persists in memory…

Posted on Tuesday 29 December 2015

Robert Spitzer, the author of the DSM-III, died on Christmas Day at age 83. While the commentaries so far praise his removing psychoanalysis from psychiatry, he gets mixed reviews for the system he developed. All agree that he became the most influential psychiatrist of his time.

I’ve never been able to say much about him or his DSM-III without hearing back that my opinion is suspect because I am a psychoanalyst. Unlike the modern KOLs, I wouldn’t argue that it’s not a Conflict of Interest that colors what I think. It definitely does. But I agree that psychoanalysis shouldn’t have been a part of psychiatry or psychiatric diagnosis in the first place. The fact that it became allied with psychiatry in America was neither what Freud wanted, nor what happened in the rest of the world. Parenthetically, psychoanalysis as a non-denominational discipline has actually thrived since the separation from psychiatry. But that’s another story.

At the time of the DSM-III introduction, I thought it read like an academic exercise more focused on itself than the patients it purported to classify. Spitzer wasn’t a clinician, and his DSM-III ablated established categorical clinical distinctions in the service of improving inter-rater reliability, most notably, Melancholic Depression versus depression as a symptom. Presumabely, he also wanted to get rid of depressive neurosis in the process, but that stroke opened the floodgates to the later SSRI/Atypical/TRD craze, and stopped affective disorder research in its tracks for no clear reason.  I personally thought the DSM-III subtracted from rather than added to or improved upon, so I paid it little mind. But within a very short time, psychiatry was undergoing a massive sea change, and there was clearly a push towards pharmaceutical treatment and research along with changes in third party payments. And for some of us, it was a time for a change in employment.

Looking back on those days, I don’t think psychiatry changed just because of Robert Spitzer. Robert Spitzer’s DSM-III was the more public face of a broader effort with strong political and economic undercurrents that transcended the stated scientific agenda. I doubt that Robert Spitzer; or the Medical Director of the APA [Dr. Mel Sabshin]; or those colleagues Spitzer called "the invisible college" [the neoKraepelinians centered at Washington University] had any inkling of the power they were ceding to the pharmaceutical and insurance industries in the process, or how that scenario would play out over the next three decades.

The biggest ringer in the story is what we now call the KOLs, the group of psychiatrists in high places who joined up with PHARMA for personal and institutional gain. I would never have dreamed that would happen. I doubt if Robert Spitzer did either. They’re still there, and without a thorough cleansing, I doubt that there will be any meaningful resolution of anything. You know who they are. Their names are spread throughout the posts on this and many other blogs. Robert Spitzer was as victimized by their antics as the rest of us.

So back to Spitzer’s legacy. Alongside of his depression gaff, there’s another place where I think he deserves to be personally blamed. He kept a lot of what he was doing under his hat, shared only with his confidants. So the DSM-III process was something of a politically maneuvered bloodless coups d’etat orchestrated in concert with an inner circle of the APA. That behind-the-scenes oligarchy has persisted, undermining any sense that the APA represents its membership [better characterized these days as its following]. Whether the stealth and all the palace intrigue was necessary or not [ends justifying the means], it has persisted as a style for 35 years to all of our detriment.

I was in training at the New York Psychiatric Institute during the time when the DSM-III was being framed and I remember him as a boyish, hurried, preoccupied guy darting down the hallway. I didn’t know who he was or what he was up to, but I recognized him from his pictures later when the Manual was published. He was one of those people who catches your attention and persists in memory…
    December 29, 2015 | 10:10 PM

    There are some who thought Mengele brought some wonderful ideas to the medical community. I don’t offer this as an analogy to Spitzer saying he was like a Nazi, but, one needs to look at those who glorify the alleged founder of innovations and progress. A Leader is only as accomplished as his audience applauds and cheers.

    Want a good laugh? Google this guy, Andrew Penn, RN and NP, and his work on using psychedelics to allegedly accelerate psychotherapy. Just read this in this vomitus rag I got in today’s mail called Psych Congress Network.

    Biology run amok. I’ll give the rag some credit, random chance article of some value, “Avoiding Polypharmacy in the treatment of Borderline Personality Disorder” by Eileen Koutnik-Fotopoulos who focused on Victor Hong, MD’s lecture at the 28th Annual US Psychiatric & Mental Health Congres, was on the mark to me.

    Wow, will we see the day the APA somehow tries to give accolades to the Fort Hood shooter? Hey, he was a psychiatrist, and got forbid we say bad things about people of Muslim/Islamic faith. Maybe gunning down patients and colleagues might give way to acute lead therapy for PTSD?!? Sorry, my cynicism and sarcasm has really peaked after my most recent temp job, being off the rest of the week might bring me down a bit!

