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that did not make it so.
    Unless our sciences can test whether what we agree on is objectively the case, agreement counts for nothing from a scientific standpoint. So even if psychiatrists reach high diagnostic agreement at some future point, this would not prove that the mental disorders with which they diagnose patients actually exist as valid disease entities. There need to be other procedures to establish that. So the issue is: Are there other procedures? And if so, what exactly are they?
    This question is so central to the entire psychiatric enterprise that I decided to ask Robert Spitzer myself.

CHAPTER TWO
    THE DSM—A GREAT WORK … OF FICTION?
    O n a sunny May morning in 2012, I catch the train from New York City. As we leave Penn Station the train slowly shunts and rattles under the Hudson River before emerging onto the wasteland of industrial New Jersey. After passing for about thirty minutes through a bleak landscape of gnarled bog land and abandoned warehouses, signs of plusher suburbia begin to break through. As the train gains pace with each passing mile, the outside scene grows steadily more affluent—the houses get bigger, the cars shinier, and the landscape lusher, until, about fifty minutes later, we terminate at the pristine dénouement of Princeton University.
    I am traveling to Princeton this early May morning because three years earlier Dr. Robert Spitzer had moved out here from nearby West Chester, Pennsylvania. His wife had taken a job at a local research laboratory, and Spitzer, now in his late seventies, had decided to embark upon one last adventure. They had chosen a large and comfortable house in the historic, leafy suburbs just northeast of the university, and as my taxi pulled up outside it was clear they had chosen well.
    â€œCome on in,” said Spitzer, dressed in shorts, sandals, and a loose sports top, as he led me into the living area. “You wanna stay for lunch?”
    Still reeling from my mountainous American breakfast, I struggled to say, “Sure, that’d be nice.”
    â€œBefore we do that,” said Spitzer, to my great relief, “how about we first sit down so I can tell you what you want to know.”
    Once we had settled comfortably in our chairs, the first question I had for Spitzer concerned one of the other major changes he introduced into the DSM . What I did not mention in the last chapter is that a further change Spitzer introduced into the DSM , alongside creating a new checklist system and sharpening the definitions for each disorder, is that he introduced more than eighty new disorders, effectively expanding the DSM from 182 disorders ( DSM-II ) to 265 ( DSM-III ). “So what,” I asked Spitzer, “was the rationale for this huge expansion?”
    â€œThe disorders we included weren’t really new to the field,” answered Spitzer confidently. “They were mainly diagnoses that clinicians used in practice but which weren’t recognized by the DSM or the ICD . There were many examples, borderline personality disorder was one, and so was post-traumatic stress disorder. There were no categories for these disorders prior to DSM-III . By including them we gave them professional recognition.”
    â€œSo presumably,” I asked, “these disorders had been discovered in a biological sense? That’s why they were included, right?”
    â€œâ€˜No, not at all,” Spitzer said matter-of-factly. “There are only a handful of mental disorders in the DSM known to have a clear biological cause. These are known as the organic disorders [like epilepsy, Alzheimer’s, and Huntington’s disease]. These are few and far between.”
    â€œSo, let me get this clear,” I pressed, “there are no discovered biological causes for many of the remaining mental disorders in the DSM ?”
    â€œNot for many , for any ! No biological markers have been identified.”
    â€œWell, it is important