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“So you're saying,” I asked, trying not to look shocked, “that there was little research not only supporting your inclusion of new disorders, but also supporting how these disorders should be defined?”

“There are very few disorders whose definition was a result of specific research data,” responded Spitzer. “For borderline personality disorder, there was some research that looked at different ways of defining the disorder. And we chose the definition that seemed to be the most valid. But for the other categories, rarely could you say that there was research literature supporting the definition's validity.”

Spitzer's admission so surprised me that I decided to check it with other members of his taskforce. So on a rainy English Monday, I called Professor Donald Klein in his New York office to ask whether he agreed with Spitzer's account of events. Klein had been a leader on Spitzer's taskforce and so was at the heart of everything that went on.

“Sure, we had very little in the way of data,” Klein confirmed through a crackling phone line, “so we were forced to rely on clinical consensus, which admittedly is a very poor way to do things. But it was better than anything else we had.”

“So without data to guide you,” I nudged carefully, “how was this consensus reached?”

“We thrashed it out, basically. We had a three-hour argument. There would be about twelve people sitting down at the table. Usually there was a chairperson and there was somebody taking notes. At the end of each meeting there would be a distribution of events. And at the next meeting some would agree with the inclusion, and the others would continue arguing. If people were still divided, the matter would be eventually decided by a vote.”

“A vote? Really?” I asked, trying to conceal that I hardly felt reassured.

“Sure, that is how it went.”

Renee Garfinkle, a psychologist who participated in two
DSM
advisory committees, also confirmed the unscientific processes by which key decisions were made. “You must understand,” Garfinkle bluntly said to me, “what I saw happening on those committees wasn't scientific. It more resembled a group of friends trying to decide where they want to go for dinner. One person says ‘I feel like Chinese food,' and another person says ‘no, no, I'm really more in the mood for Indian food,' and finally, after some discussion and collaborative give and take, they all decide to go have Italian.”

Garfinkle then gave me a concrete example of how far down the scale of intellectual respectability she felt those meetings could sometimes fall. “On one occasion, I was sitting in on a taskforce meeting and there was a discussion about whether a particular behavior should be classed as a symptom of a particular disorder. As the conversation went on, to my great astonishment one taskforce member suddenly piped up, ‘Oh no, no, we can't include
that
behavior as a symptom, because
I
do that!' And so it was decided that that behavior would not be included because, presumably, if someone on the taskforce does it, it must be perfectly
normal
.”

According to other members of the taskforce, these meetings were often haphazard affairs. “Suddenly, these things would happen and there didn't seem to be much basis for it except that someone just decided all of a sudden to run with it,” said one participant. “It seemed,” another member admitted, “that the loudest voices usually won out.”
21
With no extensive data one could turn to, the outcome of taskforce decisions often depended on who in the room had the strongest personality. “But the problem with relying on consensus,” reiterated Garfinkle, “is that in the discussion some voices will just get quieter, either because they don't want to fight or because they see they're in the minority. And
snap
, that's when the decision is made.”

Admittedly, when the taskforce lacked expertise on a particular disorder, Spitzer would consult the relevant leaders in the field. But this also led to chaotic meetings that members often found difficult to participate in. One of the only British members on the taskforce, a psychiatrist called David Shaffer, recalled how such meetings often unfolded. “[In these] meetings of the so-called experts or advisers, people would be standing and sitting and moving around. People would talk on top of each other. But Bob would be too busy typing notes to chair the meeting in an orderly way.”
22

In an article for
The New Yorker
, Alix Spiegel recounts how two new disorders (“factitious disorder” and “brief reactive psychosis”) made it into the
DSM
through such disorderly consultations:

Roger Peele and Paul Luisada, psychiatrists at St. Elizabeth's Hospital in Washington, D.C., wrote a paper in which they used the term “hysterical psychoses” to describe the behavior of two kinds of patients they had observed: those who suffered from extremely short episodes of delusion and hallucination after a major traumatic event, and those who felt compelled to show up in an emergency room even though they had no genuine physical or psychological problems. Spitzer read the paper and asked Peele and Luisada if he could come to Washington to meet them.

During a forty-minute conversation, the three decided that “hysterical psychoses” should really be divided into two disorders. Short episodes of delusion and hallucination would be labeled “brief reactive psychosis,” and the tendency to show up in an emergency room without authentic cause would be called “factitious disorder.”

“Then Bob asked for a typewriter,” Peele says. To Peele's surprise, Spitzer drafted the definitions on the spot. “He banged out criteria sets for factitious disorder and for brief reactive psychosis, and it struck me that this was a productive fellow! He comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders!” Both factitious disorder and brief reactive psychosis were included in the
DSM-III
with only minor adjustments.
23

What is striking about the construction of the
DSM
is that the procedures it followed often had very little to do with “science” as most people understand the term. Because the data and research were lacking to guide what disorders should be included and how they should be defined, all the taskforce could largely rely upon was professional agreement, consensus, and, in the event of continued disagreement, majority opinion attained by a vote. The problem here is obvious.

When a group of scientists sit down to decide whether something is true, they consult the evidence. If the evidence points to a clear conclusion, then irrespective of whether an individual scientist likes it, the result has to be accepted. That is how science works. The evidence is king. But when you don't have evidence to decide the issue for you, people's opinions, beliefs, hopes, and prejudices begin to intrude. In this instance, the scientist who desires a particular conclusion suddenly speaks up, argues loudly, and may, through sheer force of character, have his preferences accepted.

