the man who turned the DSM into a psychiatric bible
This article was first published as The Dictionary of Disorder in the January 3, 2005 issue of The New Yorker Magazine. It is reprinted here in abridged form with kind permission from the author. If you prefer, you can read the original, full-length article.
In the mid-nineteen-forties, Robert Spitzer, a mathematically minded boy of fifteen, began weekly sessions of Reichian psychotherapy. Wilhelm Reich was an Austrian psychoanalyst and a student of Sigmund Freud who, among other things, had marketed a device that he called the orgone accumulator — an iron appliance, the size of a telephone booth, that he claimed could both enhance sexual powers and cure cancer. Spitzer had asked his parents for permission to try Reichian analysis, but his parents had refused — they thought it was a sham — and so he decided to go to the sessions in secret. He paid five dollars a week to a therapist on the Lower East Side of Manhattan, a young man willing to talk frankly about the single most compelling issue Spitzer had yet encountered: women. It was this experience that confirmed what would become his guiding principle: the best way to master the wilderness of emotion was through systematic study and analysis.
Robert Spitzer isn’t widely known outside the field of mental health, but he is, without question, one of the most influential psychiatrists of the twentieth century. It was Spitzer who took the Diagnostic and Statistical Manual of Mental Disorders — the official listing of all mental diseases recognized by the American Psychiatric Association (APA) — and established it as a scientific instrument of enormous power. Because insurance companies now require a DSM diagnosis for reimbursement, the manual is mandatory for any mental-health professional seeking compensation. It’s also used by the court system to help determine insanity, by social-services agencies, schools, prisons, and governments. This magnitude of cultural authority, however, is a relatively recent phenomenon. Although the DSM was first published in 1952 and a second edition (DSM-II) came out in 1968, early versions of the document were largely ignored. Spitzer began work on the third version (DSM-III) in 1974, when the manual was a spiral-bound paperback of a hundred and fifty pages. It provided cursory descriptions of about a hundred mental disorders, and was sold primarily to large state mental institutions, for three dollars and fifty cents. Under Spitzer’s direction — which lasted through the DSM-III, published in 1980, and the DSM-IIIR (“R” for “revision”), published in 1987 — both the girth of the DSM and its stature substantially increased. It is now nine hundred pages, defines close to three hundred mental illnesses, and sells hundreds of thousands of copies, at eighty-three dollars each. But a mere description of the physical evolution of the DSM doesn’t fully capture what Spitzer was able to accomplish. In the course of defining more than a hundred mental diseases, he not only revolutionized the practice of psychiatry but also gave people all over the United States a new language with which to interpret their daily experiences and tame the anarchy of their emotional lives.
Spitzer [now in his seventies] had a brilliant medical-school career, publishing in professional journals a series of well-received papers about childhood schizophrenia and reading disabilities. He had also established himself by helping to discredit his erstwhile hero Reich. In addition to his weekly sessions on the Lower East Side, the teen-age Spitzer had persuaded another Reichian doctor to give him free access to an orgone accumulator, and he spent many hours sitting hopefully on the booth’s tiny stool, absorbing healing orgone energy, to no obvious avail. In time, he became disillusioned, and in college he wrote a paper critical of the therapy, which was consulted by the Food and Drug Administration when they later prosecuted Reich for fraud.
As Spitzer struggled to find his professional footing in the nineteen-sixties, the still young field of psychiatry was also in crisis. The central issue involved the problem of diagnosis: psychiatrists couldn’t seem to agree on who was sick and what ailed them. A patient identified as a textbook hysteric by one psychiatrist might easily be classified as a hypochondriac depressive by another. Blame for this discrepancy was assigned to the DSM. Critics claimed that the manual lacked what in the world of science is known as “reliability” — the ability to produce a consistent, replicable result — and therefore also lacked scientific validity. In order for any diagnostic instrument to be considered useful, it must have both.
Spitzer had no particular interest in psychiatric diagnosis, but in 1966 he happened to share a lunch table in the Columbia cafeteria with the chairman of the DSM-II task force. The two struck up a conversation, got along well, and by the end of the meal Spitzer had been offered the job of note-taker on the DSM-II committee. He accepted it, and served ably. He was soon promoted, and when gay activists began to protest the designation of homosexuality as a pathology Spitzer brokered a compromise that eventually resulted in the removal of homosexuality from the DSM. Given the acrimony surrounding the subject, this was an impressive feat of nosological diplomacy, and in the early seventies, when another revision of the DSM came due, Spitzer was asked to be the chairman of the task force.
