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The DSM revolution of 1980 gave psychiatry a common language by abandoning the search for underlying causes.

Even the architects of psychiatry's diagnostic system have acknowledged its fundamental limits.

The DSM achieved diagnostic agreement among clinicians but not proof that its categories match real diseases.

Between description and disease there is a gap. Patients live in that gap.

In the summer of 2016, I sat across from a clinician who asked me a series of questions. Had I been sleeping poorly? Had I lost interest in activities I once enjoyed? Did I feel worthless or guilty? Had I experienced changes in appetite, concentration, or energy?

I answered yes to enough of the questions to receive a diagnosis: major depressive disorder.

What no one asked—what the instrument in front of them was not designed to ask—was whether the depression I was describing was the whole story, or one face of something larger and more dangerous that the checklist could not see. It could not see the bipolar disorder beneath the depressive episode. It could not see the syphilis infection rewriting my neurology from the inside. It saw what it was built to see: symptoms, arranged in clusters, matched to a label.

The checklist those clinicians were using came from a book. That book—the Diagnostic and Statistical Manual of Mental Disorders, or DSM is the subject of today's post. Last week, I described what it felt like to wear a diagnosis that didn't fit. This week, I want to look at the manual that cut the coat.

The Man Who Built Psychiatry's Bible

Allan Frances was once called "perhaps the most powerful psychiatrist in America" by The New York Times. He chaired the task force that built the DSM-IV (1994)—the book that determined which forms of suffering counted as mental illness, which treatments insurers would cover, and which diagnoses would follow millions of patients through the rest of their lives.

Years later, the psychologist Gary Greenberg asked Frances a simple question: could he define what a mental disorder actually was?

Frances's answer has followed him ever since. "There's no definition of a........

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