    You end with “he was one of those people who catches your attention and persists in memory”, well, that can go both ways…

    December 29, 2015 | 11:22 PM

    I see Spitzer as extending the Iowa/St. Louis – Winokur/Guze/Robins/Feighner approach to descriptive psychiatry. I corresponded with him a couple of times and he seemed like a reasonable guy. I think this group was useful in providing an atheoretical framework for psychiatry and see that (along with the fact that observation data disagreed) as the primary reason that neurosis and neurotic depression was dispensed with. This turned one to be one of many problems with a purely atheoretical descriptive approach. I don’t think that means we return to theoretical approaches based on mental constructs or that they are any more accurate. I think it means that it is time to move on to something better and as of yet undiscovered. I think we have Spitzer to thank for exhausting to diagnostic criteria approach to an absurd level.

    I also think we have him to thank for eliminating homosexuality as a diagnostic category.

    I would never had known about this if I was not an avid listener to public radio. It is a side of Spitzer that is missed when we see him inserting another card in a typewriter and asking someone about what the diagnostic criteria for a new disorder should be. And could you imagine the fallout for modern psychiatry if he (and activist colleagues) had not done this 4 decades ago?

    Donald Klein
    December 30, 2015 | 2:12 AM

    Colleagues: Re DSM 111,Bob Spitzer,etc.
    I was a member of the DSM-III Task Force invited by Bob Spitzer. Mickey is entirely correct that we had little anticipation of the future. Neither did the APA which had initially invited Henry Brill to chair that unimportant task force and when he turned it down Bob was one of the few interested.
    To contradict Mickey, members of the Task Force had ample clinical experience. The central problem we faced was the catastrophe in clinical communication shown by repeated demonstrations of gross diagnostic unreliability.
    This was not an academic matter. It meant that when your colleague said that the patient was schizophrenic or depressed or neurotic,you did not have the faintest idea what he was talking about. Well maybe the faintest idea since the neurotics were not psychotic but that was about it. Therefore our focus was on the development of inclusion and exclusion criteria. Each diagnostic chapter started with a balanced discussion of the pros and cons and adjunctive information about this diagnosis. We attempted to make this more concrete by specific listings, mistermed operational, and suggestions concerning cutting points .
    We had no idea that these lists and cutting points would become required residency memorizations .
    There is a trade-off between sensitivity and specificity. A low cutting point meant that more people would fit the diagnosis but it would be less specific. Conversely, a high cutting point would make the diagnosis much more homogeneous but would fit fewer people. To some degree this was a conflict between those who would not deny treatment to any who needed it, despite few clinical manifestations, and those who wanted to make certain that the patient really was likely to have it.
    However DSM-III repeatedly stated that these cutting points were guidelines and not set in concrete, but this was ignored after publication for non-nosological reasons..
    Still ,lacking appropriate outcome data it remains guesswork .
    Many discussions of the DSM lll process have focused on psychopharmacology, insurance, and other social issues. These were far from our central concern, which was to allow clinicians to understand each other.

    Mickey states that the DSM process was unduly secretive. We invited the American Psychological Association and the American Psychoanalytic Association to send representatives who would become members of the task force. The American Psychological Association rejected this and strongly inferred that they would bring out their own diagnostic manual.
    Two psychoanalysts, as I recall Bill Frosch and his father,(maybe wrong) did attend several meetings and made some acute clinical observations. But after a while they stopped attending.
    There was quite a reaction in the well informed APA Assembly when it was reported that the term Neurosis would not be used as a supervening category. Some saw this as evidence of an anti- psychoanalytic plot. Our problem , was that neurosis had psychosis as an exclusionary criterion but the only inclusionary criterion was psychoanalytic theory ,that was far from factually definitive given the mutually contradictory multiple psychoanalytic behavioral and cognitive schools. Spitzer diplomatically included the term Neurosis within parentheses and the supervening term became Anxiety Disorders. “Neurosis” disappeared from succeeding editions, because of disuse atrophy, without controversy.
    Don Klein

    December 30, 2015 | 8:37 AM

    I really appreciate your responding, and giving us the view from within. I well recall the American Psychoanalytic Association’s rigidity and intransigence in those days, and I doubt that anything less than Drs. Sabshin’s and Spitzer’s approach would’ve made a dent. They had little choice. That was obvious to me even as a psychoanalytic candidate. And it wasn’t even the DSM-III that changed their stance. It was the successful suit around the same time by the Psychologists and the resulting court order that got psychoanalysis pointed in a more reasonable direction. Our first non-physician candidate back then, an Anthropologist Scholar [and now retired Dean of the Emory College] was just unanimously elected as Director of our Psychoanalytic Institute.

