The Book of Woe: The DSM and the Unmaking of Psychiatry by Gary Greenberg

neurological problems. When he returned to medical school, he settled on psychiatry as his specialty, and his interest in using computers to aid diagnosticians made that Chinese menu approach seem not quite so preposterous. “I thought, ‘Well, psychiatry is actually relatively straightforward. It’s got a book with rules in it already—an obvious good fortune if I was going to try to get a computer to be able to do this.” Which he was, and which is why he decided to go to the New York State Psychiatric Institute, the professional home of Bob Spitzer, where he planned to exploit his good fortune.
    Spitzer had already flirted with computer-assisted diagnosis in the 1970s, when he was first developing the criteria-based approach. He’d abandoned the attempt, however, and soured on the idea. First managed to negotiate a bargain: he could work on his program so long as he helped out with one of Spitzer’s—an old-fashioned paper-and-pencil test Spitzer was developing called Structured Clinical Interview for DSM Disorders, or SCID. The SCID, which is still in use, is straightforward to use. If you answer yes when the doctor asks you if you’ve been sad for two weeks or more, then he is directed to ask you about the next criterion for depression—whether or not you have lost interest in your usual activities. If you answer no, then he moves on to a criterion for a different disorder. This goes on for forty-five minutes or so, the questions shunting you from one branch of the diagnostic tree to the next until you land on the leaf that is your diagnosis.
    First eventually did develop his own diagnostic program. He called it DTREE, but it was a commercial failure. “I learned a lesson,” First said. “Doctors don’t care much about diagnosis. They use diagnosis mostly for codes. They don’t really care what the rules are.” When a patient comes in complaining of pervasive worry and jitters, with a little dread thrown in, most clinicians don’t take the time to climb around on the diagnostic tree. They don’t bother consulting the DSM’s list of criteria to diagnose Generalized Anxiety Disorder. They just write the code, 300.02, in the chart (and on the bill) and move on.
    “That was my first lesson in how people think about diagnosis,” First told me.
    First doesn’t think the solution is more reverence toward the DSM. Indeed, there may be only one thing worse than not paying attention to the DSM and that is paying it too much heed. “I think people take diagnosis too seriously,” he said. The DSM may appear to be a master text of psychological suffering, but this is misleading. “The fiction that diagnosis could be boiled down to a set of rules is something that people find very appealing, but I think it’s gotten out of hand. It is a convenient language for communication, and nothing more.” The rules are important, but they should not be applied outside of a very particular game.
    In this respect, First thinks, “the DSM has been a victim of its own success.” If it was merely the lexicon that gave psychiatrists a way to talk to one another, then it might live in the same dusty obscurity as, say,
Interventional Radiology in Women’s Health
or
Consensus in Clinical Nutrition
does. If it was treated as a convenient fiction fashioned by expert consensus, and not the embodiment of a scientific understanding of human functioning, then newspapers would not be giving psychiatrists valuable op-ed real estate to debate its merits. If it hadn’t escaped its professional confines, it would not be seen as a Rosetta Stone capable of decoding the complexities of our inner lives. If it had not become an epistemic prison, psychiatrists wouldn’t be languishing in it, trying to find the biological correlates of disorders that don’t really exist, that were invented rather than discovered, whose inventors never meant to make such mischief, and whose sufferers, apparently unreasonably, take medical diagnoses seriously