Monday, October 5, 2009

Robert Spitzer and the DSM - Part I

Psychiatrists appreciate a free meal as much as I do, which may explain why dinner symposia sponsored by various pharmaceutical companies used to the most popular events at APA annual meetings. I cannot recall what the topic was at this particular symposium at the 2003 APA in San Francisco, nor who the speakers were, but I can never forget who grabbed the empty seat next to me. “Robert Spitzer,” read his name tag.

Robert Spitzer (pictured here) is by far the most influential psychiatrist you never heard of, the man responsible for the ground-breaking DSM-III (diagnostic Bible) of 1980. It was Robert Spitzer who banged the final nail into Freud’s coffin and led psychiatry into the modern era. Until then, believe it or not, psychiatry had no practical system for distinguishing anxiety from depression, from bipolar disorder, from schizophrenia, from people who are assholes.

The first DSM, from 1952, naively attempted to separate out conditions with an obvious biological basis (such as “acute brain syndrome associated with intracranial infection”) from those for which it assumed came from a maladaptation of the individual to his or her environment. This later category included schizophrenia, which it labeled as “schizophrenic reaction.”

According to the DSM-I, these reactions (psychotic, neurotic, behavioral) “are as much determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations as by the precipitating organic impairment.”

Under this way of looking at behavior, symptoms were less important than whatever psychosis, neurosis, or behavioral quirk was supposed to be lurking beneath the surface. Indeed, only a token effort was made to differentiate the likes of “schizophrenic reaction” from “manic-depressive reaction,” both which were seen as “psychotic disorders.”

Psychosis was Freud’s prognosis for hopeless. Psychiatry virtually turned its back on these individuals, but not before blaming them and their parents for failing to adjust.

Depression, in the meantime, was viewed as part of “manic-depressive reaction, depressive type” or a “depressive reaction” under the heading of “psychoneurotic disorders.” Neurosis was the Freudian grand organizing principle to explain the walking wounded, viewed as psychiatry’s meal ticket. According to the DSM-I, “anxiety” was the driving force of neurosis, which may “be directly felt or expressed” or be “unconsciously and automatically controlled” by various defense mechanisms, such as depression.

That’s right. Depression was a “reaction” to anxiety, er, neurosis.

We’re not done. Depression could also be viewed as an expression of personality, as in “cyclothymic personality disorder.” The DSM-I saw personality disorders as a “lifelong pattern of action or behavior” rather than “mental or emotional symptoms.” These individuals were not exactly hopeless write-offs, but any psychiatrist who took them on as patients was regarded as a “hero.”

In the final analysis, none of this mattered. Whether written off as hopeless or viewed as a meal ticket, for all practical purposes the only effective treatment of the day was time. The only catch was that the time cure typically took years to accomplish.

The DSM-II of 1968 was largely a rerun of the DSM-I. Its biggest change was upgrading schizophrenia and manic-depression from adjectives modifying “reaction” to full-blown nouns. At this rate, psychiatry was ready to be dragged kicking and screaming into the twentieth century by the year 3014.

But even then, reform was in the air. By now, the first generation of psychiatric meds was on the market, along with new forms of talking therapy. Clinicians needed a rough guide to work with, along with a practical means of communicating with other clinicians and interested parties.

In the meantime, psychiatry was being subjected to attack from a variety of fronts, including a strong antipsychiatry/civil liberties movement rebelling against forced institutionalization and other abuses, an insurance industry questioning spending good money on unproven long-term talking therapies, and reform-minded psychiatrists fed up with the anti-science mindset of Freud’s followers.

On top of that, institutions were being emptied out. People with serious mental illness were suddenly on the streets. Psychiatry could either get involved or choose to keep milking its rich neurotic clientele, a business it was rapidly losing to budget-conscious psychologists and social workers.

In 1974, Robert Spitzer of Columbia University drew the assignment of overseeing the DSM-III, with the ostensibly narrow brief of harmonizing the DSM with international standards, but little did they know ...

Now, here he was seated next to me, and here I was looking up from my salad trying to think of something to say.

To be continued ...


Michelle Routhieaux said...

What?! You leave me there?! (sigh) John, I am not disciplined enough to actually come BACK to find out the rest of the story! Lol. Great story so far though. :)

John McManamy said...

Hey, Michelle. I need time to make up what's gonna happen next. :)