Andrew Scull:

FOR NEARLY FOUR DECADES now, the Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM for short, has exercised a stranglehold of sorts over the mental health sector in the United States, and indeed around the world. Since the publication of the manual’s third edition in 1980, psychiatrists have used a symptom-based approach to name and categorize varieties of mental disturbances — which essentially mirrors the 18th century’s approach to physical illness. As was also true then, there do not exist today any technologies that lend authority to psychiatric diagnoses: no x-rays or MRIs, no blood tests or laboratory analyses that would allow us to make even the most basic distinctions between mental health and mental illness. This unsatisfactory situation has invited controversy and led some misguided souls to deny the very reality of mental illness.

The fact that the DSM has passed through three editions and two interim revisions since 1980 is eloquent testimony to the psychiatric profession’s struggle with delineating its territory. Yet, however haphazard, the diagnostic category or categories to which patients are assigned have profound social and medical ramifications. And American professionals — even clinical psychologists who reject the DSM’s model — have no choice but to use (and thereby uphold) these categories if they expect to be paid by insurance companies.