The Taproot Podcast - Is The DSM Dying Part 2: What is a Diagnosis Anyway?

Episode Date: January 15, 2026

https://gettherapybirmingham.com/what-is-a-diagnosis-anyway-is-the-dsm-dying-part-2/ The Archaeology of a Label: What We Forgot About Diagnosis and Why It Matters Now The book that decides if you're sane was written by the military to process soldiers. The committees that define your mental illness hold "typewriter parties" where they shout symptoms until someone wins. And the federal government declared the whole thing scientifically invalid—two weeks before the latest edition dropped. In this episode, Joel Blackstock, LICSW-S, takes you inside the bizarre, hidden history of the DSM—the document that shapes every therapy session, every prescription, every insurance claim in American mental health. You'll learn: Why the DSM started as an Army logistics manual, not a medical document How a single awkward psychiatrist named Robert Spitzer staged a coup against Freud using checklists and political horse-trading The "dopamine miracle" that saved psychiatry from total collapse—and the price we're still paying Why the biggest research agency in mental health publicly divorced the DSM and nobody noticed What Joseph Campbell and Star Wars have to do with the therapy your insurance won't cover This isn't anti-psychiatry. This is pro-understanding. Because the system isn't broken by accident—it was built this way. And if we want to fix it, we have to see how we got here. "The DSM was never a description of nature. It was a set of administrative protocols created by the military, adapted by the bureaucracy, defended by a profession fighting for legitimacy, and captured by industries seeking profit." Subscribe. Share. And maybe question that diagnosis.

It's not the territory The code is not the man We're building as fast as we can Is it a disease? Hey guys, it's Joel with the Tapir Therapy Therapy Collective podcast, and this is a follow-up to the podcast that is the DSM dying. A lot of people ask a lot of questions

That were good questions And wanted kind of a deeper dive into that So a little bit of a retread, but also a different way of looking at the thing. So let's go ahead and get started. So, you know, what happened when you, one of the things that I didn't do in the first one was back up to the idea of what a diagnosis is. You know, some people kind of had a question that sounds simple, but it's a deceptive simplicity. So, you know, before there were psychiatrists, there's priests and shamans, and there were no diagnostic manuals.

They were just mythology. And ancient Greeks had this word for what we know called mental illness, and it was mania. But mania didn't mean what we mean by it. when Dionysius drove the women of Thebes to tear King Penthus, Lim from Lim, which is kind of a Greek play, if you haven't read it, about repression, that when you don't honor the gods in these temples, they go underground, and they come up through nature, and they come up through the hearts of women, and they come up through the blindness of men.

Or, you know, when Ajax slaughtered a flock of sheep believing them to be his enemies, because he had been bewitched. This was mania, you know, it was something that came from heaven. when the Oracle at Delphi spoke in tongues and she was possessed by Apollo, that was this kind of divine madness. And so there was this truth in madness. They understood this unconscious was this thing underneath the world that could drive you mad, but also was sort of the source of life. You know, there's that ability to hold that tension in Greek mythology. But this is alien, of course, to any modern sensibility.

Half of you guys listening are probably like, you know, what the hell is that? But it is important to go back to the beginning. And so if you believed that hearing voices meant that a God was trying to tell you something or that you had been touched by a God, your entire approach to treatment would be different. You wouldn't try and make the voices stop. You'd try and figure out what they were saying, what the purpose was. You know, you might fast or you might pray or gone pilgrimage. And it's not a disorder in the way that we understand now. It's not the diagnosis, you know, but that is the origin of diagnosis.

And, you know, around the 5th century, BC, you see something shift. There's these Hippocratic physicians all of a sudden. the founders of Western medicine, and they start arguing that madness is not divine. It's just natural. They see patterns that certain families are affected. They see patterns that certain drugs, certain behaviors are associated with it, and they start to say, hey, this isn't divine. And they start to say it's a disorder of one of the four humors, you know, blood, flim, yellow bile, or black bile. It must be some substance within you, not something coming from heaven. And the famous, you know, Hippocratic Oath, or is still used in medicine.

You know, it goes back to this tradition. But, you know, in one of the Hippocratic texts, the author is talking about how people shouldn't attribute seizures to gods. It used to be like a scene as this good thing. He said, you know, it's not any more divine or sacred than any other disease. Like when you get the flu in your body, why do you think that that doesn't come from a God? But when you get a disease in your mind, do you think it does? You know, that was what some of the Hippocratic texts are, you know, angry about.

And so there's this revolution by relocating madness from heaven to the body. The Hippocratics, they created this conceptual space for medicine. But they note this that what we keep is this idea of the patient's condition meaning something. Humors weren't just chemicals. They're connected to seasons, elements, temperaments. It was seen as something that you also were participating in with your makeup. Some of that could lead to illness, but you had a tendency to black bile or yellow bile. You know, black bile meant you were melancholic.

There was something in you, but also you weren't managing it well because you were, you know, being melancholic. And, you know, that had this kind of particularly prescient idea of there's something in the environment and there's also something in the person. And this humor system, you know, is what Western medicine sort of assumed for 2,000 years. And medieval physicians worked on this thing that, you know, Greeks came up with. And even up to the Renaissance, people were still saying, you know, bloodletting works because it's letting out the bad blood and basing things on it. So that's a long, long time to go from ancient Greece to the Renaissance. And then you have, you know, Descartes, when the Enlightenment happens,

and Descartes is sort of famous for devising reality as that there's, you know, thinking stuff. and then there's extended stuff. He creates this philosophical puzzle that we still haven't solved, and he says a body is a machine operating according to mechanical laws, but the mind was something else. You know, it was this ghost in the machine. It was immaterial and indivisible and free, but also in control of it and fundamentally tethered to it.

So this dualism made science possible, because he declared that the body was pure mechanism, and it gave Descartes permission to dissect, measure, and experiment on it without worrying about the. soul. But it created this massive problem for psychiatry. Because if the mind is immaterial, how can it be sick? You know, if mental illness is real, where is it located? You know, Jung was obsessed with finding the Psycheoma, the place where the psyche met the meat, if you will, where the deepest roots of the unconscious sort of turned into bodily reactions. And the 19th century tried

these different answers. You know, phrenologists thought that mental faculties were low-dicated in specific brain regions, and you could feel them through the the skull. So somebody had bad character if their skull bulged out here, good character if it had done it in here. A lot of that was just sort of saying that like people that are attractive traditionally tend to be better, um, yeah, mental, you know, a lot of phrodology just says, like, if you're hot, you're healthy, basically. Um, and so asylum doctors look for brain lesions and deceased patients. Maybe there's a wound, but it's on the mind. Um, and then the results were kind of disappointing. You couldn't quite cut somebody open and find what had made them

mentally ill while they were alive. So many conditions that looked like diseases such as melancholia and hysteria, neurasthenia, they seem to have no physical basis at all. And so this is this kind of secret that still haunts psychiatry. And the modern psychiatric diagnosis was essentially invented by one man. And that's Craplin. You know, Emil Kraeplin is a German psychiatrist working in the late 19th century, early 20th century. And Craplin's intervention was that it was, he stopped trying to find the cause of the mental illness and he focused instead on the course. What's it going to do? He realized that when you get bipolar, you're not just going to go do one thing like the flu is going to make you do. It's going to have a prognosis, like a course of progression and then

decline or stagnation or whatever it does, and that we should start thinking of this as a process. So he spent decades observing patients in asylums, tracking symptoms, and he noticed that certain clusters of symptoms tended to hang together and then follow these predictable trajectories. So some patients got sick young and they deteriorated steadily and then never recovered. Others had episodes of illness followed by periods of relative health. And from these observations, Craplin carved out two categories that still structure psychiatry today. Dementia Precox, which is what Young and Freud and early psychoanalyst would have called

schizophrenia, which basically means, you know, hallucination and split from reality. And then manic depressive illness, which was later split into bipolar disorder. and major depression. And his methods were not purely descriptive. He didn't claim to know what caused it. He just was charting kind of what it was doing. He stopped trying to find a location for it, you know, a substance or wound that was happening. He just said, hey, look, when we see this symptom, we know that later it's going to be accompanied

by all these other symptoms because that's what everyone else did, and so we can prepare for them. So before Spitzer, you know, that we talked about in the first one, you have, you know, Freud, and whatever else you want to And whatever else you want to say about Freud, he understood something that the DSM now, modern DSM has forgotten. Symptoms are not just problems to be eliminated. There are solutions to deeper problems that mean something. So Freud's great insight that has been validated over years by trauma research is that, you know, even the specific theories of everything going back to a sexual route because of sexual selection,

you know, being a driver of evolution, that doesn't mean that it's the determinism of everything in psychology like Freud thought. We've discarded that. But that psychological symptoms often have, they represent a return of experience that couldn't be processed when they occurred, which is what we'd call trauma now. You couldn't feel it because it was overwhelming. And so you shut down and it got stored and stagnated and now it's still interrupting or present this past event. You know, that would be like historical paralysis or I'm sorry, hysterical paralysis, something that they would diagnose you with back then, that you had been paralyzed in your hysteria then. and that was making you tend towards hysteria now and the present. So here's something that should be a scandal, but somehow it's not.

