In Sarah Fay’s harrowing medical memoir, diagnosis is revealed to be particularly perverse: it simultaneously offers vital access to treatment and care but also becomes a “self-fulfilling prophecy” that cruelly entraps and reduces lives to diagnostic categories. Having been diagnosed with six separate conditions (anorexia, major depressive disorder, anxiety disorder, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and bipolar disorder), each constructed and pathologized differently by psychiatry’s “bible,” the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fay exposes the way that this “bible” is in fact a messy “work of culture,” despite how medical professionals and scientists depend on its diagnostic authority. The DSM, in Pathological, is thus really a provisional collation of fictions, full of “misdiagnoses because all DSM diagnoses are misdiagnoses—i.e. incorrect, inaccurate, inadequate” that have profound, life-altering effects on those who become pathologized by it. Through intimate accounts of her lived experience shaped by diagnosis both within and beyond the clinical space, Fay unpacks the DSM’s not-so-implicit sociocultural biases and nosological instabilities that often fail to serve those most vulnerably in search of a narrative that explains their experience of illness. Fay writes unflinchingly about the DSM’s “open secret”: it fails and continues to fail while obscuring its own history of repeated failures. Patients ultimately bear the consequences.
Fay’s crucial intervention in Pathological is the revelation that the DSM paradoxically depends on a certainty that it simply cannot justify. This certainty and diagnostic authority are as much a series of constructions as the diagnostic categories themselves, where the latter are constantly undergoing revision, often in relation to cultural debates taking place well beyond medicine (take, for example, the removal of homosexuality from the DSM in 1973). Diagnosis becomes for many medical professionals a kind of shorthand—a more efficient way of rendering a patient knowable by medicine and therefore subject to its interventions, even if both the diagnosis and the treatment remain theoretical and fundamentally uncertain. As Lennard Davis notes of diagnosis’s etymology,
Dia means both ‘through’ or ‘thoroughly.’ Those rather different meanings point to a profound ambivalence in the concept of diagnosis. If you gain knowledge ‘through’ something, is the knowledge gained of the subject or the object? If the object is the means through which you know, then is the knowledge of the subject or the object? What makes the knowledge ‘thorough’ in that case? Gnosis, as knowledge, implies the certainty of religious knowledge, and its adjective, gnostic, is opposed to the doubtful—that is to say, full of doubt—knowledge of the agnostic.
While diagnostic “knowing” is often framed as the most certain form of knowing, it is, by nature, subject to error and misrecognition because it remains contingent upon the conditions of diagnosis and those participating in that diagnostic process. Throughout so many scenes of Fay’s encounters with physicians and psychiatrists, we witness just how fraught those conditions of diagnosis are. In terms of differences in identity, power and expertise, “thoroughness” is impossible, if not actually avoided because of the inevitable conflicts that would arise. So much of the diagnostic “reading” of a patient is ultimately a matter of presupposition based more on faith than fact (or rather, faith veiled as fact), which Fay describes in its intense violence and sometimes comedic absurdity. If the DSM is “designed to diagnose as many people as possible,” the diagnostic act seems less about knowledge-making that it is about repeating the reductive act of diagnosis over and over and therefore affirming medicine’s claim of certain knowing in the first place. Chart after chart, script after script, pill after pill.
Fay’s memoir movingly works through the politics of refusal: of recognizing how agency is consistently taken away from people even before they become patients and that it can be reclaimed through a fuller awareness of the demands that underpin diagnosis. She makes clear that she is not advocating for a complete rejection of psychiatry or the “Mental Health Medical Industrial Complex” that has come to define contemporary medical experience. Rather, she calls for a more deliberate skepticism—not one that refuses science but demands more from science and medicine as a set of institutions, practitioners, and stakeholders: transparency, accountability, advocacy. This measured, realistic approach recognizes the limits of a more radical departure from psychiatry, which still remains the primary way that many people access care. Pause, Fay implores us, because the DSM and its devotees depend on its reductionism and explanatory convenience that in turn result in devastating struggles for those made to believe they have found salvation in diagnosis.