1. Look, it’s near the end of the day and I’m stressed. Can you remind me to slow down and listen?
2. Just because I am a radical skeptic when it comes to the utility of many tests doesn’t mean I don’t care about your symptoms.
3. Put your cell phone away, please.
4. Tell me something about yourself that doesn’t have anything to do with your illness.
5. What sort of person are you really, deep down?

1. I really don’t understand what you’re saying.
2. I don’t think you care about my problem.
3. I am glad you care about my problem, but I don’t think we are seeing eye to eye about the solution.
4. Can’t you just make the decision for me?
5. What?

There has been controversy lately over the new edition of the American Psychiatric Association’s new version of their Diagnostic and Statistical Manual (DSM 5). Among a number of critiques, the most-forwarded on the Internet seeems to be that of the National Institute of Mental Health, which recommended that researchers applying for grants not use the DSM 5 – because, rather than classify diseases and diagnoses based on etiology, it does so based on symptomatology. The narrative that the psychiatrists are trying to write is a triumphal progression from anecdote to empiricism, from Freud’s couch to the colorful images of the fMRI. 

Unfortunately, the example psychiatrists would like to follow – medicine – is not as simple as all that. When we diagnose, we often apply a heuristic which relies not just on results of tests and images but also on the patients’ symptomatic report. Call it “bacterial pneumonia” all you want, but a patient without symptoms can’t be diagnosed with pneumonia even if there’s an infiltrate on the X-ray – and even if a patient is symptomatic, we don’t go and culture the bacteria from the lung tissue except in relatively serious circumstances. The point here is not the details of what makes a pneumonia, merely that we do not have a magic on-off switch within the body that we can examine when making a diagnosis. Psychiatrists know this as much as we do, which is why (to internists’ secret shame) we don’t have anything like a unified diagnostic and statistical manual – and if we did, it would be just as controversial as the DSM.