The DSM didn't really come from hospitals or research universities at all. That wasn't its origin. It emerged from the U.S. Army needing to process soldiers during World War II. It was a processing tool. The military had millions of young men that were being drafted, and a significant percentage of them were cracking under the stress of combat. And so the army needed to figure out who was fit for duty, who should be discharged, and who was entitled to a pension, you know, who deserved it, who fought well, but then the war

had actually wounded them versus somebody who came in and they just were mentally ill, and then they went to war and they got discharged because they were mentally ill, but they always were. You have to screen people before, if you want to prove that it's the war that actually hurt them. So they needed codes, and they couldn't afford 500 psychiatrists that are writing these long essays about soldiers' childhood and making an individual determination. And so the solution was this technical medical bulletin number 203 issued by the War Department in 1943, and this document created this standardized nomenclature for psychiatric conditions. The first time that American psychiatry had anything like a common language.

And after the war, the Veterans Administration adopted it. And when the American Psychiatric Association decided to create a unified diagnostic manual in 1952, they just copied the medical document 203, and then they made small modifications. So that's the origin story of the DSM 1. So it's not a hospital or laboratory. It's a military bureaucracy that is doing logistics. And Theodore Porter, the philosopher I talk about, and he's a historian of science. And he wrote, you know, trusted numbers.

He'll come up a couple times. But this kind of proves his central thesis to most of his stuff, which is mechanical objectivity, rigid rules, checklist, standardized codes. Those are used by this not the strongest science. but the weakest ones who need to defend themselves against other bureaucrats. You know, people who are doing hard science tend not to like those. So Porter argues that we reach for numbers and rigid rules, bureaucracy, essentially, when we don't trust the people doing the work. So a village doctor who has to know his patient for 30 years doesn't need a checklist.

He needs his judgment, his intuition, his relationship, and we trust him because we know him. But the army couldn't just trust thousands of random psychiatrists drafted from all over the country. Some might be incompetent. some might be too soft, giving out discharges to anybody. Some might be too harsh. The Army needed a system that would produce the same result regardless of who was using it. They needed to police the doctors, not diagnose the patient. So this is what the checklist accomplishes.

It removes judgment from the equation, or that's been the ideal for, you know, 30 years that we still have failed to get. If the patient meets criteria A, B, and C, then they have the disorder, regardless of however the doctor feels. And the DSM is not a tool for understanding patients. It is a tool for standardizing the behavior of clinicians. So Porter puts it this way. Quantification is a technology of distance.

This is a phrase he says a whole lot. And it allows a general or a bureaucrat to manage thousands of people that they'll never meet. And it makes the messy subjective world suffering of human suffering compatible with the rigid objective machinery of the state. Porter looks at basically bureaucracy as being a result of empire. When you have more territory than one person can manage, when the king can't just say, hey, go to the north wall and tell the guards to do this,

and then somebody does, when you have to have satraps or generals or commandants or like whoever doing these territories, and you don't trust them about how much taxes are coming. So they have to keep these records, and then multiple people have to keep the records, and the records have to agree. And something has to detect

if five people said that this much tax was recorded, but one guy said there wasn't. Maybe he's stealing. Empire in the ancient world is when you get bureaucracy. And it's also the origin of writing itself, because the origin of writing itself wasn't to, like, write a book. The origin of writing was people making little marks in, like, mud tablets to keep track of, like, how much they had bought and sold at a market.

It was trade. And so, you know, if you read the DSM1 with fresh eyes, you'll notice something uncomfortable. It's just completely saturated with assumptions of mid-century American Empire. You know, homosexuality is seen as sociopathic. Women are seen as hysterical. It has a lot of implicit racial assumptions that are pretty bad. And this is what I mean, you know, when I say that it's imperial.

It's written by a small group of white men who took their worldview as the default human condition. So they were healthy and everybody else was weird or mentally ill. And they built a system for categorizing from a norm that was never examined because it didn't need to be. It just was how things are, us. We order everything else is chaos. And if we look inside the closed doors of the committees for the DSM 1 and 2, the vibe wasn't military processing at all. It was this gentleman's club. The controversies inside those rooms weren't about data or NDAs like they are now.

They were just these intellectual brawls between conflicting philosophies because everybody, some people were Jungian, some were Adlerian, some were Freudians, some were Freudians. And they thought that the origin and etiology of mental illness was different. So they had to find the places where they all agreed in a subjective way. They had to convince each other in a debate. And it was a small enough group that they could actually find a consensus. So the biggest controversy inside the DSM-1 committee was that the people writing a book didn't really believe in diagnosis at all, but yet they're writing a diagnostic and statistic manual.

The main figure who, with the one, is Adolf Meyer, and he was seen as the Dean of American Psychiatry at the time. He hated labels. He believed every patient was a unique biosa-psocial story. And on one side, you had the Census Bureau who wanted these distinct bodies. schizophrenia, manic depressive, to count people, and it was the job of psychiatry to give them an inventory of what type of mental illness, how much, where, you know, all the stuff that the census wants. And on the other side, you had the, you know, Myrians who, you know, Adolf Myers people, who are arguing that putting a label on a patient was an insult to their complexity. And they did not want to complete the assignment they had been given, but they felt like if it was done by someone else, it would be done worse.

So the committee solved this by adding the word reaction to everything that psychiatrists were saying. So you didn't have schizophrenia as a disease. You had it as a reaction. It was a temporary response. It might go away. Some people become psychotic and then it leaves. And so this was this philosophical coup where it codified everything saying that mental illness was not inside the brain, but it was a reaction to the world.

And so it was sort of this victory of, you know, the system or the environment over biology, just the individual biology of the person causing everything. But there was also this power play, the chair of the D.O. one committee wasn't a doctor he was a brigadier general and he had run psychiatry for the US Army during World War II and developed Medical 203 the manual he made it so that really is the DSM you know before it's called that you know one point or I don't know one point of 0.5 you know it's the beta version and for the civilian academics these East Coast elites resented the military encroaching on their turf they viewed the military system as too crude but you know

Menninger won because he had the prestige of the war victory. And the DSM1 is largely just this copy and paste of the Army's Medical 203 with reaction added to all the diagnoses. So it didn't change that much. The first version was really the second version. When we get to the second version, the DSM2, that's 1968. And they're fighting this new war, which is globalism. Europe has their own thing.

The World Health Organization is using the ICD8, because they're also needing data to try and figure out who needs what where and what problems are happening and what problems are going away. And they were kind of telling Americans, like, stop using all this weird Freudian language, like align with the West of the world, just say they have anxiety or depression. And inside this committee, stop saying neurosis, you know, what does that mean? Does that mean they're anxious or does that mean they're depressed? What does neurotic mean?

And so these internationalists, they wanted to adopt the European ICD system or not system, but the terms. They want to take ICD terms, join with the rest of the world. Everyone's roughly on the same page. American psychiatry can still do its own thing. And it was a lot more biological, though, because it was made from the World Health Organization basically to study outbreaks, to study pathology of viruses and things like that. And so the American Freudians refused to give up neurosis and hysteria.

They really liked it. And they argued that the European psychiatry was superficial. It just wasn't going as deep because it wasn't approaching the unconscious mind, which I don't think was true of European psychiatry, but it was definitely true of the ICD-8, because the ICD8 was just trying to come up with a whole list of bad stuff that can happen to health in your country and then let you have a list of it, which is probably a bad manual to adopt for psychiatry. So the committee spent months arguing over the word hysteria, and the Europeans had banned it.

