Listen to this article.
To name something—to separate it from the rest of existence and bestow a label on it—is a foundational act. It is the beginning of understanding and control. In Genesis, the first thing God did after splitting light from darkness was to call the light “day” and the darkness “night.” After Adam was created and let loose in the Garden of Eden, his original job was human label-maker. God brought him creatures “to see what he would name them; and whatever the man called each living creature, that was its name.”
If Adam was like most people, he probably set about attaching names to “natural kinds”—groupings seemingly dictated by inherent features of the natural world. Referring to a group of animals as “pigs,” he would have assumed that the critters so designated all shared properties that differentiated them from every other non-pig animal. Psychologists say that we intuitively treat categorical distinctions—whether among fruits, emotions, or ethnic groups—as if (in Plato’s famous metaphor) they carved nature at its joints.
No sector of human activity is as serious about naming, or as intent on respecting natural kinds, as science. Across centuries of debate and revision, fields such as physics, chemistry, and biology have refined nomenclatures to better align with the natural order. Psychiatry, at first, looks like another success story. Years of research and clinical observation have yielded catalogues of presumed mental dysfunction, culminating in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. First produced by the American Psychiatric Association seven decades ago, and currently in its fifth edition, the DSM organizes conditions into families such as “anxiety disorders,” “sexual dysfunctions,” and “personality disorders.” Each diagnosis is described by clear criteria and accompanied by a menu of information, including prevalence, risk factors, and comorbidities. Although clinicians and researchers have understood the DSM to be a work in progress, many had faith that the manual’s categories would come to approximate natural kinds, exhibiting, as the Columbia psychiatry professor Jerrold Maxmen put it in 1985, “specific genetic patterns, characteristic responses to drugs, and similar biological features.”
More than any other document, the DSM guides how Americans, and, to a lesser extent, people worldwide, understand and deal with mental illness. It decrees psychiatric vocabulary, having codified terms like “attention-deficit/hyperactivity disorder” and “post-traumatic stress disorder.” It determines which conditions are taught in medical schools, which can be treated by F.D.A.-approved drugs, and which allow people to collect disability benefits and insurance reimbursements. Through its classification of mental illnesses, it establishes their prevalence in the population and indicates which ones public policy should target.
The DSM as we know it appeared in 1980, with the publication of the DSM-III. Whereas the first two editions featured broad classifications and a psychoanalytic perspective, the DSM-III favored more precise diagnostic criteria and a more scientific approach. Proponents hoped that research in genetics and neuroscience would corroborate the DSM’s groupings. Almost half a century later, however, the emerging picture is of overlapping conditions, of categories that blur rather than stand apart. No disorder has been tied to a specific gene or set of genes. Nearly all genetic vulnerabilities implicated in mental illness have been associated with many conditions. A review of more than five hundred fMRI studies of people engaged in specific tasks found that, although brain imaging can detect indicators of mental illness, it fails to distinguish between schizophrenia, bipolar disorder, major depression, and other conditions. The DSM’s approach to categorization increasingly looks arbitrary and anachronistic.
Steven Hyman, who directed the National Institute of Mental Health from 1996 to 2001, told the Times that he considered the manual an “absolute scientific nightmare.” In 2009, four leaders of the DSM-5 revision wrote about their hopes to “update our classification to recognize the most prominent syndromes that are actually present in nature.” The outcome didn’t live up to those aspirations. In April, 2013, weeks before the DSM-5’s slated release, Thomas Insel, then the director of the N.I.M.H., remarked, “The final product involves mostly modest alterations of the previous edition.” As a result, he announced, the institute “will be re-orienting its research away from DSM categories.”
In “DSM: A History of Psychiatry’s Bible” (2021), the medical sociologist Allan V. Horwitz presents reasons for the DSM-5’s botched revolution, including infighting among members of the working groups and the sidelining of clinicians during the revision process. But there’s a larger difficulty: revamping the DSM requires destroying kinds of people. As the philosopher Ian Hacking observed, labelling people is very different from labelling quarks or microbes. Quarks and microbes are indifferent to their labels; by contrast, human classifications change how “individuals experience themselves—and may even lead people to evolve their feelings and behavior in part because they are so classified.” Hacking’s best-known example is multiple personality disorder. Between 1972 and 1986, the number of cases of patients with multiple personalities exploded from the double digits to an estimated six thousand. Whatever one’s thoughts about the reality of M.P.D., he observed, everyone could agree that, in 1955, “this was not a way to be a person.” No such diagnosis existed. By 1986, though, multiple personality disorder was not only a recognized psychiatric label; it was also sanctioned by academics, popular books, talk shows, and, most important, the experiences of people with multiple personalities. Hacking referred to this process, in which naming creates the thing named—and in which the meaning of names can be affected, in turn, by the name bearers—as “dynamic nominalism.”
