Saturday, October 10, 2009

Robert Spitzer and the DSM - Part III

In Part I, I talked about finding myself at a dinner table at a symposium at the 2003 APA annual meeting with Robert Spitzer, who masterminded the ground-breaking DSM-III of 1980. Part II touched on the history of the conflict between diagnostic and Freudian psychiatry, and the triumph of Spitzer’s DSM-III. To continue ...

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. And here I was looking up from my salad trying to think of something to say.

Out of deference, I waited for the psychiatrists at the table to open the conversation. I would just be a fly on the wall. But no one spoke. Silence. Just the clinking of glasses and the rattling of plates. I always knew psychiatrists were a bit weird, but this was ridiculous.

I introduced myself to Dr Spitzer as a bipolar patient who was at this particular conference as a journalist. These days, I simply introduce myself as a journalist. Back then, I over-identified with being an entry in Spitzer’s diagnostic schema.

Let’s put it this way, if you are in a constant life-and-death struggle with testicular cancer you are understandably thinking about it every second of your life. But then comes a time when you need to forget that you have one testicle and start focusing on your own personal Tour de Life.

But, yes, I still wear a yellow and blue DBSA rubber wristband, not unlike the yellow cancer band that Lance Armstrong made famous.

Anyway, I had a few thoughts of my own about the DSM, I told Dr Spitzer. Would he be interested in hearing them?

This is like telling Einstein that I had a few thoughts about relativity, but Dr Spitzer indicated that I proceed.

What motivated me to ask in the first place was that I naively assumed that the very last person to regard the DSM to be cast in stone would be the person who broke the mold in the first place. Think of Robert Spitzer as the great auto designer Harley Earl, and the DSM-III of 1980 as the 1955 Chevy and the DSM-III-R of 1987 as the 1957 Chevy.

By contrast, the post-Spitzer era - the DSM-IV of 1994 and the DSM IV-TR of 2000 - merely played around with the fins. So now, here we were in a new millennium driving around to the mechanics of a bygone era

Mind you, at the time I lacked the both the standing and the knowledge to challenge Spitzer on this, so I decided to stick to the one aspect of the DSM that I had put some thought into. This concerned the issue of gender and depression. Here, I was on fairly solid ground, as many experts were pushing for changes to the DSM on this matter. My view, and the view of these experts, is that the DSM symptom list is biased toward picking up depression in women while men suffer in silence. According to conventional wisdom, twice as many women experience depression as men. But a bit of tweaking to that symptom list, I argued, could even out that equation.

I waited for the go-ahead, then proceeded down the list. Symptom one is “depressed mood most of the day,” and the unfortunate example is “appears tearful.” Men, by contrast, express themselves in other ways or else fail to express themselves at all. Number three concerns weight gain or loss. Think of what women go to the fridge for when feeling low. Now think of what men reach for. Symptom seven is about worthlessness and guilt, but men tend to lash out and blame others. Last but not least is suicidal thinking. Men fall victim more often than women, but women make far more attempts, and so are more likely to come to the attention of the profession and be treated.

Dr Spitzer pondered my comments, then, as psychiatrists are wont to do, said nothing. By now, the main course had come out. Any further conversation was light and inconsequential. Soon the first of several speakers started talking. It was time to go to work, to take notes.

Two hours later, the last of the speakers wrapped up. Question time was just ahead. Most members of the audience use this brief interval to leave, and so it was that Dr Spitzer got up to make his exit, but not before addressing me.

“I thought about what you said,” he told me, or words to that effect. And then his verdict: “And I don’t go along with any of it.”

Then he rose from his chair and was gone.

Hey, what did I know? He was Robert Spitzer, founder of modern psychiatry. I was just a male bipolar patient who had to deal with depression every day of my life.


Moira said...

Dr. Spitxer behaved like a man with an additional testicle.

I'm glad you were there reporting.

John McManamy said...

Hey, Moira. Definitely so. A very revealing profile in the New Yorker in Jan 2005 sheds light on his behavior. I'll be going into this in my next installment. The short version is that Spitzer is not a "people person," that he is notorious for his insensitive behavior. Following the unprecedented success of the DSM, things went to his head. He became impossible to deal with. So much so that they bumped him off the DSM-IV.

This was a tragedy for him and for us. We needed a brilliant mind and level head to guide the DSM into its next phases, to fill in the blanks, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight. That didn't happen. The DSM-IV is a dinosaur, and any clinician who uses it as a guide is endangering his patients. (Dr Goodwin can give you an earful on this - just ask him about recurrent depression.)

I know the people assigned to the DSM-V are working in good faith, but I suspect they're largely treading water. There is a strong establishment interest in keeping things the same. It would have been good to have a Spitzer to shake things up, but Spitzer made the mistake of falling in love with his earlier achievements and is wedded to the past.

Anyway, glad you're enjoying this, and stay tuned for future installments ...

Lucy Talikwa said...

I am enjoying your series here immensely, both in terms of the historical DSM info and your own mis-adventuring moments. Have looked up the New Yorker article about Dr. S in order to read more about him as you described. Looking forward to your next "take" on all this.

John McManamy said...

Hey, Lucy, Part IV is now up. Enjoy ...

Gledwood said...

Well I go along with it.

Your description of male depression is a portrait of someone I know pretty well. He never gets "depressed" ~ just supremely irritated with the world. As therapy or distraction, he engages in some typically unnecessary but practical project ~ painting the garden shed for example. When he's not in the mood for stuff like that he turns to drink. As do many millions of others!

Those DSM criteria most certainly need to be revised.

I remember being depressed for many months on end and being confounded, whenever I tried to google my condition, by those ******g DSM IV criteria, which are no good self-help-wise for anybody who has been in depression for long enough to lose sight of activities they used to enjoy, the sleep pattern they used to have etc etc. And if you're male, it's very very difficult to keep any track of how large or small your appetite might be, compared to what it was.

Yes the DSM can be very very annoying, not to mention particularly useless as far as self-diagnostics go....

John McManamy said...

Hey, Gledwood. Absolutely!