They called it antiquated, and the Americans insisted on keeping it. So they decided to keep hysterical neurosis in the two. And to appease the American analysts, making the U.S. you know, look kind of scientifically backward to Europe. They keep this, but Europe judges us, and there's kind of a split. And the biggest difference between these committees and the later ones was this complete lack of data. You know, they didn't run trials. They sent out letters to prominent psychiatrists asking, what do you think?

For the DSM2, they surveyed 12,000 psychiatrists and only 10% wrote back. And the committee shrugged and was like, okay, we'll write what we think is best, and everyone who wrote back will read what they wrote and we'll try and include it. And this submitted this idea that the DSM was just opinions of a few old men in a room. And there's no real mechanism to challenge them because they claimed authority-based. on prestige that they were very rich and powerful doctors who headed prestigious universities or had prestigious practices or both. And in the 1960s, you know, everything was sort of coming into question all American institutions.

You know, Thomas Zaz publishes the myth of mental illness in 61 and he just says it's a categorical era. The mind's not organ. It can't be sick the way the liver is sick. What we call mental illness is really just moral, social, and personal conflicts. And we've just medicalized them because we don't want to deal with the fact that our society is actually the sick one. And that becomes, you know, from Zaz, this idea that defines American psychology and charges up people like Lang and Rosenhan that we talked about before.

So, you know, Rosenhan we talked about in the first episode. And he's the one who got his psych patients, or so he says, you're not psych patients. He got his graduate assistance. And he said, we're all going to go in, 12 of us. And we're going to say that we heard somebody say empty hollow thud that wasn't there. and then otherwise we're going to act totally sane and we're going to watch how they think that we have schizophrenia that we're crazy and then start to record how everything that we were doing in the hospital was actually a result of our mental illness

based on the way that they are choosing to categorize us and that the categories really control us and others' perceptions. They don't actually help us get to the truth of anything. So Rosenen publishes that paper and it's this kind of a scandal. And there's more to it. We already covered it in the first part.

One of the things that I didn't say is that most people now think that Rosenhan probably made up large parts of that experiment. They found one graduate student who said that he went into the hospital and it really wasn't that bad and he had a good time. And he's the only one that they ever found. All the other students that Rosenhand worked with never said I was one of those people. Also, they got Rosenhan's actual medical records out of the hospital. And from those medical records, he said that he was suicidal and several things that would warrant an ER admission, even today. So either the doctors wrote that in there because he said empty dull thud and they just decided that he was crazy and that they needed a reason to

justify admission so they made one up and they forged the medical records that could have happened or Rosenand lied. So let's talk about why. You know, like I talk about, you know, Freud and the illusion of progress thing that he Freud lies a lot like he he says these are my neuroses and these are my case studies on myself. These are my dreams from self-analysts, but this is my private diary. It won't get published. And then he says, these are my neuroses and these are my case studies on myself. These are my dreams from self-analysts. But this is my private diary. It won't get published. And then he says, and then he says, he writes about what these patients are doing that looks really almost exactly the same like him. And he were published at his case studies to prove his theory and says he did it with a patient. But then he didn't think that his journals would be published when they were. It's like, oh, yeah, I think you really just took your own work. Freud lies in a couple places. Dr. Frederick Cruz's book is really good.

I won't defend him. Where I will defend Rosenhan is he was intimately acquainted with these systems. And he probably had the thing that a lot of the kind of ego in full. and mezzianic energy that a lot of these people had, which is like, dude, I don't want to wait and spend money and replicate this experiment because I see it happen like 800 times a day, and I know exactly how it works. And I just need you to believe it. Here's the Theodore Porter thing again.

So I'm just going to throw some numbers at it that are lies because you like numbers. So I think, personally, that Rosenhand probably had seen this stuff happen over and over again, that that was happening in American psychiatry, but that he faked the science. He faked the science because he didn't think that he needed it. he wasn't really why he was in the profession he didn't respect it he was an anti-psychiatry humanitarian holistic guy um he didn't like the system so you know he's anti-authoritarian he's already seen them do these things so i wasn't recording the study then but why don't i just write this stuff down and then say that it happened because i know that i've seen it a hundred times before i think that's

what happened american psychiatry is kind of on trial because they're calling basically all people that are gay sociopaths which is terrible and they can't compromise on that because some of them think that homosexuality is definitely wrong because it comes from some neurotic thing in childhood that happens to you. Other people say no, it's a totally fine way for multiple, you know, for consenting partners to live in an alternative way, and it's fine. And they storm the committee for the DSM-3. They storm the committee and they go in and, you know, basically,

make a big scene in Rosenhan, or not Rosanham, I'm sorry, Spitzer. So Spitzer is the guy who will chair the DSM 3, but I'm talking about the DSM 2, right? He's just a note taker. He's kind of been flagged as a workaholic who has a ton of energy and a lot of diligence, but it doesn't great, has a lot of great clinical, you know, rationale. And because he's not really intuitively clinical, but he likes psychiatry. He likes the numbers of it. He's the note taker for the DSM2, which is interesting. But he's the guy who stands up while the anti-psychiatry movement and the gay rights

movement, early, they can call it at that time. It was Meyer, which there's an article in my blog, Myers, the psychiatrist who went and testified wearing a mask, basically, because he said, I am a gay psychiatrist. I am an effective person. I'm a rich person. I'm one of you, but I'm going to wear this mask, and I'm going to use a voice changer to testify because I don't want American psychiatry to know who I am yet. I'm going to go in anonymously.

And later, you know, it comes out that it was Meyer, but during this movement, these people staged this protest at the DSM2, and Spitzer's the one who stands up and brokers a compromise. He has this idea to remove homosexuality from the DSM, the APA votes, and they choose that instead, of calling it a sociopathy disorder basically categorizing it is that they call it sexual deviation that it's this thing that is deviating from the norm but it's not deviant it's just deviate

and so spitzer does that but that process of them only the APL only voting in this way and then him having to deal with a group of people in the room, it's kind of the beginning of the DSM becoming a political thing that there's public interest and pressure on. And it's kind of schizophrenia that saves 1970s psychiatry in a way because the DSM2 doesn't really go far to convince anybody that it's science or that psychiatrists are doing something real. But as the really early antipsychotics start to mature,

and you start to get second generation. The first generation antipsychotic is Thorazine. It's almost never used anymore. It's the one you associated with like real blunted affect drooling, but it makes you quit screaming and hallucinating. It's a very sedating medication. It's not a great antipsychotic, but it was the first one that we ever had.

You know, I said in the 90s, everyone's obsessed with ADHD and the odds, it's autism. And then now it's kind of trauma. But in the 70s, schizophrenia represented the most broad encounter point for the public to see mental illness and the biggest expenditure of psychiatric mental health resources. And that was really furthered when the Vietnam War ends and a lot of these people come home. And a lot of these people start to take drugs. And not everyone taking drugs is in the military, but a lot of people with PTSD and the military do.

So, you know, and there was this idea that like really, it wasn't the drugs that created. It wasn't the mental illness. The drugs didn't create the mental illness. like you weren't just getting addicted to this addictive substance. It was that only the mentally ill would do drugs. So if you saw somebody who was raining and raving and doing drugs, they probably were just, you know, sick before and that's why this happened. So psychiatry and a lot of drug addiction or schizophrenia and drug addiction

are kind of linked together in a way that we don't do anymore. A little bit, you know, there's some stigma, but we've pushed back. You know, so Thorazine comes out in the 50s. But it takes a while for the implications of it to sink in and for it to kind of come out of the asylum into mainstream healthcare to a thing that doctors who aren't just keeping people that they're going to keep for realistically most of their life are prescribing. And so psychiatrists could now do something that it feels like magic. You know, there's all of this research in the 60s, mainly, you know, by the VA about talk

therapy and psychoanalysis for schizophrenia. Can it change somebody who is psychotic? Can you give them this root? There's all these theories of schizophrenia that comes from trauma and certain things in childhood. Can you go back and psychoanalyze those things and then cure the schizophrenia? And it turns out that you can. It's a largely endogenous illness. And Insight doesn't really help you reduce the symptoms.

