Ian Hacking discusses the perennially expanding petals of the Diagnostic and Statistical Manual of Mental Illness. The latest revision of the DSM is now out, it’s published, it’s a done deal, so instead of people trying to change it or delegitimize it, you’ve got people reviewing it.

Like Hacking. Hacking’s philosophical, logic-based approach considers the DSM a bureaucratically useful fiction: We couldn’t have paid mental health treatment without it. But as “a representation of the nature or reality of the varieties of mental illness,” the DSM is a total failure. Its classificatory system assumes an object with a genealogy and a reasonably stable real-world character. Yet any given mental disorder lacks originary biomarkers as much as it lacks existential discreteness. Thus Hacking makes much of the DSM‘s recourse to the NOS (Not Otherwise Specified) category:

An entry [will] begin with a generic disorder, pass to various species and subspecies, and finally to NOS. Thus in DSM-IV, genus: ‘Schizophrenia and Other Psychotic Disorders’. Eight species: e.g. Schizophrenia. Five subspecies: e.g. Catatonic Type (295.20). After the first seven species with their subspecies, we come to the eighth: Psychotic Disorder, NOS (298.9). Some 32 generic disorders end with a species NOS, where patients are judged to fall under the generic heading but not under any of the specific headings… DSM-5 does its best to drop NOS, but often ends up with a mess. Thus we now have ‘Schizophrenia Spectrum and Other Psychotic Disorders’ with a structure pretty different from that of DSM-IV. There is now a species ‘Catatonia’, with two subspecies, ‘Catatonia Associated with Another Mental Disorder (Catatonia Specifier)’ (289.89), and ‘Catatonic Disorder due to Another Medical Condition’ (293.89). The generic entry ends with a noncoded ‘Unspecified Catatonia’. This applies when we cannot make out the underlying condition, or the ‘full criteria are not met’, or if we simply lack information. Then we read ‘coding note: Code first 781.89 … followed by 293.89 unspecified catatonia’, which sounds very much like NOS.

Everything sort of gutters into anything, in other words. “If,” says Hacking, “I started trying to explain the new categories under schizophrenia, I would get lost in the forest. Indeed, in reading these sections I felt unable to see the tree – schizophrenia – for all the branches that were on display.”

The DSM embodies a strange procedure whereby, as Rilke writes in his fifth Duino Elegy:

the pure too-little

is changed incomprehensibly -, altered

into that empty too-much.

A supremely ironic, supremely self-consuming artifact, then, the DSM elaborates a thing to extinction. The book turns out to be a seek and destroy mission; only billable codes are left standing. Hacking rightly describes this take on the DSM as “a far more radical criticism of it than [NIH director Thomas] Insel’s claim that the book lacks ‘validity’. I am saying it is founded on a wrong appreciation of the nature of things.”

With a full blank slate as background, as it were, research has been easy to corrupt. “[U]niversity research departments and learned journals are [often] funded by those who stand to profit – literally – from their presumed objectivity,” writes Will Self in his review of the DSM.