    I have no complaint about the word “neurosis.” It came with a lot of baggage and implications, and so I understand why another choice might be better. But my complaint when I first read the DSM-III was the merger of the Melancholic [“Endogenous”] Depressions and the much more common symptomatic depressions related to life’s vicissitudes, past and present. The category – “Dysthymia” – didn’t fit, and I don’t know a better term. But in 1980, that looked to me like the error it turned out to be. I think I’m more upset that subsequent editions didn’t correct it when it became apparent that it was being exploited by PHARMA and their allies within psychiatry. It’s still written almost as it was in 1980, thirty-five years later. I share Dr. Shorter’s view in Before Prozac,

    “Bottom Line: Major Depression doesn’t exist in Nature. A political process in psychiatry created it.”

    My speculations about why that “loophole” has persisted are only my speculations, but the problem and its consequences have been very real.

    My comments about secrecy may be misdirected as well. That impression comes from reading the various accounts and Dr. Sabshin’s Changing American Psychiatry. As I understood Dr. Sabshin’s book, he was chosen as medical director to do just that [change American Psychiatry]. Dr. Sabshin wrote:

    “How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate. By the 1970s psychiatry in the United States had begun to undergo massive changes. The postwar glow had been replaced by the new pressures for accountability on all of medicine. Many leaders in psychiatry deplored the ideological rifts that had divided the field, and they called for a more unified, scientifically based profession. They deplored the “demedicalization” of psychiatry and its severe loss of credibility… A new strategy was essential? Producing the DSM-III stated emphatically that psychiatry in America chose an evidence-based practice rather than ideology.

    Operating from the power-base of the APA, he found the means [DSM-III] and the man [Dr. Spitzer]. It’s not that choice that I’m objecting to. I expect there wasn’t an alternative. My complaint is that the APA has continued to direct rather than returning those “emergency powers” to its membership. I’ll forgo examples as they seem self-evident.

    I’m well aware that I have more than a few scars from those days, and try to stay away from them in this blog – but I know that’s not really possible. I feel relatively unconflicted about both the category, Major Depressive Disorder, and my thoughts about the persistent “top-down” structure of the APA since 1980. That’s why I mentioned those two. Robert Spitzer may be only a messenger in those instances. He was certainly a principled person. His stand on homosexuality and his later speaking up about the secretiveness of the DSM-5 Task Force were exemplery.

    Thanks again for your response and clarifications – and for that matter, your many contributions to our field.


    James O'Brien, M.D.
    December 30, 2015 | 11:06 AM

    “There is a trade-off between sensitivity and specificity. A low cutting point meant that more people would fit the diagnosis but it would be less specific. Conversely, a high cutting point would make the diagnosis much more homogeneous but would fit fewer people. To some degree this was a conflict between those who would not deny treatment to any who needed it, despite few clinical manifestations, and those who wanted to make certain that the patient really was likely to have it.”

    In effect, this utilitarian, political and unscientific decision threw construct validity and research under the bus for the hope of insurance reimbursement. I think that was foreseeable at the time, though it was probably not foreseeable that DSM would eventually include all of life’s slings and arrows or that MDD and PTSD would be a fuzzy as they now are.

    “However DSM-III repeatedly stated that these cutting points were guidelines and not set in concrete, but this was ignored after publication for non-nosological reasons.”

    A recent APA President and a fan favorite here (sarc) said in his book that DSM precisely defined mental disorders.

    Dr. Spitzer and Dr. Frances deserve credit for recognizing that the project that they once headed has totally spun out of control in the latest edition. In the end, DSM did little to clear muddy waters of descriptive psychology and in some cases made it worse. In 1980 when clinicians discussed autism, we had a much clearer idea of what we were talking about than we do today. And as Dr. Carroll pointed out, we lost the useful construct of melancholia and now MDD includes what are essentially self-limited mood adjustment disorders.

    (If MDD is the “common cold” of psychiatry, why don’t we call it “common depression” and save “major” for melancholia or active suicidality? Isn’t it a bit histrionic to call every non-life threatening variant major? More importantly, did anyone ever bring this up?)

