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to hear you say this,” I said to Spitzer, “because this is something most people simply don’t know. I did not know it when I started out training as a psychotherapist. Most of my patients do not know it today. And I suspect for many people reading this interview it will come as a surprise too.” [If you’re one of the surprised or skeptical, I’ll inspect this claim more thoroughly in later chapters.]
    â€œSo if there are no known biological causes,” I continued, “on what grounds do mental disorders make it into the DSM ? What other evidence supports their inclusion?”
    â€œPsychiatry is unable to depend on biological markers to justify including disorders in the DSM . So we look for other things—behavioral, psychological. We have other procedures.”
    Before I discuss these “other procedures,” let me explain why you are probably surprised to hear that biological research did not guide the DSM ’s expansion. This may sound strange to you because we all expect psychiatry to work much like the rest of modern, mainstream medicine. In mainstream medicine, a name will only be given to a disease after its pathological roots have been identified in the body, such as in an organ, tissue, cells, etc. With few exceptions, that is how general medicine operates: once you have discovered the physical origins of a problem, only then do you give it a name, such as cystic fibrosis, cancer, or Crohn’s disease.
    But the surprising truth about psychiatry is that it largely operates in a completely opposite way. Rather, psychiatry first names a so-called mental disorder before it has identified any pathological basis in the body. So even when there is no biological evidence that a mental disorder exists, that disorder can still enter the DSM and become part of our medical culture.
    Of course, understanding that psychiatry operates differently does not in and of itself mean that psychiatry’s procedures are necessarily wrong. The only way to decide this is to assess whether psychiatry’s alternative procedures are scientifically valid. To find out whether this is the case, I asked Spitzer to take me through the procedures his taskforce followed when deciding whether or not to include a new disorder. For example, if the findings of biology did not help the Taskforce to determine what disorders to include in DSM-III , then what on earth did?
    â€œI guess our general principle,” answered Spitzer candidly, “was that if a large enough number of clinicians felt that a diagnostic concept was important in their work, then we were likely to add it as a new category. That was essentially it. It became a question of how much consensus there was to recognize and include a particular disorder.”
    â€œSo it was agreement that determined what went into the DSM ?”
    â€œThat was essentially how it went, right.”
    What sprang to mind at Spitzer’s revelation was the point I made in the previous chapter about agreement not constituting proof. If a group of respected theologians all agree that God exists, this does not prove that God exists. All it proves is that these theologians believe it. So in what sense is psychiatric agreement different? Why, when a committee of psychiatrists agree that a collection of behaviors and feelings point to the existence of a mental disorder, should the rest of us accept they’ve got it right?
    Perhaps in the absence of having biological evidence to convince us, they can produce other kinds of evidence to assure us that their agreements were justified. In other words, what was the evidence leading the taskforce to agree that a new disorder should be included in the DSM ?
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    Before coming back to Spitzer for an answer, let me first put this question to the psychologist Professor Paula J. Caplan, currently a Fellow at Harvard University’s Kennedy School and former consultant to two DSM committees. I interviewed