Behind The Rise of Psychiatric Diagnosis
How psychiatric diagnosis got so powerful, and why diagnosis matters. A response to Aftab.
The DSM wasn’t supposed to change all of culture—it was created to standardize hospital recordkeeping. Now, people use it to understand who they are and what to fix. Diagnostic labels have their uses, but they can also trap you. I’ve written before about the dangers of identity and addiction—how attachment to a fixed identity rather than a changeable pattern or process can actually hamper recovery. This is just one thread in the broader story of how ideas about disorder and diagnosis have evolved.
Awais Aftab has a great essay tracing how psychiatric diagnosis rose to prominence, told through the evolution of the DSM (psychiatry’s diagnostic manual). He traces how a relatively specialized professional document evolved into its current form, which has massive cultural impact. His article is a solid internal account of the intellectual development of psychiatric diagnosis. But I thought one element deserved more attention: the external story of how and why these definitions came to matter so much, beyond the profession, socially and culturally. That perspective is essential for understanding how a technical tool became a cultural force.
The DSM is a big deal today, but this wasn’t inevitable. DSM-I (1952) was mostly a bureaucratic and administrative effort to standardize hospital records. In day-to-day practice, most psychiatrists didn’t rely on it much (this was also true for DSM-II, 1968.) Hospital based psychiatry was in decline while outpatient talk therapy was on the rise. The real turning point came with DSM-III in 1980—not just in how disorders were classified, but in how the DSM itself became socially important.
With that in mind, one line in Awais’s essay didn’t ring true to me, which got me thinking. Writing about DSM-I, he says it “established the American Psychiatric Association as the central voice in psychiatric diagnosis….” It’s not key to his argument, so I don’t mean to nitpick, but my reaction to that line points to something significant.
There’s a difference between “diagnosis” as the formal act creating standardized categories—a “nosology,” in psychiatric jargon—and “diagnosis” as the actual, real-world practice of understanding, communicating with, and treating patients. At a time when the center of gravity in the psychiatric profession was already moving out of the hospital and onto the analytic couch, DSM-I in 1952 was significant to the former but not at all to the latter.
The late Gerald Grob, an excellent historian of medicine, wrote about how mid-century diagnostic systems may have been “definitive” in theory, but “only of marginal concern to psychiatrists and their patients” in practice. In that sense, the DSM-I didn’t make the APA a central voice at all; the manual was peripheral to most of psychiatric practice.
Things changed dramatically with DSM-III in 1980, but not just because of a change in how psychiatrists chose to define disorders. As Awais recounts, the stage was set over the preceding decade by growing public criticisms, such as the battles over homosexuality in the DSM in 1973 and the rise of anti-psychiatry movements. Partly in reaction, DSM-III adopted symptom-based, standardized, categorical disorder definitions. But that’s an intellectual change, internal to psychiatry. It doesn’t fully explain why DSM-III and its successors had such subsequent impact.
The true paradigm shift—both within medicine and in society—was powerfully driven by forces beyond the profession: growing government involvement in mental health research and policy, mounting pressure from insurers, and the rise of the pharmaceutical industry, which needed specific diseases to market products. As Rick Mayes and Allan Horwitz argue, the DSM-III’s standardization was both cause and effect: it resulted from those pressures on the profession, and then that standardization brought further financial, professional, and intellectual benefits. A reinforcing feedback loop between the content of the manual and its social role ensued.
Simply put, DSM-III gave psychiatry a common language that made its categories useful to insurers, researchers, epidemiologists, regulators, and pharmaceutical companies—and, soon enough, seemingly, to the rest of humanity. Once diagnosis became the shared language of research, clinical practice, and marketing, it naturally filtered into popular culture. That alignment of powerful forces—science, policy, commerce—is what made diagnosis culturally significant. Without that, the DSM is just a bunch of definitions in a book that few people bother to read. With it, DSM-III is instrumental in research, insurance coverage, public policy, law, self-understanding, and the day-to-day practice of medicine.
From that point on, diagnostic language spilled into everyday life, and Awais talks about how diagnostic labels became infused with essentialist thinking—how people perceive psychiatric categories as more “real” than they really are. I’d further add that part of the story is that the psychiatric profession, in the intervening decades, did not do a good job of defending a more measured, provisional, careful approach to diagnosis. Instead, financial and intellectual incentives pushed researchers, clinicians, and thought leaders toward portraying psychiatric disorders as essential, fixed categories.
Also—let’s be honest—simple explanations are just easier to communicate and understand. Simplistic, essentialist stories about diagnostic categories was the path of least resistance, in a way, and as we know that path often creates problems. Now, we face a conceptual muddle. People are rightly skeptical of those overclaims and oversimplifications, while at the same time TikTok is saturated with self-diagnosis. The result is an uneasy and fractious coexistence of both doubt and overattachment regarding psychiatric diagnosis.
One crucial task today is keeping the DSM in its proper place: a useful, provisional, practical tool for certain purposes, not a guide to fundamental truths about human nature. I read Awais as doing exactly that. Those of us working with suffering—clinicians, teachers, or anyone living with pain—can benefit from careful, humane skepticism: using diagnosis where it helps, while also holding it lightly and not letting it be the final word on who we are.
Here’s Awais’s essay in Asterisk Magazine. If you care about how psychiatry makes sense of suffering, I’d highly recommend it.
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For many, there´s a unique shame to having a psychiatric diagnosis that doesn´t pertain to other medical issues, say, a skin rash. Psychiatric diagnosis are also perceived, by some, to confer unique interpersonal benefits. If I have such-and-such a disorder, you have to treat me in a certain way -- or so the story goes. i think this is why who-suffers-from-what is such a battleground.
Excellent analysis, imo. From this layman's perspective it's hard to overestimate the impact of Big Pharma, it's economic influence on research, and the underlying profit motive. Dr. M. Scott Peck was a psychiatrist and author who was highly influential in the late 20th century generally and on my recovery personally. He was highly critical of the shift away from talk therapy to pill pushing. Peck's reputation was trashed in the media, not surprisingly, but much of what he said still rings true.