This article casts a critical eye over the development of American psychiatry from 1980 to the present. It notes the rapid decline of psychoanalysis that followed the publication of DSM III; the rising influence of genetics and neuroscience; the re-emphasis on the biology of mental illness; and the collapse of public psychiatry that accompanied deinstitutionalization. It argues that while genetics and neuroscience have made scientific progress, the clinical utility of their findings to date has been very limited. The fifth edition of the DSM was supposed to base itself on this new science but that proved impossible. Diagnosis remains purely phenomenological and controversial. One of the ironies of research on psychiatric genetics is that has failed to find either a Mendelian origin of schizophrenia and depression or to validate the importance of hypothesized candidate genes. Genome-wide association studies have instead uncovered risk factors for major mental illnesses, but these overlap considerably, and the genetic associations are not dispositive. Most of those who carry these genetic variants do not develop mental illness. The status of psychopharmacology since the mid-1950s is scrutinized, as is the influence of the pharmaceutical industry on contemporary psychiatry, and the implications of its recent decision to abandon work in this arena. The paper concludes with an assessment of the crisis that it contends confronts contemporary American psychiatry: its overemphasis on biology; the urgent questions that persist about diagnosis and therapeutics; concerns about the directions of future research; and its inability to reduce the excess mortality that plagues the mentally ill.

While the changes in psychiatric diagnosis introduced by Diagnostic and Statistical Manual third edition (DSM-III) have had major benefits to the field of psychiatry, the reification of its diagnostic criteria and the widespread adoption of diagnostic literalism have been problematic. I argue that, at root, these developments can be best understood by contrasting two approaches to the relationship between DSM disorders and their criteria. In a constitutive relationship, criteria definitively define the disorder. Having a disorder is nothing more than meeting the criteria. In an indexical relationship, the criteria are fallible indices of a disorder understood as a hypothetical, tentative diagnostic construct. I trace the origins of the constitutive model to the philosophical theory of operationalism. I then examine a range of historical and empirical results that favor the indexical over the constitutive position including (i) evidence that individual criteria for DSM-III were selected from a broader pool of possible symptoms/signs, (ii) revisions of DSM have implicitly assumed an indexical criteria-disorder relationship, (iii) the indexical position allows DSM criteria to be wrong and misdiagnose patients while such a result is incoherent for a constitutive model, an implausible position, (iv) we assume an indexical criteria-scale relationships for many personality and symptom measures commonly used in psychiatric practice and research, and (v) empirical studies suggesting similar performance for DSM and non-DSM symptoms for major depression. I then review four reasons for the rise of the constitutive position: (i) the ‘official’ nature of the DSM criteria, (ii) the strong investment psychiatry has had in the DSM manual and its widespread use and success, iii) lack of a clear pathophysiology for our disorders, and (iv) the absence of informative diagnostic signs of minimal clinical importance. I conclude that the constitutive position is premature and reflects a conceptual error. It assumes a definitiveness and a literalism about the nature of our criteria that is far beyond our current knowledge. The indexical position with its tentativeness and modesty accurately reflects the current state of our field.

We used structural equation modeling to test the hypothesis that a General Factor of Personality (GFP) occupies the apex of the hierarchy of personality disorders in three validation samples of the Dimensional Assessment of Personality Pathology — Basic Questionnaire (DAPP-BQ). In a general population sample (N = 942), we found a GFP explained 34% of the variance in four first-order factors and 33% of the variance in all 18 scales. In a twin sample (N = 1,346), a GFP explained 35% of the variance in four first-order factors and 34% of the variance in all 18 scales. In a clinical sample (N = 656), a GFP explained 34% of the variance in four first-order factors and 30% of the variance in all 18 scales.