Given unlimited administrative control, he established twenty-five committees whose task it would be to come up with detailed descriptions of mental disorders, and selected a group of psychiatrists who saw themselves primarily as scientists to sit on those committees. These men and women came to be known in the halls of Columbia as dops, for “data-oriented people.” They were deeply skeptical of psychiatry’s unquestioning embrace of Freud. “Rather than just appealing to authority, the authority of Freud, the appeal was: Are there studies? What evidence is there?” Spitzer says. “The people I appointed had all made a commitment to be guided by data.” Like Spitzer, Jean Endicott, one of the original members of the DSM-III task force, felt frustrated with the rigid dogmatism of psychoanalysis. She says, “For us dops, it was like, Come on — let’s get out of the nineteenth century! Let’s move into the twentieth, maybe the twenty-first, and apply what we’ve learned.”
There was just one problem with this utopian vision of better psychiatry through science: the “science” hadn’t yet been done. “There was very little systematic research, and much of the research that existed was really a hodgepodge — scattered, inconsistent, and ambiguous,” Theodore Millon, one of the members of the DSM-III task force, says. “I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.” Members of the various committees would regularly meet and attempt to come up with more specific and comprehensive descriptions of mental disorders. David Shaffer, a British psychiatrist who worked on the DSM-III and the DSM-IIIR, told me that the sessions were often chaotic. “There would be these meetings of the so-called experts or advisers, and people would be standing and sitting and moving around,” he said. “People would talk on top of each other. But Bob would be too busy typing notes to chair the meeting in an orderly way.” One participant said that the haphazardness of the meetings he attended could be “disquieting.” He went on, “Suddenly, these things would happen and there didn’t seem to be much basis for it except that someone just decided all of a sudden to run with it.” Allen Frances agrees that the loudest voices usually won out. Both he and Shaffer say, however, that the process designed by Spitzer was generally sound. “There was not another way of doing it, no extensive literature that one could turn to,” Frances says. According to him, after the meetings Spitzer would retreat to his office to make sense of the information he’d collected. “The way it worked was that after a period of erosion, with different opinions being condensed in his mind, a list of criteria would come up,” Frances says. “It would usually be some combination of the accepted wisdom of the group, as interpreted by Bob, with a little added weight to the people he respected most, and a little bit to whoever got there last.”
Because there are very few records of the process, it’s hard to pin down exactly how Spitzer and his staff determined which mental disorders to include in the new manual and which to reject. Spitzer seems to have made many of the final decisions with minimal consultation. “He must have had some internal criteria,” Shaffer says. “But I don’t always know what they were.” One afternoon in his office at Columbia, I asked Spitzer what factors would lead him to add a new disease. “How logical it was,” he said, vaguely. “Whether it fit in. The main thing was that it had to make sense. It had to be logical.” He went on, “For most of the categories, it was just the best thinking of people who seemed to have expertise in the area.”
Not every mental disorder made the final cut. For instance, a group of child psychiatrists aspired to introduce a category they called “atypical child” — an idea that, according to Spitzer, didn’t survive the first meeting. “I kept saying, ‘O.K., how would you define “atypical child”?’ And the answer was ‘Well, it’s very difficult to define, because these kids are all very different.’” As a general rule, though, Spitzer was more interested in including mental disorders than in excluding them. “Bob never met a new diagnosis that he didn’t at least get interested in,” Frances says. “Anything, however against his own leanings that might be, was a new thing to play with, a new toy.” In 1974, Roger Peele and Paul Luisada, psychiatrists at St. Elizabeths Hospital, in Washington, D.C., wrote a paper in which they used the term “hysterical psychoses” to describe the behavior of two kinds of patients they had observed: those who suffered from extremely short episodes of delusion and hallucination after a major traumatic event, and those who felt compelled to show up in an emergency room even though they had no genuine physical or psychological problems. Spitzer read the paper and asked Peele and Luisada if he could come to Washington to meet them. During a forty-minute conversation, the three decided that “hysterical psychoses” should really be divided into two disorders. Short episodes of delusion and hallucination would be labelled “brief reactive psychosis,” and the tendency to show up in an emergency room without authentic cause would be called “factitious disorder.” “Then Bob asked for a typewriter,” Peele says. To Peele’s surprise, Spitzer drafted the definitions on the spot. “He banged out criteria sets for factitious disorder and for brief reactive psychosis, and it struck me that this was a productive fellow! He comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders!” Both factitious disorder and brief reactive psychosis were included in the DSM-III with only minor adjustments.