Three new books—Paige Layle’s “But Everyone Feels This Way: How an Autism Diagnosis Saved My Life,” Patric Gagne’s “Sociopath: A Memoir,” and Alexander Kriss’s “Borderline: The Biography of a Personality Disorder”—illustrate how psychiatric classification shapes the people it describes. It models social identities. It offers scripts for how to behave and explanations for one’s interior life. By promising to tell people who they really are, diagnosis produces personal stakes in the diagnostic system, fortifying it against upheaval.
Just as personality tests (see, I’m an introvert!), astrological signs (I’m a Libra!), and generational monikers (I’m Gen Z!) are used to aid self-understanding, so are psychiatric diagnoses. When Paige Layle was fifteen, a psychiatrist told her that she had autism spectrum disorder. She describes the rush of clarity she experienced when hearing the DSM-5 criteria: “I’m not crazy. I’m not making it up. I’m not manipulative or trying to fake anything. . . . There’s a reason why I’m the way that I am.”
Layle’s diagnosis—and her discovery that “so many of my questions have one clear answer”—comes halfway through her book. The chapters leading up to it recount the frustration and confusion of being inexplicably different. She lists her “traits” early on: picking at her skin, pulling out her hair, cutting tags from her clothes, dissociating at the sound of fireworks. By the first grade, she says, she could read almost as well as a sixth grader, and in later years, she consistently earned high marks, yet she failed to decipher implicit meanings of texts in English class. She also struggled with anxiety; she was, in her words, “the weird kid who cried all the time and was so stressed that she wanted to die every single day.”
In 2020, she posted a video on TikTok slamming a trend that used “autistic” to mean “dumb.” It went viral. With a bluntness easily mistaken for vanity, she told the camera, “Hi, there, I’m autistic. I’m also the smartest person I’ve ever met, O.K.?” In the years since, she has become one of the most popular autism-awareness activists on the platform, attracting more than two and a half million followers. Bubbly and socially perceptive, with expertly applied makeup and a way of looking into the camera that’s both intimate and intense, she defies common expectations of what an autistic person looks like—while also delivering a message about the diversity of autism’s expressions, and especially its different presentations in men and women.
Some organizations and style guides now urge what is called person-first language (“person with autism”) over diagnosis-first language (“autistic person”). These recommendations are “straight-up, basic ableism,” Layle writes in her book. “I am autistic. I am always autistic, in every situation, all of the time, 24-7. . . . I would be a completely different person if I wasn’t autistic, and the idea of who that person would be is something I could never figure out, because autism is such an integral part of my identity. To take it away would be to take all of me away, and I find it ableist to want to try.”
What it means to be autistic, however, is constantly in flux. Over the past twenty years, the prevalence of autism in the United States has quadrupled, according to the C.D.C. A major driver of this surge has been a broadening of the definition and a lowering of the diagnostic threshold. Among people diagnosed with autism, an international meta-analysis in JAMA Psychiatry found, evidence of the psychological and neurological traits associated with the condition declined by up to eighty per cent between 2000 and 2015. Although many celebrate the expansion of autism as better characterizing its many varieties, leading researchers, such as Laurent Mottron and Uta Frith, worry that the heterogeneity dilutes a natural category. Temple Grandin, the academic and autism spokesperson, told the Observer in 2022, “The spectrum is so broad it doesn’t make much sense.”
Layle’s autism is likely a product of this expansion. Her psychiatrist told her that, had she visited a couple of years earlier, he would have diagnosed her with Asperger’s syndrome, not autism. But one of the few big changes implemented between the DSM-IV and the DSM-5 was the collapse of “pervasive developmental disorders,” including Asperger’s, into “autism spectrum disorder.” The act that Layle considers such a violation—being deprived of her diagnosis and thus her identity—was inflicted on the entirety of the “Aspie” community. What’s more, many people once diagnosed as having Asperger’s learned that, under the new criteria, they wouldn’t qualify as having autism spectrum disorder. The change caused fear and confusion, and, for some, felt like a denial of nature itself. “It surprises me that they’d remove that label when it’s very clearly something that exists,” a British man formerly diagnosed as having Asperger’s told the psychologist Bethan Chambers. “I’m now a member of an endangered species.”
