In his 2013 essay “Book of Lamentations,” cultural critic Sam Kriss reviews the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as if it were a work of dystopian literature, a kind of nightmarish encyclopedia in the lineage of Borges. Kriss argues that the manual is a literary object with a deeply unreliable narrator, who writes with a coldly compulsive voice that cannot perceive its own madness. “As you read, you slowly grow aware that the book’s real object of fascination isn’t the various sicknesses described in its pages, but the sickness inherent in their arrangement.”
Kriss sees the DSM as a device of absurdity and detachment because he reads it as making assumptions that are not explicitly present in the book itself: that madness is internal, individual, and biologically determined. The DSM’s silence on these issues does little to dispel this interpretation.
Since its first edition in 1952, the DSM has gradually evolved from a slim document meant to standardize psychiatric recordkeeping into a sprawling classification system that shoulders a set of responsibilities it was never designed to bear. It is expected to guide clinical care, enable research, satisfy insurance companies, anchor epidemiological studies, shape patient self-understanding, and serve as a platform for public policy. Each of these demands pulls the manual in different directions.
In advance of the DSM-5, there were hopes for a “paradigm shift” which would incorporate findings from neuroscience and create a more dimensional, biologically based system.The neo-Kraepelinians had believed that with iterative research, biological validators would point towards the hidden disease entities, in much the same way that syphilis had been identified in the early 20th century as a cause of a then-common condition “general paralysis of the insane.” But by the 1990s, it was becoming obvious to scientists that validators of DSM categories did notconverge in any neat fashion.
DSM-5 became the symbol of a deep tension within the field. Psychiatry wanted to be seen as part of clinical neuroscience, but didn’t yet have the evidence to fully support that shift. The controversy around DSM-5 also hurt its public image. While it remains the go-to manual in practice — since no alternative has been able to displace it — it no longer carries the same unquestioned authority.
Even if genes or brain scans do not line up with DSM categories, researchers have found plenty of evidence that biological processes such as genetic factors, inflammation and brain circuitry are involved in mental illness. These patterns aren’t random or meaningless; they’re just far more complicated and messier than we had hoped. “Biology never read that book,” Thomas Insel famously said about the DSM.
And yet, in the new clinical, atomized, and oddly impersonal idiom, “having OCD” or “having ADHD” invites one to imagine essences within oneself that do not exist. This linguistic shift, McWilliams observes, often accompanies a deeper psychological distancing. People present themselves as hosts to diagnostic entities, rather than agents struggling through difficulties. In the most extreme cases, that essence becomes all-pervading, a core of who they are.
The DSM was never crafted with the purpose of helping individuals make sense of their own psychological struggles, nor is it particularly well-suited for that task. The DSM is a tool for clinicians and researchers. It presumes a baseline of clinical training and medical knowledge, and an appreciation of methodological limitations. It is not a guidebook for laypeople navigating their inner worlds.
The DSM, with its deliberately “user-friendly” format and preference for everyday language, appears vulnerable to misinterpretation by the public.
The psychologist Eric Turkheimer has commented that psychiatric diagnosis is a “relief from the Sisyphean burden of understanding the relationship between our bodies and our intentions.” It’s exhausting to ask, again and again, why we suffer so intensely, despite our efforts to feel otherwise, or why we return to self-destructive habits even when we know better. Our struggle with these questions leaves us emotionally depleted. If calling these struggles “disorders” offers a kind of balm, a way to temporarily suspend the ambiguity, then maybe that’s a mercy.
Where in Turkheimer’s perspective diagnosis offers a reprieve, it offers only confinement to Oyler. She doesn’t want to be cornered by language, to have her fluctuating experiences pinned under a diagnostic term. This resistance, however, shows just how powerful those terms can be. We seem to need them for our suffering to feel real, and yet we bristle when they confine us.
The debate around Asperger’s syndrome should have sparked a collective realization: that the sense of self shared by those who identify as “Aspies” never needed to hinge on whether the DSM retained that term. How can a medical manual, subject to change, driven by evolving criteria, have the authority to define or dissolve a social identity? Social identities live and die on their own terms.
Psychiatric classification as a clinical and scientific project is not designed as a tool for existential self-definition. It is not for you. No diagnostic manual can tell people who they really are.
My hope in these conversations with patients is to plant a seed of resistance, to offer an account of suffering that acknowledges complexity, contingency, and context beyond categories. I try to say, in effect: this pattern of symptoms reflects something meaningful about your psychological life, but it doesn’t define you. It shouldn’t be the scaffold upon which you build your entire self. You’re free to acknowledge it, even to use it as a lens, but don’t let it confine you. Do not let it determine your story.
And yet, I am aware that at a certain level this message is deeply unsatisfying, both to those who see diagnosis as a scaffolding and to those who see it as a trap. In gesturing toward the messy interweaving of temperament and trauma, and softening the solidity of diagnoses, I refuse to indulge our strange masochistic desire for categorical self-confinement.