Secrecy and Made-Up Illnesses: The Latest Fight over Psychiatric Diagnosis

Psychiatrists are having one of their periodic dust-ups over the question of diagnosis. The back-and-forth has to do with the development, by the American Psychiatric Association, of a new diagnostic bible, DSM-V, the manual that will determine how mental health professionals in this country divide wellness from disorder and, in the disorder category, one condition from another. The updating is always controversial. Outright opponents of psychiatry find any change suspect: How is it that a person might be judged ill in one era and healthy in another?

In this case, the critics, Allen Frances and Robert Spitzer, are psychiatrists who have been responsible for just that sort of shift. They led, respectively, the task forces that developed the two prior diagnostic and statistical manuals, DSM-IV and DSM-III. In effect, the old guard says that the new undertaking is too secretive—scholars reshaping the DSM categories have signed nondisclosure commitments, a highly unusual step in the academic world, where the science of diagnosis resides. The critics also claim that the time is not ripe, that research results do not yet justify the adoption of a new framework for classifying mental illnesses.

For the record, I think the APA’s attempt to keep the decision-making process secret is indefensible. The other matter, whether the diagnostic system needs and is ready for revision, is extraordinarily complex. DSM-IV appeared in 1994; the fifth edition is expected in 2012. The interval is long enough for a good deal of research to have been generated and also stable enough, in terms of the way we treat most patients, that any paradigm shift should be suspect. We want our practices to reflect important new findings about the nature of mental disorders, but we don’t want psychiatry to lurch around—and especially not when social issues seem to be at stake, like the boundary between hyperactivity and boyishness, social anxiety and shyness, sadness and depression.

What hasn’t yet surfaced in the current debate is acknowledgment of a fundamental change in the way that informed psychiatrists see the project of outlining and justifying diagnoses. Psychiatry has, by and large, dropped the illusion that its diagnoses are what philosophers call “natural kinds.” A natural kind is something that simply exists in nature. A mental disorder that arises from a simple gene defect (think of Down syndrome) is close to being a natural kind: When you name the genetic difference, you imply a good deal about what may be disabling in the person. But even this example is flawed—some people with the syndrome function well—and most mental illnesses are yet farther from any diagnostic ideal.

In past manuals, when psychiatrists said that schizophrenia was characterized by typical symptoms (delusions, hallucinations, loss of motivation) and prolonged social and occupational dysfunction, they were trying to distinguish patients who shared a common disease that exists in nature. How schizophrenia arose and persisted was unknown—perhaps through common genetics or brain pathway disruption. Still, the idea was that by specifying manifestations of dysfunction and testing the results (does the disease run in families, lead to predictable bad outcomes, respond to given treatments?), the profession would get ever closer to a natural phenomenon, a disease state like pneumococcal pneumonia. One of the standing metaphors in the field—sometimes used more as a joke, sometimes less—had to do with the search for the “schizococcus,” a fictional bacterium, which (depending on the era) might stand in for one or another cause that would explain schizophrenia and determine once and for all which of the diagnostic criteria had been helpful and which had been misleading. The key metaphor here is “carving nature at the joints.”