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Many mental health professionals admit they don’t pay much attention to the Diagnostic and Statistical Manual of Mental Disorders (DSM). They recognize, as leading psychiatrists have pointed out, that the diagnostic categories have little validity or clinical value. However appropriate and harmless this may be for them as professionals, though, they need to be aware of the DSM’s influence on ordinary people. My research suggests there are good reasons to believe that it can mislead us about the nature of our suffering and how we might respond to it.
For professionals, the DSM often serves a merely practical purpose. Therapists consult the field guide only to get the right diagnostic code for the insurance forms. Without a diagnosis, the third party won’t pay. Psychiatrists rely on the DSM somewhat more. In the pharmacological realm, treatment is supposed to be guided by accurate diagnosis and the symptom checklists and questionnaires typically used to make a diagnosis are loosely based on DSM criteria. But even among psychiatrists, the manual often draws a shrug. As the therapist and writer Gary Greenberg reported after talking with “virtually every prominent psychiatric nosologist in the country,” nary a one would say that the DSM is of clinical benefit. Besides, both psychiatrists and regular physicians acknowledge prescribing the most common psychiatric drugs, such as the SSRIs, on a trial and error basis, and, despite names like “antidepressant,” use them for a broad spectrum of conditions. When choosing treatment for these patients, the diagnosis isn’t very informative. The important question is what works to relieve distress.
Because they view the DSM as clinically inconsequential in the everyday cases, professionals often treat worries about the diagnostic categories as much ado about nothing. Don’t fret, they say, diagnoses are for administrative purposes and the needs of researchers. And, they add, there is one clear clinical benefit: Many people find a diagnosis reassuring. It gives them a medically recognized name for their suffering, which helps ease feelings of differentness, facilitates communication with others, and can suggest a positive prognosis. Otherwise, professionals insist, DSM categories are at best heuristic devices and personal experience is heterogeneous. Treatment decisions are based on their clinical judgment of the needs of each individual. Consulting the DSM is unnecessary.
I am not a mental health professional, but the interviews I did for my book Chemically Imbalanced: Everyday Suffering, Medication, and Our Troubled Quest for Self-Mastery suggest that a sanguine attitude toward diagnosis misses something critical. What is missed is the role that the DSM has come to play in our society. DSM diagnostic categories have been widely popularized and are shaping how ordinary people understand and speak of their experience, a shaping that can take place before they ever seek professional help. This influence does have an impact on treatment.
There is no question, as the interviews indicated, that many people find getting a formal diagnosis comforting. A diagnosis of generalized anxiety disorder (GAD) helped Eric (a pseudonym), for instance, see that his problems are not “like me just being whacked out in my head or nervous or stressed about stuff that’s ridiculous.” GAD, he emphasizes, “is recognized” as a medical condition and in this framework, Eric’s anxiety is “real” in a new way. GAD is something he has, a specific condition that affects many people and is not peculiar to his personality and his circumstances. Now his painful struggle to teach in a competitive and stressful school environment has an ontology—a reality independent of him—and an incipient explanation. While the diagnosis is, strictly speaking, a mental illness, Eric, like most people seeing regular physicians and therapists, doesn’t accept the idea that he’s mentally ill. He thinks the professional he’s seeing doesn’t believe this either and, in fact, talk of diagnostic categories in clinical and popular venues often leaves out the unpleasant part about mental illness. For ordinary people like Eric, the very act of official naming gives anomalous experience a clear, knowable, and objective existence.
So, while clinicians might take a dismissive view of the DSM, ordinary people do not. They didn’t get the memos from Thomas Insel or Steven Hyman, former directors of the National Institute of Mental Health, who have each argued that the problem with the DSM is that its disorder categories lack validity. The categories are not, in other words, “just like diabetes”—real entities in nature, independent of human observers. Consequently, the NIMH dropped the use of DSM categories in its research. Insel did allow that the categories were reliable—i.e., “clinicians use the same terms in the same ways”—but if you’re a patient, where’s the comfort in that? For them, as Eric attests, what makes a diagnosis valuable is that it confers social recognition and legitimacy on suffering by establishing its facticity. It is not his response to his situation.
Further, for many people, and in popular discourse more generally, “real” suffering is physical. It is not, as another interviewee stressed to me, “just in your head” or something you can “just snap out of,” as another put it. The common belief was that a diagnosis establishes that the root cause of one’s distress is in the body. The DSM itself has an implicit biological orientation but has little explicit to say about root causes because little is actually known. The theory expressed in much current psychiatric research is that mental disorder arises from some complex interaction of biological, behavioral, psychosocial, and cultural factors. However, over the past generation, the story that ordinary people have been exposed to is that DSM conditions like GAD, major depression, and the like reflect an underlying flaw in neurochemistry, a “chemical imbalance.” Many people I interviewed took this account with them to the therapist or doctor, having already appropriated a diagnosis from their exposure to family members, friends, popular media, or pharmaceutical advertising. This explanation mediated the way they understood their experience and what they expected from treatment.
But even for those who did not reference brain chemistry, the exposure to the medicalized language of the DSM appeared to have a clear impact on the way they related to their experience. One of the most striking features of the interviews we did was the typically thin, impersonal vocabulary people used to talk about themselves and their distress. The English language has more than 400 emotion words. It was remarkable how few of these words the interviewees actually used. Though this was perhaps partly due to the interview context, there was a strong tendency to displace any richer emotional terms with the flat, homogenous language of symptoms and disorders. In telling their story, many reduced every negative feeling to being “depressed” or “anxious” and seldom made any mention of such complex emotions as jealousy, envy, betrayal, disappointment, embarrassment, or resentment that one might reasonably expect them to feel given their circumstances. Casting troublesome feelings in such mechanistic terms constrained how they perceived and evaluated the import of their experience and often seemed to foreclose further reflection or reassessment.
In our ever more bureaucratic world of health care, even diagnoses that lack validity and clinical value serve too many research, commercial, and administrative functions to be abandoned. But we all, professionals and laypeople, need to be cognizant of how the extensive popularization of these categories has influenced the parameters of our understanding and the pathways of potential care. Where possible, we would do well to avoid diagnostic language and its implicit biologizing of mental health struggles. Reassurance does not require diagnostic language, and keeping free of it will facilitate reflection in a richer, more natural vocabulary on our particular situation, emotional responses, and distress.
