, are inevitable given the way the APA conducts nosology, the science of disease classification. The DSM defines mental disorders by listing their symptoms. People who have the symptoms of a given diagnosis—in DSM parlance, people who meet the criteria—can be given the diagnosis if a clinician believes their suffering is clinically significant—an assessment that is largely left up to the doctor. Since the descriptive method first appeared, in the DSM-III (1980), it has provided psychiatrists with a common language for discussing their patients and given millions of patients access to care they believe is vital for coping with their life problems. Since 1980, however, many critics have pointed out that these disease categories do not exist in nature, at least not in the same way that streptococcus and influenza do.
If the DSM is not a map of an actual world whose contours can be independently confirmed, then opening up old arguments or starting new ones is an invitation to chaos. With each revision of the DSM comes the potential for instability and discord that cannot be settled by turning to the microscope or the computed tomography (CT) scanner. Knowing this, Frances says the goal of a DSM revision should be to stabilize an inescapably fragile system rather than to perfect it—or, as he put it to me, “loving the pet, even if it is a mutt.”
The mutt has certainly caused some mischief. Among its more prominent detractors was Steven Hyman, who in 1996 became the head of the National Institute of Mental Health (NIMH). A neurogeneticist by training, Hyman hadn’t thought much about nosology before taking over at NIMH. It “seemed a bit like stamp collecting,” he once wrote in a 2010 article in the Annual Review of Clinical Psychology, “an absorbing activity perhaps, but not a vibrant area of inquiry.”
But then he realized that the DSM was “a critical platform for research.” Its categories and criteria were the basis of decisions made by journal editors, grant reviewers, regulators, and the Food and Drug Administration, which meant that scientists were bound to frame their proposals in the DSM’s language. “DSM-IV diagnoses controlled the research questions they could ask, and perhaps, even imagine,” he wrote.
“The tendency [is] always strong,” John Stuart Mill wrote in 1869, “to believe that whatever receives a name must be an entity or being, having an independent existence of its own.” To Hyman, who quoted Mill approvingly, this tendency had led all the stakeholders in nosology—scientists, regulators, editors, doctors, drug companies, and, of course, patients—to take the labels not as arbitrary descriptions but as the names of actual diseases. They had, at least according to Hyman, reified what were intended only as concepts.
And this was no mere abstract concern. “It became a source of real worry to me,” Hyman said, “that as Institute director I might be signing off on the expenditure of large sums of taxpayers’ money for…projects that almost never questioned the existing diagnostic categories despite their lack of validation.” The DSM, Hyman concluded, had “created an unintended epistemic prison,” and anyone with a stake in the mental health treatment system was trapped inside.
The Termite-Riddled Foundation
While he was at the National Institute of Mental Health, Hyman had occasion to confide his reservations to at least one colleague: Steven Mirin, then the APA’s medical director. On a weekend afternoon in the summer of 1998, the two were eating lunch by the side of Mirin’s swimming pool in the D.C. area when Mirin asked Hyman if the NIMH would give the APA money to get the next revision of the DSM up and running.
Mirin’s request for taxpayer money to kick-start a project from which a private organization would profit was not as untoward as it might seem. After all, the DSM is indispensable to public health, and the NIMH had helped fund the DSM-IV. Nonetheless, and despite their friendship, Hyman said no. He told Mirin that a revision was premature, not only because the ink was barely dry on DSM-IV but also because psychiatrists had yet to come up with a better way to chart the landscape of mental illness.