Kenneth Kendler, writing in the American Journal of Psychiatry, reviewed all the major English textbooks of psychiatry from 1900 to 1960. There were 13. And he notes that some of the symptoms that the psychiatrists who wrote those books thought were important aspects of depression were lost. He then expands this, with some ideas as to why the US DSM5 has lost clinical utility.

Furthermore, if meeting DSM criteria constitutes a psychiatric disorder, why should we evaluate anything but the DSM criteria? This view is deeply problematic. Psychiatry is the inheritor of the richest tradition of description in all of medicine because the features of the disordered mind/brain system that is the subject of our discipline are so diverse, so innately fascinating and profound in the degree to which they illuminate the human condition. Part of the process of good clinical care is to explore the experiences of our patients. This helps us better understand their experiences, and this sense of shared understanding can be directly therapeutic. This cannot be done without knowledge of the world of psychopathology outside of DSM. DSM might provide a guide to but can hardly be a replacement for our rich psychopathological tradition.

From a historical perspective, psychiatry has been appropriately proud of the “DSM revolution.” However, we still lack gold-standard validators like coronary angiography. The presence of such validators helps illustrate the difference between indexing and constituting a disorder. Given our pride in our diagnosis and our lack of definitive validators, it is understandable that our field has had undergone a “conceptual creep” in which our criteria have mistakenly become our disorder.

The DSM is a US variation of the International Classification of Disease (ICD) mental health chapter. The DSM and ICD were being revised in parallel, but the DSM was released first. The ICD will, like Debian, come out when it is ready. The rest of the world uses DSM for research — usually the older version — or the new Research Diagnositic Criteria of the NIMH (that have little clinical utility). But the rest of us don’t have to code everything to be paid.

We can say a person has a difficulty, not a disorder. We tend to be parsimonous in our diagnoses. No one who has done any work in psychiatric epidemiology or classification treats the DSM as authoratative, but as a best guess of how to classify things.

Because we lack confirmatory tests. Because we don’t have a full understanding of biology.

But into that vacuum, particularly when funding is involved, there is a creep to add more, so that more interventions can be funded. This is less of a problem locally, where we have capped funding, and the issue is helping as many people as we can with not enough money, for socialized medicine is an exercise of triage and risk.

But hold these documents lightly. They are more likely to be wrong than right.