The Passing of Robert Spitzer
Architect of the DSM
Posted Dec 28, 2015
Bob Spitzer just passed away at age 83 in Seattle, where he had recently moved with his wife Janet Williams. He was the architect of DSM-3, the revolutionary reclassification of psychiatric illnesses, that turned a page for psychiatry.
The first two editions of DSM, in 1952 and 1968, were thin little things that pretty well reflected the conventional psychoanalytic wisdom of the day. They had no international impact and were not terribly influential at home because in the 1950s and -60s Freud’s psychoanalysis was in the saddle and the psychoanalysts were not very interested in diagnosis. In fact, they had one diagnosis – psychoneurosis – and it could take on depressive, hysterical, or phobic forms but psychoanalytic treatment was a remedy for all of them and the exact form was of no great importance.
The drug revolution in psychiatry changed all that. For the first time in decades it became important to have a precise diagnosis because the new panoply of psychopharm had differential effectiveness: Valium did not work for psychosis.
In 1974 the American Psychiatric Association asked Spitzer to take charge of editing a new edition of the DSM, not because the APA recognized any of this but because they wanted the domestic US manual to keep pace with the international manual of disease classification, the ICD, that the World Health Organization published. (On these events, see Edward Shorter, “The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders,” Dialogues in Clinical Neuroscience 17 (1) (March 2015): 59–68).
Yet when Spitzer took command of the Task Force to revise the DSM, he had something entirely different in mind than just fiddling with semicolons. He wanted to recast completely the entire DSM, which is to say, the entire classification of diseases. And he had the kind of driving, authoritarian, manipulative personality that let him take charge of the Task Force and bend it to his will. The DSM-3 that emerged in 1980 was very much Spitzer’s baby. The Task Force members were largely window dressing, at least for the main diagnoses.
So estimating Spitzer’s place in history is largely a matter of assessing the impact of the DSM-3, and the revised version, DSM-3-R, which he edited as well, that appeared in 1987.
Was the DSM-3 good or bad? This is the question the obituarists will be battling over, as indeed the entire field of psychiatry has been battling for the last three decades. I want to make two brief points.
One, DSM-3 initiated the exit of psychoanalysis from American psychiatry. Although Spitzer had successfully completed psychoanalytic training, he hated psychoanalysis and was determined to eradicate its influence upon conceptions of illness. So all of the cherished psychoanalytic diagnoses were thrown out: hysteria, psychoneurosis, depressive neurosis. All were toast.
The analysts were furious about DSM-3 and tried to block it, but such was the dissatisfaction with psychoanalysis within the APA that they failed. The field was embracing drugs, and Freud’s wisdom was starting to seem like astrology.
So this was positive: Spitzer initiated the destruction of psychoanalysis, and opened the way for psychiatry to rejoin the rest of medicine as a proper medical specialty and no longer be considered as some kind of wacky branch of social work.
Point two, DSM-3 itself has had a devastating effect upon psychiatric diagnosis. To be sure, it broke with Freud, but what the DSM-3-ers put in its place was a tottery pile of artifacts and half-entities. Spitzer personally created “major depression,” and ended psychiatry’s long tradition of having two depressions: one serious melancholia, the other a less serious catch-all of complaints that used to be called “nerves.”
Spitzer solidified the tradition, begun by German psychiatrist Karl Leonhard in 1957, of treating manic-depressive illness as entirely different from unipolar depression (in DSM-3 “major depression”). It made little sense to classify depressive illnesses on the basis of polarity, but Spitzer was not really a clinician, and did not have the gut sense of a senior psychiatrist that mania, unipolar depression, and bipolar depression were all pretty well smushed together in the same ball of wax.
But you know what? Spitzer didn’t really care about the science here. What he cared about was the politics. He did not want any single group to be offended or left out of the action. The Viet-Nam vets want PTSD? Hey, we’ll give it to them and shut them up. The parents want attention deficit disorder as a way of explaining their unruly offspring? Hey, we’ll give it to them as ADD, later ADHD.
Finally, he pieced off even the psychoanalysts, by inventing something called “dysthymia,” supposedly a chronic form of depression, and then putting “depressive neurosis” next to it in parentheses.
So, thirty years later, we’re stuck with the topsy-turvy structure of diagnoses that Spitzer created. Anxiety disorders? Too numerous to mention. Schizophrenia? We’ll make it one disease, one-size-fits-all. The scientific basis for most of this crooked castle is minimal to non-existent. But the drug companies have latched onto these new diagnoses and have milked billions of dollars in profit from them.
But patient care has not benefited from the legacy of Robert Spitzer.
All the diagnoses respond to the same treatments. Patients easily flip from one “disorder” to another, or end up with three or four diagnoses at the same time (on the grounds that these disorders may be “co-morbid,” or occur simultaneously). This would never happen in a serious specialty such as internal medicine.
In retrospect, Bob Spitzer played the same role in psychiatry as Jean-Martin Charcot did a century earlier. Charcot, a senior neurologist in Paris, sent the field chasing after “hysteria.” Spitzer sent psychiatry in the late twentieth century chasing after similar phantoms. Subsequent generations will not be grateful to him.
When Max Fink and I interviewed him several years ago, we asked, “In light of subsequent criticisms, is there anything you would change about DSM-3?”
“Nothing,” he replied.
He had no insight into the chaos he had brought about.