If the DSM is not a map of an actual world whose contours can be independently confirmed, then opening up old arguments or starting new ones is an invitation to chaos. With each revision of the DSM comes the potential for instability and discord that cannot be settled by turning to the microscope or the computed tomography (CT) scanner. Knowing this, Frances says the goal of a DSM revision should be to stabilize an inescapably fragile system rather than to perfect it—or, as he put it to me, “loving the pet, even if it is a mutt.”
The mutt has certainly caused some mischief. Among its more prominent detractors was Steven Hyman, who in 1996 became the head of the National Institute of Mental Health (NIMH). A neurogeneticist by training, Hyman hadn’t thought much about nosology before taking over at NIMH. It “seemed a bit like stamp collecting,” he once wrote in a 2010 article in the Annual Review of Clinical Psychology, “an absorbing activity perhaps, but not a vibrant area of inquiry.”
But then he realized that the DSM was “a critical platform for research.” Its categories and criteria were the basis of decisions made by journal editors, grant reviewers, regulators, and the Food and Drug Administration, which meant that scientists were bound to frame their proposals in the DSM’s language. “DSM-IV diagnoses controlled the research questions they could ask, and perhaps, even imagine,” he wrote.
“The tendency [is] always strong,” John Stuart Mill wrote in 1869, “to believe that whatever receives a name must be an entity or being, having an independent existence of its own.” To Hyman, who quoted Mill approvingly, this tendency had led all the stakeholders in nosology—scientists, regulators, editors, doctors, drug companies, and, of course, patients—to take the labels not as arbitrary descriptions but as the names of actual diseases. They had, at least according to Hyman, reified what were intended only as concepts.
And this was no mere abstract concern. “It became a source of real worry to me,” Hyman said, “that as Institute director I might be signing off on the expenditure of large sums of taxpayers’ money for…projects that almost never questioned the existing diagnostic categories despite their lack of validation.” The DSM, Hyman concluded, had “created an unintended epistemic prison,” and anyone with a stake in the mental health treatment system was trapped inside.
The Termite-Riddled Foundation
While he was at the National Institute of Mental Health, Hyman had occasion to confide his reservations to at least one colleague: Steven Mirin, then the APA’s medical director. On a weekend afternoon in the summer of 1998, the two were eating lunch by the side of Mirin’s swimming pool in the D.C. area when Mirin asked Hyman if the NIMH would give the APA money to get the next revision of the DSM up and running.
Mirin’s request for taxpayer money to kick-start a project from which a private organization would profit was not as untoward as it might seem. After all, the DSM is indispensable to public health, and the NIMH had helped fund the DSM-IV. Nonetheless, and despite their friendship, Hyman said no. He told Mirin that a revision was premature, not only because the ink was barely dry on DSM-IV but also because psychiatrists had yet to come up with a better way to chart the landscape of mental illness.