It may help you relate to the symptoms. It may help you manage them. But it doesn't really make them go away. Whereas, you know, 10 years of psychoanalysis don't work. Now we have a medication and the medication just works. And so this made psychiatry have this validity because everyone can sort of see this very valid thing that they're doing that is not, that is not deniable. Whereas something like the unconscious and,

these woo-woo concepts like those are. You can't show me them in a test tube, and I don't believe you, so I don't think they're real. So the dopamine hypothesis of schizophrenia emerges, which we now know is kind of not right, but it basically says that because we know that these drugs block dopamine, maybe too much dopamine is what's causing schizophrenia. And that's an operating assumption until about the 90s when it starts to get discredited and you get theories like the indirect pathway dysregulation and sensory gating theories and other and other theories. And so that success with schizophrenia and severe bipolar disorder became psychiatry's

big trump card. And it legitimized everything else. And so the logic went something like this. We can treat schizophrenia with medicine and that affects brain chemistry. Therefore, mental illness is caused by brain diseases of chemistry. And therefore, all our diagnostic care categories must correspond, not that we can see, but we're just assuming in all these categories that we made, they must correspond to real biological entities. that are somewhere. And therefore, the DSM is scientific. So notice that leap, though, the fact that the antipsychotics helpless schizophrenia doesn't prove that a major depressive disorder or a generalized anxiety disorder, you know, other types borderline personality disorder are biological entities in the same

way. That doesn't prove that. Just because you made up one category and that category is affected by medication does not mean that every single other category has this biological root in the way that they were thinking. But that it was what they were thinking and what they were writing. And so this is what saved psychiatry. It wasn't just the checklist of the DSM3. The DSM3 was an attempt to assume this harder, but it was really caused by these drugs.

So finally psychiatrists had something that they could prescribe. It wasn't just an addictive drug like cocaine or sedatives. And so the price of all this stuff is that we still assume that about all the die disorders in the DSM a little bit too much, just because of this one movement, you know, at this time. And so in the 1970s, psychiatry is in this existential crisis still. I'm setting the stage for the thing we talked about the first time. There's insurance companies that are starting to just refuse to pay, and the public thought psychiatrists were kind of fraud, an authoritarian, and cranky. And researchers couldn't replicate findings because

nobody could agree on what the disorders even were and the two because they're all these subjective things. And so now Robert Spitzer is hired to chair the writing of the three, the guy who brokered the compromise that made the two. And so Spitzer is this kind of revolutionary. He's like this awkward, obsessive guy, and he's not very socially graceful. And he has skills that are largely administrative, not really clinical. And so when he's at, asking psychiatrists for their ideas. One of the reasons he ends up here is he's supposed to broker between a fight between all these psychiatrists, but he also doesn't really have a point of view because

he's not really a practicing psychiatrist who has an axe to grind theoretically with anyone else. He's just trying to get them to agree. And so he was too focused. He was too, you know, measure, he was focused on measurable things. And so he had been kicked upstairs into administrative role. because he didn't really have what they needed in a clinician. And then he's very successful at them.

And so Spitzer makes his name by the DTHM2 thing, and then he's brought in and chaired to write the three. So what happens during the writing of the three is they're trying to solve that reliability crisis of why this thing isn't really very reliable. And the US-UK diagnostic project has shown that American doctors diagnose schizophrenia twice, often as British doctors for the exact same patients. So when you look at the symptoms and

then you look at the diagnosis, the people who are checking the same boxes in the U.S. are getting diagnosed differently in the U.K. So these labels mean different things and the subjective descriptions about reaction no longer work. And, you know, Spitzer was obsessed with reliability and he wanted doctors to agree. And so he had developed this research criteria that used checklists instead of vague feelings so that people could just ask the patient six questions that all patients were getting asked the same six questions and assess for the same thing. And then hopefully you end up with the same diagnosis. We know now that's not what happened, but that was the assumption at the time.

It's a reasonable one. So until Spitzer, the DSM is heavily influenced by Freudian psychoanalysis still. There's unconscious conflict and neuroses and depression and anger is turned inward. And there's these Freudian assumptions about how these things work. They thought that depression was a rage that was going inward towards the self, shutting it down, instead of outward towards the world. And Spitzer hates this. Like, you can't measure unconscious conflict. You can't get two analysts to agree on what's being repressed or what the event is or what they're reacting to in the environment.

So the whole framework is just too wishy and it's too poetic. And so his solution was to make the DSM have no theory at all to be a theoretical. No assumptions about where the stuff comes from. Don't say why people are depressed. You just say that they are. and you give them a disorder. And so this diplomatic masterstroke allowed the Freudians and the more biological psychiatrists from like the Evo-Syck people that are coming out at this time, early versions of that,

to use the same code. They could now agree about causes and the profession could talk to each other. And so this is where it gets kind of wild, though, that I didn't say in the first one, is like Spitzer did this in a pretty chaotic way. Like everyone would get drinks. They would call them typewriter parties. Like he sits behind a keyboard typing the stuff up and then crossing it out when they're disagreeing and then typing up again. And he's yelling, okay, if a patient feels worthless on Tuesday but not on Wednesday, does that count?

And half of them yell, yeah, that's depression. That's an instant. The other one's going to know, everyone goes up and down. Depression has to last six days. And then they argue. And then they say, okay, but if he feels worthless and he feels bad and he's crying, but he lost his job and he's depressed for a week. Is that a symptom or normal reaction? And then they all argue, no, that's just the environment.

It didn't come out of nowhere. Well, no, but the environment can make you depressed. And they fight. And then this goes on weeks, you know, while they're all just sort of getting people in a room and he's forcing them to agree. But that was his gift was that he came in, not as a scientist, but a lover of science who was more of a politician because he would sort of outside of the world that they were in. He didn't care about theory. Everyone cared about theory. And so he forced them to make these binary.

choices of where would you draw the line? Okay, fine. What if it's two days more? What if it's this? What if there's nothing? You know, he made them come up with numbers of this amount of symptoms have to happen before I say depression. No one was thinking in that way before. No one was diagnosing like we diagnosed. They were speaking in this language just as a conceptual thing, but no one was really thinking about frequency and intensity and duration like we'd think about now. Spitzer had this other agenda that was more personal. He wanted to destroy the power of psychoanalysts. Until the three, the language of psychiatry was still Freudian, and Spitzer stripped out all the DSM-3 stuff to make it a theoretical. And then here's the thing that nobody talks about, Spitzer's method, though, like it was completely backwards as somebody who loved science from how science is supposed to work.

Because the scientific ideal would be to gather data first. You would observe thousands of patients, record all the symptoms, and then you would use statistics to group those symptoms together and see where they co-occur. and then the patient's data is telling you what the diagnosis is. What they did with the DSM3 was they said, hey, here's these diagnoses. What are the symptoms for them? So maybe you discover if you did the data that way. Well, everyone who calls depression,

who says they're depressed or who's been called depressed, it's actually three different conditions that need different names because these people are anxious, these people, it's a life event. But they didn't do that. They said, hey, depression exists. We know that. that's self-evident. So what are the symptoms of it?

Well, if somebody lose their job, I call them depressed. No, no, no, that's environment. Do you see what I'm saying is that if you looked at the data directly, it would have given diagnoses to you, but they didn't start with symptoms. They started with diagnoses that had just already been around and then assumed these things must have symptoms because we've been talking about them.

So we have a different perspective looking at this history than these guys would have thought. So, you know, this approach has a name, though. It's called the approach that I'm describing of looking at the symptoms and then letting them tell you what the diagnoses are. That's literally what factor analysis is. That's what the high top model does for mental health today. And if Spitzer had done it that way, the DSM would look totally different. Like you could never have said, hey, when you come in, what are the biggest symptoms that your patients have?

Okay, here's 50 symptoms. Well, which are the ones that you see in, what are like the ones that you see? this guy who has no eating, he doesn't eat. What are other symptoms do you see at the same time with him? Oh, he also doesn't sleep. Okay, well, how many you guys have somebody who doesn't eat and doesn't sleep? Yeah, we all have one. I mean, sometimes somebody doesn't eat, but it's for this reason,

but most of the time they don't eat and they have that symptom. Okay, when somebody doesn't eat and they don't sleep, what other of these symptoms do they have? Well, they're sad, and they also, oh, okay, well, some of these people, they have a negative life event, and then they don't eat and they don't sleep, and they're sad for, like, a week. but then other of these people, there's no reason for it at all,

and they don't eat and they don't sleep, and they're sad, and it comes out of the blue when something's going well, and then it doesn't go away ever. Okay, well, it looks like, you know, temporary life event depression is different fundamentally

from just an endogenous genetic deep brain depression that's now we have two diagnoses. If you do it that way, the brain will tell you what the diagnoses are, the data will. And dopamine disorders, they would look completely different. Like you would, under high top, they would say,

okay, it looks like you're prone to psychosis. You're having these symptoms, just like the original people were doing in the hospitals. And because you have these symptoms, we think this is probably going to happen. You're probably going through the prodromal phase of schizophrenia or bipolar or something. Or early phase of bipolar.