The erasure of Asperger’s offers a glimpse into what a larger diagnostic revolution might herald. The term was coined in 1981 and first appeared in the DSM-IV, in 1994. Thriving communities soon developed around the label, including Aspies for Freedom, an online group that had close to fifty thousand members in 2013. Individuals with Asperger’s led the opposition to a unified autism diagnosis. Once they failed, and it became clear that the new manual would not only remove Asperger’s syndrome but also deprive many former Aspies of a place on the spectrum, the Autistic Self Advocacy Network successfully lobbied the DSM-5 neurodevelopmental-disorders working group to broaden the diagnostic criteria and allow people with previous Asperger’s diagnoses to be recognized as autistic. A community created by a label sought to keep that label alive and, barring that, to maintain their inclusion in the system writ large.
“But Everyone Feels This Way” is a heartfelt, vulnerable book about understanding and accepting autism in a world that constantly demands normalcy. At the same time, it hinges on the disorder being as it is presented in the DSM-5: both a spectrum and a natural kind, wildly various but biologically grounded. “I hope that, with knowledge and technology continuously improving in the science world, neurologists and other experts on neurodevelopment will eventually be the ones diagnosing ASD, not psychiatrists basing their diagnosis on arbitrary actions,” Layle writes. Yet the same research threatens to destabilize the spectrum and her place on it.
Like Layle, Patric Gagne noticed that “something was off” as a child. By the age of seven, she had a box full of stolen trinkets. When a classmate invited her over for a slumber party, she left after everyone else fell asleep and walked the streets of San Francisco. Around the age of nine, she locked two girls out of her house; after one of them told Gagne, “Your house sucks, and so do you,” Gagne stabbed her in the head with a No. 2 pencil. (The girl survived.) Emotions such as anger and happiness came easily, she writes in “Sociopath: A Memoir,” but “empathy and guilt, embarrassment and jealousy were like a language I couldn’t speak or understand.”
During her first year at U.C.L.A., Gagne says, she started “stealing” cars, which meant persuading drunk boys at frat parties to lend her their keys, going on nighttime joy rides, and then returning the cars before morning. It was around that time, she writes, that she first understood the meaning of “sociopath,” through an introduction-to-psychology class. The professor described sociopaths as people prone to apathy who behave badly out of a desperation to feel something. The concept clicked for Gagne. “I’d always longed for some sort of evidence that I wasn’t alone, validation that I wasn’t the only person in the world who didn’t feel things like everyone else,” she writes. “I’d always suspected, but now I knew for sure. There were enough people like me to justify an entire psychological category.”
But sociopathy isn’t a psychological category, at least not diagnostically. The first edition of the DSM included “sociopathic personality disturbance”—a grouping that spanned callous lawbreakers, sexual deviants, and people with substance-abuse problems. The term “sociopathic” was dropped from the DSM-II with the arrival of “antisocial personality disorder,” even as the word remained popular outside clinical diagnoses. Some scholars associated sociopathy with remorseless and impulsive behavior caused by a brain injury. Other people associated it with an antisocial personality. In “The Sociopath Next Door” (2005), the psychologist Martha Stout used it to mean a lack of conscience. Gagne, for her part, positions sociopathy as something real but missing from the DSM, a stand-in for her own categorically confounding antisocialness.
Of course, trusting a self-professed sociopath can be tricky. “The story you are about to read is true,” she declares in the preface, before admitting, in the introduction, “I’m a liar,” and describing herself as “highly manipulative.” Her credibility feels especially thin when she talks about scholarship. Despite many mentions of “my doctorate” and “my research,” her book never cites that research; it hardly ever cites other researchers, either. Her academic credentials have been a matter of public scrutiny, with both Redditors and a recent Times reviewer pointing to the unavailability of her dissertation online. She does have a doctoral degree and did complete a dissertation, but I couldn’t locate any published papers by her in the usual databases.
