The New Yorker, By Gary Greenberg
April 23, 2013

In 1886, Pliny Earle, then the superintendent of the state hospital for the insane in Northampton, Massachusetts, complained to his fellow psychiatrists that “in the present state of our knowledge, no classification of insanity can be erected upon a pathological basis.” Doctors in other specialties were using microscopes and chemical assays to discern the material causes of illness and to classify diseases accordingly. But psychiatrists, confronted with the impenetrable complexities of the brain, were “forced to fall back upon the symptomatology of the disease—the apparent mental condition, as judged from the outward manifestations.”

The rest of medicine may have been galloping into modernity on the back of science, but Earle and his colleagues were being left in the dust.

Thirty years later, they had not caught up.

In 1917, Thomas Salmon, another leading psychiatrist, echoed Earle’s worry in an address to his colleagues, drawing their attention to the way that their reliance on appearances had resulted in a “chaotic” diagnostic system, which, he said, “discredits the science of psychiatry and reflects unfavorably upon our association.” Psychiatry, Salmon continued, needed a nosology that would “meet the scientific demands of the day” if it was to command public trust.

In the century that has passed since Salmon’s lament, doctors in most medical specialties have only gotten better at sorting our suffering according to its biochemical causes. They have learned how to turn symptom into clues, and, like Sherlock Holmes stalking a criminal, to follow the evidence to the culprit. With a blood test or tissue culture, they can determine whether a skin rash is poison ivy or syphilis, or whether a cough is a symptom of a cold or of lung cancer. Sure-footed diagnosis is what we have come to expect from our physicians. It gives us some comfort, and the confidence to submit to their treatments.

But psychiatrists still cannot meet this demand. A detailed understanding of the brain, with its hundred billion neurons and trillions of synapses, remains elusive, leaving psychiatry dependent on outward manifestations for its taxonomy of mental illnesses.

Indeed, it has been doubling down on appearances since 1980, which is when the American Psychiatric Association created a Diagnostic and Statistical Manual of Mental Disorders (D.S.M.) that intentionally did not strive to go beyond the symptom. In place of biochemistry, the D.S.M. offers expert consensus about which clusters of symptoms constitute particular mental illnesses, and about which mental illnesses are real, or at least real enough to warrant a name and a place in the medical lexicon. But this approach hasn’t really worked to establish the profession’s credibility.

In the four revisions of the D.S.M. since 1980, diagnoses have appeared and disappeared, and symptom lists have been tweaked and rejiggered with troubling regularity, generally after debate that seems more suited to the floors of Congress than the halls of science. The inevitable and public chaos—diagnostic epidemics, prescription-drug fads, patients labelled and relabelled—has only deepened psychiatry’s inferiority complex.

But it’s not entirely clear that psychiatrists want a solution to the problem, at least not to judge from what happened when the experts conducting the most recent revision of the manual, the D.S.M.-5, were offered one… Read the rest of the article here