Why We’re Turning Psychiatric Labels Into Identities: So you’re on the spectrum, or you’ve got borderline personality disorder, or you’re a sociopath: once you’re sure that’s who you are, you’ve got a personal stake in a very creaky diagnostic system. (Manvir Singh, May 6, 2024, The New Yorker)
The DSM as we know it appeared in 1980, with the publication of the DSM-III. Whereas the first two editions featured broad classifications and a psychoanalytic perspective, the DSM-III favored more precise diagnostic criteria and a more scientific approach. Proponents hoped that research in genetics and neuroscience would corroborate the DSM’s groupings. Almost half a century later, however, the emerging picture is of overlapping conditions, of categories that blur rather than stand apart. No disorder has been tied to a specific gene or set of genes. Nearly all genetic vulnerabilities implicated in mental illness have been associated with many conditions. A review of more than five hundred fMRI studies of people engaged in specific tasks found that, although brain imaging can detect indicators of mental illness, it fails to distinguish between schizophrenia, bipolar disorder, major depression, and other conditions. The DSM’s approach to categorization increasingly looks arbitrary and anachronistic.
Steven Hyman, who directed the National Institute of Mental Health from 1996 to 2001, told the Times that he considered the manual an “absolute scientific nightmare.” In 2009, four leaders of the DSM-5 revision wrote about their hopes to “update our classification to recognize the most prominent syndromes that are actually present in nature.” The outcome didn’t live up to those aspirations. In April, 2013, weeks before the DSM-5’s slated release, Thomas Insel, then the director of the N.I.M.H., remarked, “The final product involves mostly modest alterations of the previous edition.” As a result, he announced, the institute “will be re-orienting its research away from DSM categories.”
In “DSM: A History of Psychiatry’s Bible” (2021), the medical sociologist Allan V. Horwitz presents reasons for the DSM-5’s botched revolution, including infighting among members of the working groups and the sidelining of clinicians during the revision process. But there’s a larger difficulty: revamping the DSM requires destroying kinds of people. As the philosopher Ian Hacking observed, labelling people is very different from labelling quarks or microbes. Quarks and microbes are indifferent to their labels; by contrast, human classifications change how “individuals experience themselves—and may even lead people to evolve their feelings and behavior in part because they are so classified.” Hacking’s best-known example is multiple personality disorder. Between 1972 and 1986, the number of cases of patients with multiple personalities exploded from the double digits to an estimated six thousand. Whatever one’s thoughts about the reality of M.P.D., he observed, everyone could agree that, in 1955, “this was not a way to be a person.” No such diagnosis existed. By 1986, though, multiple personality disorder was not only a recognized psychiatric label; it was also sanctioned by academics, popular books, talk shows, and, most important, the experiences of people with multiple personalities. Hacking referred to this process, in which naming creates the thing named—and in which the meaning of names can be affected, in turn, by the name bearers—as “dynamic nominalism.”
Three new books—Paige Layle’s “But Everyone Feels This Way: How an Autism Diagnosis Saved My Life,” Patric Gagne’s “Sociopath: A Memoir,” and Alexander Kriss’s “Borderline: The Biography of a Personality Disorder”—illustrate how psychiatric classification shapes the people it describes. It models social identities. It offers scripts for how to behave and explanations for one’s interior life. By promising to tell people who they really are, diagnosis produces personal stakes in the diagnostic system, fortifying it against upheaval.
Just as personality tests (see, I’m an introvert!), astrological signs (I’m a Libra!), and generational monikers (I’m Gen Z!) are used to aid self-understanding, so are psychiatric diagnoses.
Adopting an Identity is an effort to avoid personal responsibility.