    Donald Klein
    December 30, 2015 | 11:16 AM

    Re Sabshin
    Many autobiographies take credit for leading social developments when the actual case was quite different. As i pointed out the DSM III Task Force was considered by the APA as unimportant. There was no competition for Chairman and Sabshin appointed Henry Brill MD, a learned man, Director of Research for NY State (I was active at Creedmoor then) who was far from an activist. He turned it down and Bob lucked in. The curious might look at the 8/18/1978 Cong. Rec.,SubComm. Health,Comm, Finance, concerning the Testimony about a proposal that Medicare-Medicaid should pay for psychotherapy. It was supported by the Hawaii Senators who also supported the independent clinical practice of psychologists. Most of the Testimony were from the variousr organizations, psychiatrists, psychologists,nurses, Mental Health Associations who welcomed such funding and stated that their membership were Well qualified to absorb these funds. The two oddballs were Martin Gross and myself. I took the firm stand that psychiatrists were the most broadly trained and should be in charge of whatever the government funded. However, psychotherapy had been poorly researched, did not regularly show great efficacy, required far more research, particularly about what level of training was needed, as the Strupp study indicated, and it was premature to fund all who claimed to be able to do it. That proposal died and another proposal for funding psychotherapy research to the extent of $20 million a year, was killed under obscure circumstances, largely I believe due to opposition from the APA and NIMH. I also received a severe reproach in a letter by Mel Sabshin who stated, approximately – I lost the letter – how can I expect the APA to support research if I don’t support the APA. So considering him to be the leader of psychiatric rational development sticks in my craw.

    Don Klein

    December 30, 2015 | 12:30 PM

    Would love to hear an account of the role of the insurance industry in all of this! As I remember it, insurance moves to restrict therapy led to a fight for mental-health “parity”. The idea took hold that if at least some psych conditions could be established as Real Medical Diseases, insurance would have to cover them.

    Lots of folks, both professionals and family carers, rallied behind E. Fuller Torey’s proposal: Stop wasting resources on psychotherapy for “problems of living”, and you could provide the funds to care for those with schizophrenia and other Real Medical Diseases. (It was all too easy to mobilize these families against a psychotherapy establishment that had repeatedly accused them of causing their loved ones’ illnesses.)

    Of course, once that hatchet started to swing, the cuts didn’t just affect long-term psychotherapy for the “worried well” a la Woody Allen. Everyone seemed to agree that schizophrenia was a Real Medical Disease, although they couldn’t define it or test for it. But every other condition, mild or severe, was on the chopping block.

    The result was predictable: If you wanted to be paid for treating your patients, you must establish their problems as Brain Diseases. From the perspective of a patient, it seemed like insurance gave the orders and medicine had to lie down, roll over and beg. Was that how it looked to y’all?

    Bernard Carroll
    December 30, 2015 | 2:08 PM

    Don Klein’s point about the tradeoff between sensitivity and specificity confirms the pragmatic nature of the DSM III process. Pragmatism is fine if it works in the service of improving outcomes or the ability to predict prognoses, but that is one of the big holes in the fabric of DSM III. It was silent on the matter of managing patients.

    James mentioned that this approach was utilitarian, political and unscientific – that it threw construct validity and research under the bus in the hope of insurance reimbursement. In agreement with Don, my recollection is that the DSM III task forces just wanted to improve reliability. Nevertheless, the process indeed was utilitarian, political and unscientific. The one person I remember who placed insurance reimbursement on the agenda was Gerald Klerman. In the late 1970s he was Administrator of ADAMHA, and he had the backing of Mel Sabshin. I should also say that the DSM III process was innocent of entanglement with pharmaceutical corporations. But once DSM III appeared, they saw their opening and exploited it to the full.

    It is ironic now to look at the reliability data garnered for DSM-5 and to realize that they are no better than the poor performance that Don refers to from the 1960s.

    James O'Brien, M.D.
    December 30, 2015 | 2:39 PM

    I don’t think insurance gave orders, I think they created the round hole and DSM whittled a square peg to make it fit.

    Whether or not a diagnostic entity is covered by insurance should be absolutely immaterial to whether or not it is a scientific construct. But of course money talks and now I’m being utopian, which I always advise against.

    Anyway, I think he tried to do the right thing and it got derailed by special interests. We could blame FDR for today’s problems in Social Security or Reagan for today’s 20 trillion dollar debt but I think that’s easy an intellectually dishonest.

    Every revolution needs a second revolution, as Camille Paglia once said.

    Regardless of my intellectual beefs, my condolences to his family and colleagues.

    December 30, 2015 | 2:50 PM

    With genuine respect to the usual people here, I have been reading this blog for at least 18 mos or more, and I just don’t get most of you. People pontificate about studies, statistics, authoritative experts, academic experience and expertise, and yet, the providers like me in the trenches, doing the community mental health work for decades, trying to find a niche among the garbage that is managed care insurers in part time private practice, well, it’s just a PISS match, eh?