Or it doesn't have a prodromal phase. But, you know, the walls between schizophrenia, bipolar disorder, manic depressive, like even OCD, they would have been more squishy. They would have had more overlap if you'd done it that way, because dopamine disorders share a lot of features now. So Spitzer didn't do it that way, but why? Because that establishment already existed. You couldn't come in and tell these people the language that you've talked in for 50 years.

Don't talk in it anymore because it's wrong. Depression doesn't exist. Anxiety doesn't exist. Neurosis doesn't exist. Schizophrenia doesn't exist. So let's figure out every single disorder that exists. And then we'll publish a book and tell all the psychiatrists in the world. They build their careers around those categories.

Their books were called Blankety Blank of Neurosis, Depression and Anxiety because of blah, blah, blah, blah. You know, what is schizophrenia? They're, their whole, you couldn't tell them that those words don't exist anymore because to them those words were real, even though the data didn't support those words. So he worked backwards. He started with the diagnosis, and then he built the symptom clusters around them. And so if it done it the right way, starting with symptoms and then letting them cluster naturally, the political complications would have been enormous. imagine a room full of psychiatrists with a patient asking, what would you diagnose this person's with?

And then if they agreed, and they inevitably would, it would expose the unreliability of the whole system. It would be this other Rosenhand experiment, showing that doctors couldn't agree on how these symptoms were supposed to be clustered together, which would have been more of an insult. But if you instead asked for patients, you have already diagnosed with depression,

what symptoms do you see, then you could get agreement, because you could get them to decide how long, how much, how deep, and what does depression look like? but the doctors weren't being tested. They were being consulted. And their expertise was being respected, not challenged.

And this is why typewriter parties worked. One psychiatrist would say, depression lasts for two weeks. And another might say, no, it could just be dysregulation. It has to be four. And Spitzer would sit down and he'd make them compromise. And he literally would lock the door and say, you're not getting out of here until you all tell me how long this is.

I don't know. I don't do it. You tell me. And then these guys had to fight and go, okay, fine, three weeks and then leave. And this was politics. Again, it wasn't science. but it produced reliability in that they agreed with each other when they wrote the book, but not necessarily reliability when you use the book outside the room.

And so here's the crucial point. Checklists aren't inherently bad. They can be a scientifically valid tool, but they have to work forward, not backward. A forward checklist starts with observations. You observe hundreds of thousands of patients. You record every symptom you see. You use statistics to find patterns, which symptoms tend to appear together, which predict certain outcomes, which respond to certain treatments.

And then you define your categories based on what you find. But a backwards checklist starts with the categories you already believe in, and then it defines them however you can get people to agree. And this is what Spitzer did. That's not discovery. That's just codification of existing prejudice. You're just taking your bias and then saying, what can we do to the data to kind of assume that what we're thinking is already right. And so when Spitzer was having as typewriter parties,

there's this quieter revolution happening in the basement of American medicine. basement of American medicine. And the revolution wasn't about philosophy or diagnosis. It was about money. Unlike the DSM, which was public and controversial, this revolution happened in a room that nobody knew existed. It's called the RUC or the AMA Special Society, Specialty Society Relative Value Scale Update Committee. But because relative value scale is one word, they say Ruck or relative update committee is the acronym. I don't know. If you've never heard of it, that's by design. It's a private committee

and it's run by the AMA and it essentially tells the federal government how much Medicaid should pay for every medical procedure. And because the private insurance companies must universally follow Medicaid's lead and Medicare's lead, this committee effectively sets the price

for health care in America. If therapists did that, it would be illegal. But the RUC is just advising. They're not a cartel getting all the doctors together. They're just getting the doctors to kind of say what they're. think it should be and Medicaid's going to accept that 90% of the time. So the RUC is exempt from laws that would normally prevent you from doing that. You can't

really do that in any other kind of profession. Like if you sell bread and then you go to all the other bakers and you say we're charging $2 for bread but we're the only people who sell it in Birmingham. So why don't we charge $50 for bread? The Sherman Trust Act could be used against you. You could be accused of operating a cartel. The way that the RUC advises, it's not really part of it. It's just all the doctors getting together and then telling Medicaid this is what we think, and then Medicaid doing it 90% of the time and then insurance making that mandatory. But that's a thing that is popping up that is related to the way that the DSM is used

and why it gets to be viewed as a Bible and not really what it was intended as, which was just sort of trying to consolidate all of the statistics around diagnosis, that everybody was doing so that we sort of know what's changing and what's not. And so, you know, the RUC is dominated by these specialists. And so their bias is structural and it's overwhelming. They value doing things to people, cutting them, scanning them, injecting them. A lot of times that costs, that has all this equipment, that there's this huge cost associated with, diamond knives and lasers and, you know, x-rays.

And so we're going to say that that labor is more valuable because it has all this specialty stuff. that cost is associated with. Because they're saying, well, yeah, putting a band-aid on your knee by a doctor, shouldn't cost the same as heart surgery. So how do we set this? And that's what the RUC's job was, was to tell Medicaid, hey, we're all the doctors. We're not lying to you. We're just going to kind of tell you what we think this is worth this year.

Cancer treatment just got more expensive because you have to buy this new kind of chemo and it costs a whole lot. And so if we do one session of chemo of this type, we think that the payment rate should go up now because the new best practice is to do it a way that it's more expensive. So remember, too, that this was a point where schizophrenia was vanishing and people are being given antipsychotics. So being able to prescribe medication in a time where American medicine is becoming service-based, not relationship-based, service-based. There's not a lot of services that psychiatrists can do other than talk. Because there's not a lot of services they can do, they make the one that they can do really expensive.

And they start to downplay the value of talk therapy. because that's something that all these other professions can do that aren't doctors. So it's the moment when it becomes impossible to pay your med school loan back, just doing talk therapy. And that happens relatively quickly at the same time, that all of these other things that we talked about in the first episode and all of those things about schizophrenia and the backlash to mental health and the crisis of confidence in any of these things to be real is taking place.

And so prescribing medicine sort of becomes the thing that they double down on. All of these things happen, you know, in between the three and the four, the DSM three and the four. And they change American medicine quite a bit. Alan Francis, who chairs the DSM4, he explicitly does not want to be Spitzer. He's like Spitzer created too many of these diagnostic categories. He created too much. We want to get rid of axes. We want to get rid of all of these categories because it needs to be simpler.

And when you make less, then you have to broaden the definitions, or else you're telling somebody who used to be mentally ill and have a diagnosis, you're not mentally ill anymore. Because if you've got fewer categories, they've got to be bigger. So he thinks that to try and get rid of this, this explosion in too many diagnostic categories, that what you should do is just make a couple. But what that does is it means that you broaden the gates so much

that now everybody has ADHD. everybody has bipolar, everybody has autism, because you're putting so many people in those categories by broadening the definition that now anyone can go in and get diagnosed with it. And so Francis spends the rest of his life basically apologizing for the ADHD and bipolar disorder epidemic, and he says, my opinion's changed.

I think that any change in the manual that can be misused will be misused. So he expresses tons of regret about the DSM4. he thinks that it pathologized normal behavior. He particularly does not like the ADHD epidemic that gets, you know, every kid in the 90s just gets, I got put on Adderall because I don't even know what I did. I didn't talk, so it wasn't that. I didn't run around, so it wasn't that.

I got on Adderall, and I still don't know. I saw a psychiatrist in 20 minutes, maybe, probably more like 15, and he asked me if I wet the bed and if I wanted a sucker, and then I got put on a horse dose of Adderall for the next three years of my life. And that is sort of a result of the changes that Francis makes. So like the Asperger's diagnosis in the DSM4 expands autism more to say people who have social impairment, not, you know, direct functional impairment now can be considered kind of autistic. But it still keeps those pretty separate.

like you either have Asperger's or you have autism, which seems silly because there's quite a, it's a spectrum. And so, so you have to realize that, one, the society's ability to recognize these things trickles out of this book. So when you hear people say something like,

oh, well, everybody has autism now, so there must be poison in the water or whatever. Well, there probably is poison in your water. But I don't, you have to look at the change

in the DSM, which said one in basically 2,500 people had autism to the 1980s where you're saying one in 36 people are on the autism spectrum somewhere. And that's a huge change. So yes, a lot more people are autistic or diagnosed as autistic, but it's not because all of a sudden people start getting more autistic really quickly. It's because the diagnosis changed for some reason, whenever people are pointing out autism rates. I'm not talking about researchers. I'm talking about social media.