If we take her at her word, though, she exists in a psychiatric purgatory. She only half identifies with antisocial personality disorder as it is presented in DSM-IV. When a therapist screens her using the Hare Psychopathy Checklist, her score is higher than average but not high enough to qualify her as a psychopath. She also violates many popular assumptions about antisocial people. “I don’t care what other people think,” she says, before describing how she longed for her mother’s approval. She says that love doesn’t come naturally yet talks about it extensively, mostly in connection with her husband, David, but also to describe her feelings toward her mother, her father, her sister, and a ferret named Baby. “I’m not interested in morals,” she announces on the first page; a few chapters later, she says that she set a rule of “NO HURTING ANYBODY” as a teen-ager.
These contradictions sit at the heart of Gagne’s memoir. She craves diagnosis and uses clinical labels as a framework for self-understanding. But the fit is always awkward, and the implications are disheartening. “I don’t want to feel like things like relationships and love and family are out of reach just because I don’t ‘internalize emotions’ the same way everybody else does,” she says at one point. Confronted with the failure of existing schemes to explain her distress, she sees not a broken system but a space for a new diagnosis of her own devising: “sociopathic spectrum disorder.” To be named is to be acknowledged, to be situated in a natural order.
If Gagne’s sociopathy falls outside DSM diagnoses, borderline personality disorder cuts across them. A condition of volatility, B.P.D. is defined by sudden swings in mood, self-image, and perceptions of others. Patients with B.P.D. tend to have intense, unstable relationships and often describe an agonizingly raw sensitivity. The psychologist Marsha Linehan has compared B.P.D. to a psychological third-degree burn: “Even the slightest touch or movement can create immense suffering.”
B.P.D.’s nebulous nature is encoded in its name. The concept is generally attributed to the psychoanalyst Adolph Stern, who used it in 1937 to describe patients who were neither neurotic nor psychotic and thus “borderline.” The committee charged with designing measures for personality disorders for the DSM-III discussed its confusing status when debating its inclusion. Some members noted that key symptoms such as identity disturbance, outbursts of anger, and unstable interpersonal relations also featured in narcissistic and histrionic personality disorders. During the internal deliberations, Donald Klein, then a professor of psychiatry at Columbia University, complained that “every conceivable variety of character disorder has been described as borderline at one time or another.” In “Personality Disorders: A Short History of Narcissistic, Borderline, Antisocial, and Other Types” (2023), Allan Horwitz, the medical sociologist, asks why the DSM still treats B.P.D. as a disorder of personality rather than of mood. “Its trademark indicator—emotional dysregulation—is virtually the opposite of the rigidity that characterizes a PD,” he writes.
Alexander Kriss, in “Borderline: The Biography of a Personality Disorder,” embraces this categorical quagmire. A psychotherapist and a professor of psychology at Fordham University, Kriss takes an expansive view of B.P.D., finding traces of it in Hippocratic writings about hysteria, early-modern accusations of witchcraft, and a range of diagnostic categories, including complex P.T.S.D. His book is eerie, lyrical, and erudite—fitting for a man who, as we learn, switched to clinical psychology from playwriting, and who seems more interested in Freudian theories than in modern psychiatric constructs. He prefers not to make declarative statements about the nature of B.P.D., choosing, instead, to study it through others’ attempts to name, treat, and demonize psychological instability.
He’s openly contemptuous of the DSM. By distancing itself from its psychoanalytic roots, he says, the manual abandoned useful insights about etiology and treatment, and about psychological mechanisms like splitting and projection. He also condemns its “categorical approach to illness,” which he thinks poorly represents reality. “A disease was a disease because the book said it was disease,” he writes, comparing the DSM’s institutional authority to religious scripture. “Perhaps it is time to reject the naming of things once and for all,” he suggests at one point. “To at least consider the possibility of leaving the world of categories behind.”
Kriss recognizes how the process of labelling reifies categories, especially in the age of the Internet. Online communities such as the subreddit r/BPD crystallize psychiatric tags into identities to be socially accommodated and invite people to diagnose themselves. Such communities, Kriss fears, can “pervert” B.P.D. into a self-serving justification for misconduct. He cites the musician Abby Weems’s post about her relationship with the podcaster Dustin Marshall: “He made it so easy to rationalize his behavior, telling me ‘that’s just what happens when someone has BPD.’ His personality disorder made up so much of his identity that any abusive behavior fell under the umbrella of his condition.”
