My abnormal psych professor made a big deal of the fact that the DSM names things first and foremost so they can be talked about. So that when one psychologist says to another "This patient exhibits blahdebleh with specific hemahummahoo", they have reasonable expectations that they are at least talking about the same symptoms. Perhaps they are talking about the same underlying cause, perhaps not, but at least they'll be talking about what appears on the surface to be the same thing, which is better than nothing.

Psychologists are well aware that, for instance, "schizophrenia" (and I'm not going to check whether that's still in the DSM V, if not the point here holds) is probably more than one thing, and as soon as they work out the details, they will be given multiple names. In the meantime, so that everyone is on the same page, it has a description as clear as possible (which is not always very clear).

The DSM is intended to be descriptive, not prescriptive, and not exhaustive. It is also not intended to be casually perused by people who don't understand the purpose, because of the high probability of suffering Medical Student's Disease [1] as a result.

[1]: http://en.wikipedia.org/wiki/Medical_students%27_disease

Kind of like how "a headache" is a grossly simplistic term, given how many varieties and underlying causes we know of today, but we still need that anchor point long before discussing the prescription of aspirin vs. tumor surgery.

I feel like the core criticism here isn't necessarily of structure itself, but that the type of structure applied when creating the DSM-V is not necessarily a helpful structure. Grouping things into neat categories and assigning them a name is useful in the case where structure actually helps patients, but it's possible to harm them just as much if it goes beyond being a diagnostic tool and rule of thumb.

I don't think the DSM-V protects against the problem you observed when seeing a psych, either. I saw one a while back who did believe in the DSM-IV (V wasn't out at the time) and his approach was still 'it sounds like you fit the clinical definition of this; I can prescribe you this medication'. The diagnostic process was, ultimately, 'if this medication helps you probably have this condition'. I think it's reasonable for that to unnerve you, but that's really just a symptom of how difficult it is to actually draw concrete, verifiable conclusions about this stuff.

Many of the conditions described in a tome like the DSM-V as a singular condition end up having wildly varied symptoms and there end up being treatments that only work for one subset of people with the condition, while another treatment only works for another subset. Some people who have a condition only show a tiny subset of the symptoms. I think it's reasonable to look at that and ask if some well-meaning people have gone overboard in an attempt to label and categorize everything.

On a related note, there are many marginalized groups out there that feel victimized by the authors of tomes like the DSM, because it often classifies things as 'disorders' that ought not necessarily be a disorder. Those with unusual sexual orientations, gender identities, or social habits are among the people who at one time or another have been considered mentally deficient or mentally ill due to classification. I don't think the people authoring those classifications necessarily intended to harm those marginalized groups, but that often IS the result.

The problem is that psychiatrists aren't really interested in much other than prescribing medications. Therapy is left to those with degrees in clinical psychology or social work.

And from what I have experience with--the eating disorder community--many professionals actually discredit the DSM's categorization (though it has much improved in the DSM-5) because of its insistence on weight for diagnoses of anorexia nervosa. But great American insurance often will pay for nothing if the patient does not have either AN or BN leading to patients being "not sick enough" for treatment when really, they need it as soon as possible for recovery to be most successful.

It also seems like there's a rivalry between psychiatrists and the psychologists. I wonder if the latter have their own equivalent text to the DSM.

i don't really disagree with you, but it seems to me that the problem is that there are good doctors and crappy doctors. DSM-V seems to be a side-issue; it's just a tool. arguing about it seems to be the psychiatric equivalent of criticising programming languages...

(i got a second opinion from someone who spent much more time talking with me, understanding what was happening, and discussing possibilities. he used DSM-V as a framework that allowed him to structure things. that was all. he was awesome and i was happy with his decision. and that's because he was a good doctor, not because of DSM-V. but as a good doctor, he wasn't discarding a useful tool for "religious reasons")

[edit: all the above is necessarily simplified; i now feel a bit guilty in portraying the first doctor so negatively. there's clearly factors like client-doctor "fit" involved, too.]

I read this piece as using the "what if the DSM was a novel" part mostly as a jumping-off point to satirize how we treat the idea of happiness and normality, rather than being explicitly a criticism of the manual itself as a diagnostic tool.

A "weak interpretation" of the DSM where it's a collection of clustered symptoms, together with some advice about what treatments appear to have worked or not worked in the past for them, wouldn't really run into that. But some people do seem to have a stronger interpretation where the manual acquires a normative/definitional component, in which it's supposed to define the line between "mentally ill" and "normal psyche". Then you get into a huge amount of uncertainty that we still have over the etiology of any of these conditions, plus political battles over what counts as normal in the first place, the long fight over whether homosexuality should be included being probably the most famous example. Occasionally legal status can even be tied to being diagnosed as "mentally ill", which is where it starts coming closest to the dystopian-novel feel, although that may be the fault of legislators more than psychiatrists.

I guess the part of this article that's most explicitly a critique is this:

> DSM-5 seems to have no definition of happiness other than the absence of suffering.

...but that only really applies to certain ways of using the DSM, the weak pragmatic one not being among them, since it would recognize that treating acute suffering is only a small component of human psychology in the more general sense.

The problem is that the DSM has become the de facto authority on what exactly constitutes an illness -- i.e is coverable by insurance. If your problem isn't in the DSM, insurers can in many cases safely deny coverage.

So now we have the situation where an unelected, private body (the American Psychiatric Association) wields immense power over people's daily lives.

This is the problem the author is alluding to in this passage:

> On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the “Diagnostic and Statistical Manual” is something that might actually be used, and that its caricature of our inner lives could have serious consequences. Sections like those on the personality disorders offer a terrifying glimpse of a futuristic system of repression, one in which deviance isn’t furiously stamped out like it is in Orwell’s unsubtle Oceania, but pathologized instead.