They forget that the three and the four were different books. And the four TR was a different book. And so that's why this fight is sort of happening now around the five even with autism, where you have people that are like, we should look at this star model where it's not a spectrum left right. It's a spectrum like, where is the impairment? Is it an interpersonal functioning? Is it in special interest?

Is it in the ability to read emotions? Is it the ability to regulate sensory things? Those are pretty different. You know, I like the star model a lot, but one of the things I've pointed out about it is when you're doing that, you're putting even more people than one in 36 people potentially in the category of having autism. So at that point, what's neuronormal, what's neurotypical, what's neurodivergent, maybe you're just, maybe psychology is defying those categories at you and you are still struggling to try and

categorize them. So Francis learns this bitter lesson. Bureaucratic methodologies are inherently inflammatory, and once a checklist exists, the pressures from patients wanting validation or enabling in the worst case. And parents that are seeking help or in the worst case to control their children will pressure pharmaceutical companies to pressure doctors to get this thing and pharmaceutical companies are rushing to fill the void. Look how fast you go from Adderall alone, which is basically a World War II drug, to, you know,

just hundreds and hundreds of these things that are getting patented all the time. and they still are. I mean, there's still new non-generic forms of Adderall. And like an oral, a lot of those stimulants are so weird because it really is the same drug. Like it's, it's really just kind of like the base is just that meth. But the salt and everything that you bind it with does change the way that you feel it a lot. Like a lot of those new drugs, patients report feeling completely different. And this is the one that works, the patients that have ADHD and need it. And they can't afford it. So it's they're not, it's not, it's not, totally different, but there's a huge, they're not all totally the same. I'm not making that case,

but there's this huge rush to make new patentable drugs. Parents really like it, schools really like it. Francis really regrets it. So when the DSM-5 is starting, and the NIH is already kind of angry because they've watched how they've been promised basically for 30 years that they're about to get the biological root of all this stuff. Schizophrenia has a biological route, so we're going to find the other ones. We just need more drugs. Once the drugs are discovered, then they'll treat the disorder, and then that proves that the disorder is real. It's been 30 years that DSM4 has zero biological basis and a lot of the changes that it makes. The scientists are frustrated with the psychologists, and when they see that they're chairing the panels of the five with these huge, huge, huge committees that are basically listening to people's views on the politics, but the structure, the actual change is these people that basically wrote the DSM4, which the NIH didn't like.

They do this thing that's pretty wild, which is before the DSM-5 even comes out, two weeks before it's published after the committee's over. They say, yeah, we haven't read the book yet, but it's garbage and we're not going to use it. And no longer can any of this be used for research. And I think probably if Thomas Ensel wasn't director of the NIH at that point, like if he wasn't the director of the National Institute of Mental Health, I said NIH. I'm sorry, NIMH. But one part of it. But like, if he wasn't over that, that anyone else probably would have done that anyway. Like this tension had been building for a long time.

And so Encel says, you know, the DSM has been described as a Bible for the field, but it's at best a dictionary and its weakness is that it has no validity. This was extraordinary. The federal government is saying all of American health care funding, because most of that comes from DARPA and from the government, is no longer ever going to use these. And it should have been bigger news because for three decades, You know, the NIMH had forced researchers to use these DSM categories.

If you wanted to grant a study on depression, if you wanted to get a grant and study depression, you had to study DSM depression. Patients who met the specific checklist criteria. But if you wanted to study schizophrenia, you had to study DSM schizophrenia. And Insull realized that this was sabotaging research, and he called it a bucket of sludge. He said that you were just throwing these things into these buckets, but that the buckets didn't really tell you anything. They were useless. You know, if you're trying to cure a fever and you gather a thousand patients who all have elevated body temperature, some of them have the flu,

some have cancer, some have heat stroke, some have autoimmune disorders, some have, you know, just a fever from a cold. And you run all of the drug trials through them, you don't really find out which one cures the common cold. You don't really find out which one cures the flu. You don't really find out which one cures cancer because you put all the people that had elevated temperature in one room and assumed that the route was the same, which has been an accusation that the APA was doing that with the DSM for a long time. You're just putting all this stuff together, but that doesn't really tell you anything. And so the trials fail, you know, and the DSM task force had promised the NIH something revolutionary. They said, give us money in time and we'll find these

biomarkers, these brain scans, and we'll prove the disorders are real. They spend 14 years. They spend $25 million, and then they fail. And they basically had made that promise 30 years ago. The DSM-5 comes out. It still just shows lists of symptoms. There's not really any kind of theoretical change. There's still no neurobiological marker for condition or test. And the science has plenty of data.

There were biomarkers for mental health that they could have followed, but they're not following them. Those are kind of inconvenient because we're looking for the biomarkers for the diagnosis. we have, not looking at what the biomarkers are telling us about how these brain conditions actually work. And so the NIMH walks away from the DSM and they say that the research domain criteria, or RDOC, is what they're going to replace it with. But RDOC is not a diagnostic manual.

You can't use it to diagnose a patient. You can't use it to bill insurance. It's a research framework with Rose constructing like fear or working memory or reward responsiveness. and its columns of units of analysis for those traits like genes, molecules, circuits, behavior. It's sort of trying to cross-analyze all of these measurable variables in this giant database. So most of the boxes in that grid are empty. And that's the point.

The NIMH's message to researchers was stop studying depression, start studying the specific brain circuits, the control mood. We don't know what goes in these boxes yet, but your job is to find out. We're telling you what you have to use. You failed. We're taking the keys away. from you we're going to drive the car in this direction and this was intellectually honest and scientifically sound but it left research stranded because essentially they had said ardoc is this massive massive

massive massive project it's basically a database to cross-reference all of the variables that we have and it'll probably be wet ready in like 10 to 20 years and then the thing that was supposed to take two decades to make they force everybody to use because they think so lowly of the dsm 5 And it's worth noting that, you know, the NIMH itself said that Ardok wasn't ready. They said that it wasn't good to go. So you're probably wondering, like I mentioned high top before, that does the thing that Robert Spitzer should have done if it wasn't for all the politics. You know, there's high top and it clusters everything around the P factors and G factors.

It looks for, it basically, without re-explaining high top, it looks for you know comorbidity like a puzzle and it finds you know where symptoms are actually clustering so why didn't that in iMH and thomas insul why didn't he say i'm going to use

uh high top instead of ardoc r doc's not going to be ready for 20 years it's not designed to do this anyway um high top is you don't like the direction the dsm is going high top gives you all of the empirically derived data that you need it's already being seen in psychics research for certain things as this gold standard. So why not use that? It solves your

comorbidity problem. It maps better onto what we already know about genes and circuits and how they're basically competing networks, not like one thing that you can find like a brain tumor and cut out and then your depression is cured. But Hightop still has the same fundamental flaw as the DSM. It's based on symptoms. And it tells you which symptoms cluster together, but it doesn't tell you why. It doesn't give you biomarkers. It's still looking at how people feel. and not what's in their brain. And so I don't really like what the NIMH does. Two things can both be the wrong direction, right?

Because Insul and the NIMH, they wanted to skip symptoms entirely and go to biology so they didn't have to listen to how people felt ever again. And they didn't want a better map of how people describe their suffering. They wanted a map of what's happening in the brain. And so Ardoch was their attempt to build that biological foundation from scratch too early because they didn't like the direction that the DSM5 went in so much, even before it came out. But the irony is that Ardok might never have been clinically useful.

It might never be. It's been over a decade since Ensel's announcement, and we still can't diagnose anyone using brain circuits. But meanwhile, Hightop offers a genuinely superior symptom-based system that could be implemented tomorrow, but nobody's implementing it. But the thing is, with Hightop, you could examine genuine longitudinal data, how much the these conditions are genetic, how much is learned, how much is environmental, we could finally start to untangle the nature versus nurture knot that's made psychiatric research so frustrating. What is what and where do they intersect? But part of nature versus nurture will always remain this mystery because science can only see so

far into the deep brain where things are happening in split seconds. And that's just the reality of a complex system like that. Probably one of the most complex system that exists. But one of the deepest problems with current diagnoses is that they point at something that's almost always both, a predisposition nature and an environmental trigger, nurture, that sit on top of each other. And here's the kicker, the genetic predisposition,

and the environmental trigger are found in the same environment because families share both genes and environment. And a child inherits their parents' neurobiology and then has those parents as parents. So trying to separate these things with something like Ardok is probably impossible. And if it ever gets any kind of consensus, it's going to be very reductive. So there's a famous case that illustrates this complexity.