    PISS meaning Power, Income Stream, and Status, at the end of the day. How do people like me really trust the KOLs, the Academic leadership, and god knows what really are the bare bones that is the APA? It is agenda and personal interest at the end of the day, and I kinda read that by some here as well. I think Mickey wrote about Occam’s Razor in the past, and I believe in the concept fully. It really is the simplest explanation makes the most sense until proven otherwise, and a responsible and well disciplined provider never knows what is the true diagnosis of the person in their office on day 1, maybe not even at day 90, and certainly throwing multiple drugs at people is not treatment, but just playin’ darts, at the patient’s expense.

    So, yes, I have been a cynical, jaded, sarcastic crank at this blog most often, because I really know I am surrounded and alleged led by a bunch of self serving, egotistical, and clueless bunch of colleagues, not directed to commenters here mind you, but, debating these studies and history of psychiatry really is just a fascinating process of trying to make sense of the senseless at the end of the day.

    I finish with this: people will debate if not dismiss my focus on the antisocial issues, especially in psychiatry specifically, but, what if I am right to some level, and we have people masquerading as providers and clinicians, god forbid the title of leaders, who are just antisocial cretins trying to figuratively and literally feed off the masses that are patients and the public? What are you, invested and caring colleagues, doing to expose and rid us of these hyenas and sharks?

    I honestly hope people give a little thought to my concerns. Because I know you know we are seeing it in politicians and business leaders of late, and I end with this pathetic example of pervading trust and defenders of a man who is the prime example of sociopathy at it’s worst: Bill Cosby.

    Keep minimizing, rationalizing, or plain dismissing the people who are running psychiatry not only into the ground, but beneath it.

    Being a mensch in 2016, see how far that takes you of impact. Right now, I’d rather be an obnoxious critic, but be right, than be a pious respected person and see people crash and burn behind me.

    It is what the antisocial and flagrant personality disordered loser wants of those who play by the rules the antagonist won’t follow…

    Again, Happy New Year, what does The Who sing at the end of “Won’t Get Fooled again”, “meet the new boss, same as the old boss…”

    December 30, 2015 | 7:42 PM

    While I’ve come to believe that PHARMA was an opportunist rather than an originator in the DSM-III process, they were sure Johnny-on-the-spot in Atlanta. They appeared in force as soon as we got a new chairman in 1984 providing Grand Rounds speakers, institutional and research grants. We had a crop of new arrivals from Wash U. who started their own Clinical Research Centers before I even knew what they were. So the psychopharmacology wave hit town before Prozac was released. In my 50 years in Medicine, I’ve never seen any thing change so rapidly…

    James O'Brien, M.D.
    December 30, 2015 | 8:15 PM

    Feighner and the Wash U./St.Louis group originally suggested 12 or 15 diagnoses. If they’d have stopped at 20 or so, clearly and specifically defined, it would have all worked out very well. Insurance wasn’t fooled by the nebulousness of DSM, by the mid eighties they stopped paying for conduct disorders and adjustment disorders. Torrey basically had it right.

    And we wouldn’t be bombarded by so goddam many comorbidity articles. (No kidding that blue and red are “comorbid” colors when you define blue to include purple.) Geniuses at work there.

    December 30, 2015 | 11:28 PM

    In my opinion, the pharma influence was initially very subtle but clearly there from the outset. I saw it played out in National Depression Screening Day beginning in about 1990. I happened to be the Public Affairs director for a state branch and practically everything was funded by one pharmaceutical company that got us whatever we needed. We screened a lot of people and of course the sponsoring organizations did not really have the money to put on that level of a media event. The implicit message is – you have depression and it needs to be treated with a medication.

    The same thing is true for NAMI events today. At least the ones I am familiar with – pharmaceutical companies and managed care organizations are the biggest sponsors.

    Bernard Carroll
    December 31, 2015 | 12:09 PM

    You are quite right, George, about the early 1990s. I was referring to the ur-period of the late 1970s leading up to DSM-III. That process was innocent of entanglement with Pharma. Cheers, Barney.

    January 3, 2016 | 1:24 PM

    really great opinions here.

    not much i can disagree with. i also agree that dr spitzer wasn’t perfect, but left a legacy that includes some controvery.

    i’m inclined to also agree with people who say the DSM3’s focus was to systematise diagnosis such that it was more reliable, but introduced other issues while doing so. far from perfect, but i have always seen it the way dr klein describes.

    RIP Dr spitzer. loved that scid interrater reliability paper.

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