> i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition".

You do realize that one of the biggest criticisms of the DSM-5 is that the inter-rater reliability for many diagnoses is no better than a coin flip, right?

then fix those, but don't throw the baby out with the bathwater.

the problem is that, at least in my case, DSM-V was replaced with an appeal to authority.

when the alternative is "ok boss, you know best" i prefer a list of symptoms where i can argue, "look, almost anyone could tick half these boxes at some point in their lives". at least i can see what's happening.

i am not saying that DSM-V is a rule book that should be followed blindly. i am not saying that it is "right", or that it carries some kind of moral weight. all that i am saying is that any communication - even dissent - needs a common vocabulary, and DSM-V can provide that.

from my outside perspective it seems that it's a tool; that the real problem is some of the doctors. discarding the tool won't improve the bad doctors, it will just make them less accountable. how is that an improvement?

You seem to not realize that the DSM-5 can be used to justify treating you with a wide variety of medications.

If you feel a little down, occasionally feel a bit energized and happy, and sometimes anxious, using the DSM 5 your shrink can gladly give you:

antidepressants antipsychotics anxiety medications

and more.

doctors can do what they want anyway. getting rid of DSM-V won't remove those powers. it just removes a way to describe / discuss (and perhaps challenge) what they are doing. so you're actually making things more open to abuse.

but i'm not sure if this will help explain things, as i thought my comment above was pretty clear anyway.

It might help to borrow a smidge from Foucault's History of Madness. What impact does labelling have beyond a purely descriptive belief? Is there an ideological conflict between what is mad and what is not?

The simplest example that comes to mind is hysteria. We can easily see how this well discussed ‘ailment’ was actually an undercurrent of misogyny and class warfare.

This goes hand in hand with the various forms of dysfunctional medicalization over the years. From Lombroso to the medicalization of the woman, the African American, the Jewish Race, etc.

There appears much more at stake than benevolent labelling.

> but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition

DSM or no, too many doctors prescribe medication off-label. People with one of the personality disorders get a diagnosis and then some semi-random medication with some experimental[1] psychotherapy. All the clinicians disagree about what the treatment should be, but they see that as a feature of the patient's illness. Thus, if the patient is doing exactly what Dr A wants (but not what Dr B wants) Dr B will say it's the patient's manipulation which is part of the illness, and not that it's just a conflict among the team

I'm not sure how it works in the US, but some psychiatric diagnoses can be used to detain a person in hospital against their will. There's no court process, no judge. There are some protections, but these are not great.

On the latter part, this is pretty rare now in the US. Involuntary "holds" are almost always short-term, and only initiated when there's some disturbance that results in the police being called. In California, for example, a 72-hour hold is the most common, although 2-week and longer holds are possible: http://en.wikipedia.org/wiki/5150_(involuntary_psychiatric_h...

The downside is that the old system of involuntary commitment, which I do believe civil-liberties campaigners were right to campaign against, has not really been replaced with anything. Some proportion of those who were previously involuntarily committed are better off, living some kind of life, whether a normal one, or some kind of bohemian one, or with family, or otherwise getting by. But some proportion are a mixture of homeless and in and out of jail or 72-hour holds, without any serious long-term attempt to do anything about their situation. Especially true if either they lack close family, or lack family with enough means to take them in, or have psychotic episodes that their family finds threatening. A schizophrenic guy I know through the tech scene is in that category; has been 72-hour held 4 or 5 times, on a 2-week hold once, arrested for various kinds of minor disturbances a dozen times, etc., but never received much treatment, except during the short periods of psychiatric confinement.

Varies from state to state, http://en.wikipedia.org/wiki/Involuntary_commitment#United_S...

I did a 6-week rotation in a psych ward for exclusively psychotic patients ( mostly schizophrenic, some manic). I can't recall if they were all held specifically for being a danger to themselves / others, but remember court orders being regularly obtained (and always required) and then only for patients who were very psychotic (medically psychotic --> delusional, typically to the point of being unable to function).

you need to understand that DSM-V is the same intuition voted into existence by many doctors instead of one. The same BS at the end of the day. Who in their right mind would call a science a subject where we vote/unvote things into existence or deny their existence by voting process? Can you imagine the best in the world physicists voting in the beginning of 20th Century if Einstein theory of relativity is true or not? 90% of the vote would be that Einstein is wrong. However, nature and real science don't give a shit about democratic process. It's all about facts. And the facts, especially in pseudo-science like psychiatry - could be very, very damaging to the status quo.

But is it really different than when the IAU decided our solar system has now planet less? The DSM isn't - from what I can tell - deciding that observable phenomena doesn't exist, but changing its classification, and that's something not derivable from facts.

Another good example, 620 nm, is that red or orange light?

For me it's more of is Sun going around the Earth, or the Earth around the Sun types of questions. Something very basic. I.e. is there a sex addiction or not? Is homosexuality a "disease" or not? I mean you do have whole movements like anti-psychiatry movement that basically are in total opposition to everything that psychiatry claims.

I can go to a psychiatrist and persuade him/her that I have a bipolar disorder. Or that I'm schizophrenic, or depressive. And that's because there is no way for psychiatrists to know. You can talk all day long about all types of brain imaging tests that could reveal the diseases. But if that in fact was true then psychiatry would use the tools in the diagnostic process. If nothing else then at least to shut up guys like me who laugh at that "science".

Do you think that I can't go to 3 doctors and persuade each of them that I have a psychiatric condition and that they wouldn't give me a diagnosis?