Monday, October 12, 2009

Spitzer and the DSM - Part IV

In Part I, I introduced Robert Spitzer, architect of the ground-breaking DSM-III of 1980 and what psychiatry was like when Freud ruled the roost. Part II described the Spitzer's triumph in unseating Freud, and Part III recounted Dr Spitzer's boorish behavior at the dinner table at the 2003 APA in San Francisco. To pick up where I left off ...

Yet when I surveyed all that my hands had done
and what I had toiled to achieve,
everything was meaningless, a chasing after the wind;
nothing was gained under the sun.

- Ecclesiastes 2:11

Nearly two years later, the Spiegel profile in The New Yorker gave me an insight into Dr Spitzer’s table manners. According to the piece:

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?’ ”

Then, following the runaway success of the DSM, things apparently went to his head. According to the New Yorker, “emboldened by his success, he became still more adamant about his opinions, and made enemies of a variety of groups.”

And again:

“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-III-R 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.”

This sense of ownership cost Spitzer his chance to head up the DSM-IV. The new chair, Allen Frances MD of Duke University, put his committees on notice to cut back on “the wild growth and casual addition” of new mental disorders. In a piece published in the June 29, 2009 Psychiatric Times, Dr Frances appeared to be bragging about how little the DSM-IV task force actually accomplished:

“In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III ...”

This is one hell of an admission. Basically, Dr Frances is telling us that the diagnostic psychiatry of 2009 is based on a book that was published in 1980, back when psychiatric science virtually didn’t exist.

It is speculative to ponder on the “what-if’s,” but that’s my job. So, suppose Dr Spitzer hadn’t fallen in love with his 1980 opus. Suppose he possessed some rudimentary people skills. Suppose he had been able to combine his innovative brilliance with a sufficiently level head to guide the DSM into its next critical phases - to fill in the blanks from the earlier editions, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight.

Imagine, in effect, if you could pick up a current DSM right now and open the pages to an accurate description of your clinical reality. That book doesn’t exist. The DSM-IV is a dinosaur, and any clinician who relies on it as an authority is endangering his patients.

Things could have been a lot different. But the man who - through his superhuman efforts - unseated that twentieth-century icon Freud, through his own mortal foibles, wound up unseating himself. His personal disappointment turned out to be our huge loss.

To be continued ...


Loretta said...

Great history lesson, John.

John McManamy said...

Thanks, Loretta. I think someone once said you can only understand the present if you understand history. Anyway, I'm saying it now. :)