What’s more striking is that Kriss, for all his misgivings, doesn’t just diagnose patients as having the disorder; he also advertises himself as someone who specializes in B.P.D. The market demands it, he says. You need to be known for knowing something, and people presumably look up therapists proficient with existing DSM labels. “Even as I was discovering that being borderline was not so ‘special,’ that it was common and somehow related to the human condition, including my own, I wanted people to see me as an expert,” he reflects. Despite his exceptional resistance to the DSM, Kriss, like his patients, finds himself inhabiting its categories.
If the existing taxonomy is such a mess, what would a better diagnostic system look like? In 2015, following the disappointment that greeted the release of the DSM-5, three psychologists formed a consortium to build one. Two of them, David Watson and Robert Krueger, had been involved in the revision of the DSM; a third, Roman Kotov, was a young researcher who sensed that the profession would be grateful for a different system. Two years later, they and thirty-seven other researchers, including Steven Hyman, the former N.I.M.H. director, published a proposal for a new approach to classifying mental illness. They called it the Hierarchical Taxonomy of Psychopathology, or HiTOP.
The taxonomy sets aside existing diagnoses and starts by asking what goes with what. Symptoms and traits that occur together constitute syndromes, and so on, up the hierarchy, giving rise to “subfactors,” “spectra,” and “super-spectra.” Everything is measured continuously; the taxonomy consists of dimensions rather than categories. The result is a provisional scheme of up to six spectra, including “internalizing,” which covers symptoms of anxiety and depression; “externalizing,” which splits into disinhibition and antagonism; and “thought disorder,” which encompasses psychotic and some bipolar symptoms.
The creators of HiTOP claim that it overcomes some of the biggest issues of the DSM: It embraces continua rather than black-and-white entities; it avoids the wild heterogeneity of some disorders; it results in fewer patients like Gagne, who experience dysfunction yet struggle to meet the criteria for any disorder. They also say that it fits better with findings from the fields of genetics and neuroscience. HiTOP has garnered an enormous amount of excitement. In just seven years, the article presenting the system has been cited nearly three thousand times. The consortium, meanwhile, has expanded more than fourfold.
As the hype has grown, so has criticism. Detractors argue that a taxonomy designed using superficial commonalities is still a long way from mapping the nature of psychopathology. They also point out that HiTOP draws partly from self-reports of symptoms, which can be unreliable, and suggest that, whatever its lofty claims, it has replaced one set of abstractions with another.
Yet there’s a broader issue here. People’s symptoms frequently evolve according to the labels they’ve been given. Following Layle’s visit to the psychiatrist, her mother observed, “You’ve been acting more and more autistic since we got the diagnosis.” Layle took the comment as a sign that her mom didn’t understand her—“I hate it when someone thinks I’m a liar,” she writes—but people everywhere encounter models of illness that they unconsciously embody. Some instances are subtle; others are dramatic and startling. In 2006, a student at a Mexican boarding school developed devastating leg pain and had trouble walking; soon hundreds of classmates were afflicted. A fifteenth-century German nun started biting her companions; eventually, the strange hysteria infected convents from Holland to Italy. Ian Hacking, the philosopher, argued that such a dynamic fuelled the epidemic of multiple personality disorder in the late twentieth century, and something similar seems to be playing out now with the growing portrayal of dissociative identity disorder, the current name for M.P.D., on social media. One of Kriss’s patients, a student who went by Haku, developed a multiplicity of selves after being introduced to the concept of dissociative identity disorder. “It’s not that I thought he was faking it,” Kriss recalls. “It seemed more that Haku wanted to have multiple personalities, even if that meant he had to force himself and others to believe in it.”
Any new psychiatric taxonomy develops in the shadow of the old. It must contend with the echoes of the previous scheme, with people whose selves have been cast in the shape of their former classification. By failing to take these into account, models such as HiTOP risk re-creating the categories of their predecessors. Psychiatric diagnosis, wrapped in scientific authority and tinged with essentialist undertones, offers a potent script. As Layle wondered after she was told about her autism, “How did I know what was truly me, and what I had convinced myself I was?” ♦
An earlier version of this article failed to make clear that Patric Gagne completed her dissertation and received her doctoral degree.