Spitzer labored over the DSM-III for six years, often working seventy or eighty hours a week. “He’s kind of an idiot savant of diagnosis — in a good sense, in the sense that he never tires of it,” Allen Frances says. John Talbott, a former president of the American Psychiatric Association, who has been friends with Spitzer for years, says, “I remember the first time I saw him walk into a breakfast at an A.P.A. meeting in a jogging suit, sweating, and having exercised. I was taken aback. The idea that I saw Bob Spitzer away from his suit and computer was mind-shattering.” But Spitzer’s dedication didn’t always endear him to the people he worked with. “He was famous for walking down a crowded hallway and not looking left or right or saying anything to anyone,” one colleague recalled. “He would never say hello. You could stand right next to him and be talking to him and he wouldn’t even hear you. He didn’t seem to recognize that anyone was there.”
Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’” After years of confrontations, Spitzer is now aware of this shortcoming, and says that he struggles with it in his everyday life. “I find it very hard to give presents,” he says. “I never know what to give. A lot of people, they can see something and say, ‘Oh, that person would like that.’ But that just doesn’t happen to me. It’s not that I’m stingy. I’m just not able to project what they would like.” Frances argues that Spitzer’s emotional myopia has benefitted him in his chosen career: “He doesn’t understand people’s emotions. He knows he doesn’t. But that’s actually helpful in labelling symptoms. It provides less noise.”
The DSM was scheduled to be published in 1980, which meant that Spitzer had to have a draft prepared in the spring of 1979. Like any major American Psychiatric Association initiative, the DSM had to be ratified by the assembly of the A.P.A., a decision-making body composed of elected officials from all over the country. Spitzer’s anti-Freudian ideas had caused resentment throughout the production process, and, as the date of the assembly approached, the opposition gathered strength and narrowed its focus to a single, crucial word — “neurosis” — which Spitzer wanted stricken from the DSM.
When word of Spitzer’s intention to eliminate “neurosis” from the DSM got out, Donald Klein says, “people were aghast. ‘Neurosis’ was the bread-and-butter term of psychiatry, and people thought that we were calling into question their livelihood.” Psychoanalysts bitterly denounced the early drafts. Without the support of the psychoanalysts, it was possible that the DSM-III wouldn’t pass the assembly and the entire project would come to nothing. The A.P.A. leadership got involved, instructing Spitzer and the dops to include psychoanalysts in their deliberations. After months of acrimonious debate, Spitzer and the psychoanalysts were able to reach a compromise: the word “neurosis” was retained in discreet parentheses in three or four key categories.
“A lot of what’s in the DSM represents what Bob thinks is right,” Michael First, a psychiatrist at Columbia who worked on both the DSM-IIIR and DSM-IV, says. “He really saw this as his book, and if he thought it was right he would push very hard to get it in that way.” Thus, despite the success of Spitzer’s two editions, and despite extensive lobbying on his part, the American Psychiatric Association gave the chairmanship of the DSM-IV task force to Allen Frances. “The American Psychiatric Association decided that they had had enough of Spitzer, and I can understand that,” Spitzer says with a note of regret in his voice. “I think that there was a feeling that if the DSM was going to represent the entire profession — which obviously it has to — it would be good to have someone else.” This certainly was part of the reason. But Spitzer’s colleagues believe that the single-mindedness with which he transformed the DSM also contributed to his eclipse. “I think that Spitzer looked better in III than he did in IIIR,” Peele says. “IIIR, for one reason or another, came across as more heavy-handed — ‘Spitzer wants it this way!’”
During one of our conversations, I asked Spitzer if he ever feels a sense of ownership when troubled friends speak to him of their new diagnoses, or perhaps when he comes across a newspaper account that features one of the disorders to which he gave so much of his life. He admitted that he does on occasion feel a small surge of pride. “My fingers were on the typewriter that typed those. They might have been changed somewhat, but they all went through my fingers,” he said. “Every word.”