'How has the DSM evolved to become seen as the "authoritative medical guide to all of mental suffering"?

The credibility of psychiatry is tied to its nosology. What developed over time is the number of diagnoses, and, more importantly, the method by which diagnostic categories

are established.

You're a practicing psychotherapist. Can you define "mental illness"?
No. Nobody can.

The DSM lists "disorders." How are disorders different from diseases or illnesses?

The difference between disease and disorder is an attempt on the part of psychiatry

to evade the problem they're presented with. Disease is a kind of suffering that's caused by a bio-chemical pathology. Something that can be discovered and targeted with magic bullets. But in many cases our suffering can't be diagnosed that way.

Psychiatry was in a crisis in the 1970s over questions like "what is a mental illness?" and "what mental illnesses exist?" One of the first things they did was try to finesse the problem that no mental illness met that definition of a disease.

They had yet to identify what the pathogen was, what the disease process consisted of, and how to cure it. So they created a category called "disorder." It's a rhetorical device. It's saying "it's sort of like a disease," but not calling it a disease because all the other doctors

will jump down their throats asking, "where's your blood test?" The reason there haven't been any sensible findings tying genetics or any kind of molecular biology to DSM categories is not only that our instruments are crude, but also that the DSM categories aren't real.

It's like using a map of the moon to find your way around Russia.

So would you say that these terms—disorder, disease, illness—are just different names for the same concept?

I would. Psychiatrists wouldn't. Well, psychiatrists would say it sometimes but wouldn't say it

other times. They will say it when it comes to claiming that they belong squarely in the field of medicine. But if you press them and ask if these disorders exist in the same way that cancer and diabetes exist, they'll say no. It's not that there are no biological correlates

to any mental suffering—of course there are. But the specificity and sensitivity that we require to distinguish pneumonia from lung cancer, even that kind of distinction, it just doesn't exist.

What are the most common misconceptions about the scientific nature of diseases

such as depression?

I guarantee you that in the course of our conversation a doctor is telling a patient, "you have a chemical imbalance—that's why you're depressed. Take Prozac." Despite the fact that every doctor who knows anything knows that there is no biochemical imbalance

that causes depression, and most doctors understand that a diagnosis of depression doesn't really tell you anything other than what you already knew, that doesn't stop them from saying it.

Research on the brain is still in its infancy. Do you think we will ever know enough about

the brain to prove that certain psychiatric diagnoses have a direct biological cause?

I'd be willing to bet everything that whenever it happens, whatever we find out about the brain and mental suffering is not going to map, at all, onto the DSM categories. Let's say we can

elucidate the entire structure of a given kind of mental suffering. We're not going to be able to say, "here's Major Depressive Disorder, and here's what it looks like in the brain." If there's any success, it will involve a whole remapping of the terrain of mental disorders. And

psychiatry may very likely take very small findings and trump them up into something they aren't. But the most honest outcome would be to go back to the old days and just look at symptoms. They might get good at elucidating the circuitry of fear or anxiety or these kinds of

things.

What is the difference between a disorder and distress that is a normal occurrence in our lives?

That distinction is made by a clinician, whether it's a family doctor or a psychiatrist or whoever. But nobody knows exactly how to make that determination. There are no

established thresholds. Even if you could imagine how that would work, it would have to be a subjective analysis of the extent to which the person's functioning is impaired. How are you going to measure that? Doctors are supposed to measure "clinical significance." What's that?

For many people, the fact that someone shows up in their office is clinical significance. I'm not going to say that's wrong, but it's not scientific. And there's a conflict of interest—if I don't determine clinical significance, I don't get paid.

You say one of the issues with

taking these categories too seriously is that it eliminates the moral aspect behind certain behaviors.

It's our characteristic way of chalking up what we think is "evil" to what we think of as mental disease. Our gut reaction is always "that was really sick. Those guys in Boston

—they were really sick." But how do we know? Unless you decide in advance that anybody who does anything heinous is sick. This society is very wary of using the term "evil." But I firmly believe there is such a thing as evil. It's circular—thinking that anybody who commits

suicide is depressed; anybody who goes into a school with a loaded gun and shoots people must have a mental illness. There's a certain kind of comfort in that, but there's no indication for it, particularly because we don't know what mental illness is. [. . .]

What are the dangers of over-diagnosing a population? Are false positives worse than false negatives?

I believe that false positives, people who are diagnosed because there's a diagnosis for them and they show up in a doctor's office, is a much bigger problem.

It changes people's identities, it encourages the use of drugs whose side effects and long-term effects are unknown, and main effects are poorly understood.'

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(source: https://www.theatlantic.com/health/archive/2013/05/the-real-problems-with-psychiatry/275371/)