Carl Jung treated Lucia Joyce, which is the daughter of James Joyce, the writer. And in the 30s, Jung treated Lucia for what was called schizophrenia. And she was the daughter of, I mean, Joyce wrote Ulysses in Fenningens Wake. You know, he was one of the biggest writers in the world. And he was this modernist that was throwing everything out and going into these kind of wild landscapes that classical literature didn't do and that were very modern and chaotic and explorations of stream of consciousness

and dream logic, linguistic fragmentation. And Jung saw, you know, the genes in Joyce, but that he could go to this place and he could return, but that the daughter couldn't. She was just drowning. And Joyce, you know, could access the unconscious voluntarily for his art and then he could return. But Lucia was pulled into this under involuntary place that she couldn't find her way back to reality from.

And this image of a diver versus the drowning person became one of the most powerful ways that Jungian conceptualization entered non-Yungian audiences. Because Joseph Campbell at the same time, the mythographer, is writing about schizophrenia and mythology and the unconscious and their effect on our life. This is this unseen world that's affecting this. It's the way we tell stories. It's the way we make meaning. It's the keys to our soul. And so Jung's interpretation was that Joyce, as this untethered modernist and bohemian, had never taught his daughter how to handle the unconscious.

And so Joyce retreated into those depths of the unconscious on a whim for his work, but he had the capacity to return, and his daughter lacked that capacity. And Jung was probably sensing subjectively that part of Lucia's condition was hereditary, that she may have shared some of her father's unusual relationship to primary process thinking. And that part was environmental. Her father's inability to structure his own life and really be a father, even though he's very close with her, he was very, you know, kind of wild guy, didn't give her this model of psychological groundedness.

And so he blamed Joyce, Jung did, and said, you know, the unlived life of the parent is the biggest force in the child's life. All this stuff that you haven't reckoned with in your olden life as a father is now eating your child. Now, we know now the genetic genes there. some of this maybe would have happened. Jung is feeling it. Some of it probably comes from James Joyce's inability to be a father that can provide order and be what this kid needs.

Some of it, you know, is a genetic capacity that is just endogenous to Lucia and Joyce's genes and they're manifesting in Lucia in this way where she's going to have schizophrenia anyway. But that's the kind of area where High Top could help. if we had dimensional data based on psychosis proneness across generations correlated with family environments and parenting styles and creative professions and substance use, we could start to make their finer judgments about these correlations. We could bring science to the questions that analysis could only address through intuition, and we could understand when the artistic temperament is a gift and when it becomes a vulnerability and what the environmental factors are that tip the balance, if any. And, you know, Theodore Porter, one of the things, one of the

of the things he says is that sciences that are softer, like economics, they use numbers more because they're insecure. Psychiatrists don't have the same authority as a heart surgeon at justifying why they made a decision that they made. And so from the beginning, the profession has been looked down upon by these real doctors. So when you lack authority, you reach for mechanical objectivity, and you create checklist and codes and rigorous seeming procedures, not because they reveal truth, but because they protect you from criticism. If someone challenges your diagnosis, you can point to the checklist. I did make this up. I followed the criteria. The DSM is a technology of self-defense, low trust, as Porter would say. And, you know, that genealogy of authority,

he talks about. He says when institutions lack confidence in their own foundation, theoretically, they try and ground themselves in something that's beyond question. Churches trace their authority to divine revelation, royal families constructs, constructs, constructs, to genealogies linking them to mythical ancestors. You know, Saddam Hussein famously fabricated this lineage to the prophet Muhammad that it was impossible and to ancient Babylonian kings from, you know, Proto Persia. And psychiatry does the same thing. It has to ground its authority in science and biology, in neuroscience, and genetics.

And it imports the prestige of the hard sciences to cover for its own uncertainty. And the checklists are dressed up as operationalized criteria. The symptoms are counted as scientific measure. and the whole apparatus is designed to look more like a hard science than it really is. I think probably the failure of the DSM 3, 4, and 5 are proof that we're never really going to build this objective model that makes all the people disagree unless we change the language quite a bit. But, you know, Nichi had that insight that the claim to authority often reveals this depth of insecurity. And the more desperately you insist that your knowledge is objective and scientific, the more that you are really revealing that you know it's not. A secure discipline doesn't need to constantly prove itself.

An insecure one is always generating data, publishing studies, adding more criteria to the checklist, you know, checking its assumptions, having bigger fights, trying to prove that this time it's really, truly science is what we've been doing in psychology for a really long time. And I think one of the reasons why that is is that there is this underlying insecurity because we're talking about emotion. So we have to retreat into logic and then pretend that we arrived at it purely by logic. But what really happens is that you're just hiding your own blind spots, your own emotional and subjective assumptions from yourself when you pretend that you're beating this purely objective thing. And here's the deeper issue that neither the DSM nor its critics want to face. you have to start somewhere. Science rests on assumptions that can't be proven

within the science itself. You know, physics assumes that the universe is regular and comprehensible. And biology assumes that living things can be explained mechanistically. And psychology has to assume

something about what minds are, what self is, how they work, what health means. And I think that it has to assume that these things are back and forth between a biology and an environment

and that you're always imperfectly measuring how much is what, a little bit more than we do now. The DSM's problem is not that it makes assumptions. It's that it pretends not to. By claiming to be a theoretical,

by refusing to say why symptoms cluster the way they do, the manual hides its own assumptions and the way that it got to them instead of examining them. So what are those hidden assumptions? That mental disorders are discrete categories rather than continuous dimensions. That's probably wrong. That symptoms can be meaningfully separated

from the context that produce them. That's probably wrong. But reliability where people agreeing matters more than validity, which is what's true. Maybe most people were just wrong when they assessed the patient because the profession's gone in this weird way. And that suffering can be measured without being interpreted. That's probably wrong. That the individual is the proper unit of analysis rather than the family, the community, the social system, the economic system. That's debatable.

I'm probably going to lean more towards that one than what the DSM. assumes. So one of the profound failures of the checklist is that it flattens everything to sort of pretend that a diagnosis is just a diagnosis and that all diagnoses are the same. If they're not in this book, they don't exist. And if they are, they do, this binary. It treats them as all the same kind of thing. And I don't really think when we talk about diagnosis that they are at all. If you had a layered model, what you could do is say, okay, layer one is pretty deep. mental conditions. These things have biomarkers that are present from early life. They don't fundamentally change. Intellectual disability like autism at the more severe end. You know,

these aren't diseases that come and go. Their differences in how the brain is structured. And then genetic and endogenous conditions is layer two. Things that are probably biological that respond consistently to medication that run in families. You know, the dopamine disorders, schizophrenia, bipolar, we may not fully understand the mechanism, but we have external markers. And every time they take lithium, they stabilize. So even if we don't have a marker, we kind of know it's related because it responds to the medication consistently. And every time they take antipsychotics, the psychosis remits.

Something biological is happening. You know, and then you have layer three, and you say things that used to be the core psychiatric diagnosis, we now call depression, anxiety, PTSD. Here's the system is out of whack. Maybe medication helps, but probably changing perception or the environment through talk therapy is the most indicated thing. It's not schizophrenia, it's depression. Like maybe an antidepressant helps,

but you also probably have to restructure your thinking in order to stay better. Maybe it's trauma. Maybe it's genetic vulnerability. Maybe it's both. The key insight is that these conditions often respond to non-biological treatment. So therapy works for them.

You know, sometimes it works better than medication. The disorder isn't a brain disease. It's a pattern of dysregulation that can be changed. Layer four, characterological, things that aren't primarily symptom base, but are about the person's pattern of living, personality disorders, avoidance, rigidity, places where people deflect from change or they avoid big parts of life. This isn't about their brain chemistry.