When objective science is lacking, subjective inclination steps in. When there is no evidence to guide me, it can easily become largely a matter of personal or professional preference whether I vote this way or that. Voting, in other words, is not a scientific activity. It is a cultural activity. People vote for class presidents, union leaders, political parties, and a host of other things. And yes, sometimes their votes are vindicated, but often they are not. Votes can disappoint. This is because a vote is not a guarantee that the thing voted for is real or true or good or certain. Votes are at best informed guesses, and at worst punts in the dark; so when anything is voted into existence, whether it be a new leader, a political policy, or, indeed, a new mental disorder, the likelihood that we have got it wrong is never far away.

4

As soon as Spitzer's
DSM-III
was published in 1980, it became a sensation overnight. The almost 500-page-long manual sold out immediately. The publisher of the
DSM
, the American Psychiatric Association, was taken completely off guard. It took approximately six months to catch up with the orders that came flooding in. The new manual was purchased not only by psychiatrists but by nurses, social workers, lawyers, psychologists—by anyone with any connection to psychiatry.
24

The enthusiasm quickly spread far beyond the United States. In Britain, for example, the manual had such impact that by the end of the 1980s most British psychiatrists were being trained to use the
DSM
.
25
Furthermore, Spitzer's
DSM
categories quickly became those that guided all research into psychiatric disorders internationally. This meant that the disorders studied by researchers in Germany, Australia, Canada, Britain, India, and so on, were those defined and listed in Spitzer's
DSM
. In short, the book ultimately changed the fundamental nature of research and practice within the field, not to mention the lives of tens of millions of people diagnosed with the psychiatric disorders listed therein.

And yet, even as the influence of the manual spread, the truth about its construction remained obscure. Most professionals using the manual simply did not know (and still do not know today) the extent to which biological evidence or solid research failed to guide the choices the taskforce made. They did not know that the definitions of the disorders contrived, the validity of the disorders included, and the symptom thresholds people must meet to receive the diagnosis were not decided by serious scientific evidence but were the product of committee decisions which, at best, reflected the well-meaning professional opinions of a small subset of psychiatrists.

In short, most people did not know that the fundamental changes Spitzer brought to global psychiatry only required the consensus of an extremely small group of people. Indeed, as Spitzer openly confirmed to me in our interview, “Our team was certainly not typical of the psychiatry community, and that was one of the major arguments against
DSM-III
: it allowed a small group with a particular viewpoint to take over psychiatry and change it in a fundamental way.”

“What did you make of that criticism?” I asked him.

“What did I think of that charge? Well, it was absolutely true! It was a revolution, that's what it was. We took over because we had the power.”

Within a couple of years, this powerful few had established for a whole new generation where the thin membrane separating psychiatric disorder from the ordinary troubles of life should be set. They had also created and defined approximately eighty new mental disorders, which very quickly became household names or, for many, established disease realities. Disorders like Post-Traumatic Stress Disorder, Major Depression, Social Phobia, Borderline Personality Disorder, and so on, gradually became as real and solid in the popular imagination as tonsillitis, shingles, or the common cold. And all the while, the truth about the processes going on behind the scenes remained carefully hidden—processes which, as the next chapter will show, have dramatically increased the number of us today being branded psychiatrically unwell.

5

On the evening of my interview with Robert Spitzer, I decided to take a walk through Princeton's pristine university campus before meeting an old friend for drinks. It was a joy to be walking in the warm evening air, as only days earlier I had flown in from London and one of the wettest Aprils since records began. In contrast, Princeton was positively Mediterranean, and I couldn't believe my luck. So after walking a while I sat down on a bench, stretched out my legs still heavy with jet lag, and looked up contentedly at the dust of stars beginning to illuminate the night sky. And it was at that moment, on that bench, that a crucial realization dawned.

It started by my recalling something Paula J. Caplan had mentioned to me days earlier. “Mental disorders,” she had said, “are nothing more than constellations.” At the time I'd not given the comment much thought, but now, after having spoken to Spitzer, her analogy seemed perfect.

Just think about it. As far back as historical records go, we have tried to order this chaos of sparkling orbs into meaningful patterns or configurations, drawing lines between individual stars to create the constellations we know from our schoolbooks: Orion, Leo, Apus, and Aquarius. Most other cultures have also engaged in this astrological map making; Hindu, Chinese, Inca, and Australian Aboriginal have all forged their unique celestial maps. This is why when someone from Bangalore or Sichuan looks up at the very same night sky as you, she identifies different constellations. Her culture has taught her to read the sky differently. She sees her own, not your, astral designs.

And that's why Caplan's analogy now made so much sense to me: mental disorders are also man-made maps. Maps linking up our separate feelings and behaviors like astrologers do the galactic stars. One star characterizes sleeplessness, another a visual hallucination, another a constant tick, a violent outburst, or sexual lethargy. And when these separate items are joined with lines, a new pattern—a new disorder—is forged.

Viewed from this standpoint, the
DSM
committee did not actually
discover
mental disorders, at least not in any traditional scientific sense. Rather, they literally
contrived
them, by drawing lines between painful, emotional experiences. One disorder linked up fear, panic, and uncontrolled bouts of anxiety (this would be called Specific Phobia); another disorder linked up low self-esteem, lethargy, and a low capacity for pleasure (and this would be called Dysthymia). And so it went until hundreds of separate patterns had all been given individual names: major depressive disorder, self-defeating personality disorder, oppositional defiant disorder,
somatization disorder
, and so on.