It's about their assumptions, their habits, their learned responses. These are what therapists work with every day, the personality and the negative self-understanding and the lack of insight. And then the layer five, the things that they keep trying, special interest groups, keep trying to lobby to get into the book that people don't want to do it because they're so environmental, but they also relate to mental health, so they probably should be in the book. You know, things like in mesh family systems, parental alienation, effects of racism, poverty, discrimination. The DSM doesn't want to turn those things into a pathology because they're so environmental,

but those environmental variables probably should be relevant to discussing like the first four layers. So an advantage of that layer system, you know, you can go through and decide what the best treatment is a little bit quicker. You know, and also, let's ask the question what mental health even is. Let's define that one before we start trying to figure out how to do it. Let's decide what it is. You know, Rebecca Goldstein, she offers a crucial insight with this mattering map in one of her recent books. In the mind-body problem, she says, the map, in fact, is a projection of its inhabitants perceptions, a person's location on it is determined by what matters to him matters overwhelmingly. Who are the nobodies and who are the somebodies? She was on David Eagleman's podcast recently, which is how I found

that book because I enjoyed her talk. That's another good one if you like things of this vein, and he definitely is a lot smarter than me. But she's saying basically the brain's job is to make order in the world. When it can't do that, when it can't figure out how to make sense of what's happening and who you are and what's out there and how you fit into it, then, it is feeling mental illness. And when it is doing that, relatively accurately or accurately enough for you not to be encountering a problem,

then that's not mental illness. If you want to go in a more poetic, you know, direction, that's probably what I would say. But I think the system is unstable, you know, to follow up from that last article, I don't think that it can hold much longer. Younger generations are already laughing at therapist

and demanding a new therapy. And they aren't doing it because they know this history that I'm saying. They're doing it because they know that the current system is not working for them. The further we have followed the evidence basis in this direction and said that this is evidence based, the worst mental health outcomes have gotten from therapy, and we know that. So if we're going into direction and it's making people worse, maybe our assumptions are wrong.

And we have a diagnostic manual that the government's own research agency says isn't scientifically valid. And then you have people who will yell at you for not using that same book and call you not evidence-based. You know, we have a profession that splits between clinicians using one paradigm and researchers using another, and we have insurance companies demanding categorical diagnoses for a reality that's dimensional. And the way that they want to bill may not be the way that psychology works. And letting an insurance company tell you how they prefer to bill and then trying to make the brain fit that paradigm is definitely not scientific. So something's going to break. The question is when and how. And if you're somebody who's scared politically, one of the

the questions is who's in charge, not just the president, but like who's in charge of these scientific systems and who's willing to speak up that has power, because I'm willing to speak up, but I don't have much power, dude, like when this thing happens, because they're the one that's going to set the next paradigm that's going to last a long time. You know, Porter would probably say that the transition is going to come in a recession when there's economic pressure on health care systems, and that becomes unbearable. And when someone decides that we can't afford to keep doing things in inefficient old ways. That's when they'll wipe the board. The danger is whoever is positioned when that moment comes will get to design the replacement.

And right now, the people positioned are not therapists and they are not patients. They are technology companies. They are pharmaceutical giants. They are insurance bureaucracies. If we're not careful, the next diagnostic system will be designed to serve their interest, not the interest of human flourishing. So let me try and summarize where we are here, you know, to put a pen on this before we end. Part of this critique is not that many of the modern assumptions about the way we diagnose are wrong. The problem that, as I see it, is that the modern neuroscience and clinical observations that we have are being held at bay by outdated, unconscious, and implicit assumptions baked into the context of how the system was created and still present in the DSM-5.

Strip of conceptualizations that let psychology acknowledge and study an unconscious or implicit reaction in the therapy room, which is what we did with CBT, the macro system itself is not able to analyze the unconscious and implicit biases that are not evidence-based that are baked into its own system. And so academic training largely strips this broader context out of what it teaches. Therapists and mental health professionals are taught that whatever is evidence-based or considered evidence-based at the time that they're in grad school is just the way that it will always be and the way that it always should have been. And we don't need to learn or to analyze systems or see if they change.

We don't learn history and the debates within the profession. And this means that we're not able to diagnose the point in history, in the history of science that we're in. While we learn about diagnosis, and these are wild ironies, right? You know, again, I make the point a lot that the micro of the individual is a lot of times the macro society. The same mental illnesses that are popping up are explained by the world. that we inhabit. And a lot of the problems with the world are vice versa, explained by the

illnesses and all of the individuals. And so this explains why so many therapists continue what they're doing when they're in graduate school, even if they were in graduate school in the 1980s, and they don't continue to self-educate. And you'll find older people that are just operating under paradigms that they're calling evidence-based that have been categorically wrong for 20 years. And continuing education is supposed to stymie this problem, but it often just repeats whatever the current conception is, and it doesn't look for these biases or analyze these systems. Look how we got here. That's why I'm doing this series.

Should we still be doing things that we were doing in 1950? Look at the history of a diagnosis like borderline personality disorder. It's essentially three conceptualizations that contradict each other in assumption grafted together. And the three conceptualizations, no one even remembers the tension between them because no one remembers the history. And it is easy to sit back and blame psychopharmacom companies. That's not wrong. Major psychopharmaceutical companies have admitted at board meetings by this point that they would rather treat to treat, not treat to cure because cures are not profitable.

The profit motive in health care is definitely an incentive structure that should be kept at bay with regulation because it is not in and of itself scientific. In many places, it's at odds with science. However, these arguments do not go to the root of the system and they fail to understand it. In my experience, it's not just these granted, you know, nefarious forces that cause the problem in the modern DSM. The real root of this problem is the academic insecurity of professionals. Like Theodore Porter and Nietzsche are diagnosing. Academics are taught to defend systems. Research psychologists live solely within those systems. And when we put garbage into these systems, we get garbage out. Even looking at the same data the wrong way can lead you to the wrong

story and the psychiatry and the psychological establishment need to back up and admit that they don't know everything because we don't know everything yet. We need to adjust our assumptions to fit the data, not the data to fit our assumptions, and we need to do that yesterday. How little the public pays attention to these things is part of the reason why we're in the state we're in. It should have been national news that you had the largest scientific body saying that the DSM no longer was scientific. In my experience, not even therapists know about that. 2013 is when the DSM 5 came out. It's been seen as not having evidence by the biggest research institution in the country for more than 10 years, and most people have no clue. The DSM was never

really even designed to try and describe nature. It was a set of assumptions that people in the military made about what was normal, and too much of that is still there. It was a sense. It was a set of administrative protocols adapted by bureaucracy, defended by a profession fighting for legitimacy, and captured by industries seeking profit, and then it achieved reliability by sacrificing validity. It made doctors agree on labels while ignoring the question of whether the labels meant anything. And the NIMH and RDOC is an honest acknowledgement that all the labels don't work for science. But it's also a retreat into pure materialism. What RDOC is, is a decision to study the machine while ignoring the ghost. It has no place for meaning.

for narrative for the human experience of suffering. It's for neuroscientists. It's useless for therapists. And so we're left with a split. The DSM is a map of human stories that has no biological grounding. Ardoc is a biological map that has no human story. Neither one can guide treatment. What would a synthesis look like?

Maybe something like the layered model that I sketched, different frameworks for different kinds of problems with the biological at the bottom and the psychological in the middle and the systemic on the top, like the biopsychosocial model of social work. Maybe something that starts from a definition of health like Goldstein's ability to matter rather than a cataloging pathology. Checklists could work in the synthesis, but they'd have to work forward, not backward. They'd have to start with observations and let categories emerge rather than starting with categories and then forcing observations to fit in them. And they'd have to be tools for organizing knowledge, not substitutes for it.

Nietzsche would say, admit your assumptions. You cannot create a completely logical system as an emotional being. that does not know its own blind spots. Stop pretending the DSM fell from evidence-based practice heaven. It was a product of history and the blind spots of history and the systems and bureaucracies of history that still run our world. If you don't see it as such, you're being a scientific. You're being a child.

You're incapable of handling the uncertainty that it takes to be an adult. Stop acting like the categories are carved in nature. Say, this is how we currently think the brain operates. And then be willing to make an assumption that you can't have, numbers and biology for yet. Science isn't a story we tell once and then we repeat forever. It's a process of telling better and better stories of revising our maps when they stop matching the territory. And the DSM has become a story that cannot be revised. A sacred text defended by institutions whose survival depends on it to be true. The story will change.

It always does. It is changing. The only question is whether we'll change it carefully and thoughtfully with attention to what's being lost as well as what's being gained, or we will wait until the whole thing collapses and then scramble to build something new from the rubble. I hope it's the former. I fear it'll be the later.