1 Boring Old Man

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned;
The best lack all conviction, while the worst
Are full of passionate intensity.

Surely some revelation is at hand;
Surely the Second Coming is at hand.
The Second Coming! Hardly are those words out
When a vast image out of Spiritus Mundi
Troubles my sight: a waste of desert sand;
A shape with lion body and the head of a man,
A gaze blank and pitiless as the sun,
Is moving its slow thighs, while all about it
Wind shadows of the indignant desert birds.

The darkness drops again but now I know
That twenty centuries of stony sleep
Were vexed to nightmare by a rocking cradle,
And what rough beast, its hour come round at last,
Slouches towards Bethlehem to be born?
            William Butler Yeats [1919]

In the time of the drafting and release of the DSM-III, I was in the midst of my own training and early days on a faculty – way too busy with the surround to have any editorial perspective on what was happening in the field at large. That sounds defensive, like I should’ve been more aware, but I think it’s more reflective of the times. The upper levels of academic psychiatry, biological psychiatry, psychoanalysis, and neurobiology may have felt the winds of change, but we foot soldiers were just fighting the daily fight – kind of oblivious. As I’ve looked back at those times, I’ve more clearly recalled my bewilderment when I looked at the DSM-III when it appeared. We talk about it now as having been a revolutionary revision, but I didn’t see that then. I didn’t know what it was, much less its ramifications. I remember repeatedly picking it up from the desk and thumbing through it without finding any anchors to focus my attention, then putting it aside for another day. I guess the "other day" was thirty years in coming.

I got a book today [Before Prozac: The Troubled History of Mood Disorders in Psychiatry by medical historian Edward Shorter]. While the scope of the book covers the history of Mood Disorders and their treatment, I immediately jumped to the chapter about the DSM-III before reading the whole book. Before talking about what I found there, I have a  slight introduction. Decades ago, I read a book, FACES IN A CLOUD – Subjectivity in Personality Theory By: Robert Stollerow & George Attwood, Jason Aronson, 1979. It was one of those books that lands on a question in your mind that you haven’t yet even formulated – the answer comes before the question. The premise of the book was that you cannot transcend your own subjectivity, your own experience of life. They illustrated their point with the unique biographical underpinnings of theories of the early psychoanalysts in great detail, one after the other. It was a convincing argument and I believe it to this day [it’s ego-syntonic, because I know I can’t escape my own either]. So as I look back at the DSM-III, I know it didn’t come out of the blue like it felt. And it increasingly appears to me that big piece of it came out of Robert Spitzer himself, or at least his experience of his life and the psychiatry of his times.

^{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. Spitzer found this methodical approach to the enigma of attraction both soothing and invigorating. The real draw of the therapy, however, was that it greatly reduced Spitzer’s anxieties about his troubled family life: his mother was a “professional patient” who cried continuously, and his father was cold and remote. Spitzer, unfortunately, had inherited his mother’s unruly inner life and his father’s repressed affect; though he often found himself overpowered by emotion, he was somehow unable to express his feelings. The sessions helped him, as he says, “become alive,” and he always looked back on them with fondness. 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…}

^{At Columbia Psychoanalytic, however, Spitzer’s career faltered. Psychoanalysis was too abstract, too theoretical, and somehow his patients rarely seemed to improve. “I was always unsure that I was being helpful, and I was uncomfortable with not knowing what to do with their messiness,” he told me. “I don’t think I was uncomfortable listening and empathizing—I just didn’t know what the hell to do.” Spitzer managed to graduate, and secured a position as an instructor in the psychiatry department (he has held some version of the job ever since), but he is a man of tremendous drive and ambition—also a devoted contrarian—and he found teaching intellectually limiting. For satisfaction, he turned to research. He worked on depression and on diagnostic interview techniques, but neither line of inquiry produced the radical innovation or epic discovery that he would need to make his name…}

^{After training in Psychiatry at New York State Psychiatric Institute and in psychoanalysis [which he came to hate], in 1961 Spitzer joined the Biometrics Department of PI, as the Psychiatric Institute is called…}

^{In 1974 Spitzer struck a task force to guide him in this effort. It created a kind of St. Louis-New York axis. Spitzer later said, "The two universities that had a major influence in DSM-III were PI and Wash U, there’s no question about that." Washington University in St. Louis, with its genetically oriented Department of Psychiatry, was one of the birthing sites of biological psychiatry in the United States, The New York Psychiatric Institute was the other. So the alliance between the two in the core membership of the task force forecast the direction the DSM-III would take, even though Spitzer resolutely insisted throughout [to ward off the analysts] that the orientation of the document was to be "atheoretical."}

… Spitzer joined this effort in the early 1970s and became quite close to the Wash U group, staying at Eli Robin’s home when he went down to St. Louis. The summit of his collaboration occurred in 1978, just as the final drafting of DSM-III was in full swing, and became known as the Research Diagnostic Criteria [RDC].

With his" boyish energy and often naïve assessment of human relations, Spitzer saw the clinicians at Wash U almost as special chums, soul mates to help him against the bad guys. In 1979, as he and the task force were swept up in a virtual firestorm about some of the ideas in the DSM-III draft, he prepared a "confidential" version of a possible introduction to the manual and sent it to "Fellow Deans of the Invisible College [Drs. Eli Robins, Lee Robins, Eli’s wife and a noted epidemiologist in her own right, Sam Guze, Gerald Klerman,George Winokur]" Of those on that list, only Gerry Klerman, then at Cornell, was not affiliated with Washington University. The memo began, "Buddies! Enclosed is a draft of the introduction to the DSM-III… What is your reaction to the whole shebang? If you have any suggestions for changes, I must know immediately." Spitzer had no awareness at this point that Eli Robins was furious with him for hogging the spotlight. The St. Louis school considered themselves the true architects of the DSM-III…

So in the twenty years after his own psychoanalytic program, he had developed a powerful aversion to psychoanalysis, an attitude that pervaded the creation of the DSM-III. It’s fair, to say that "atheoretical" meant anti-psychoanalytic. But it’s not fair to say that the DSM-III was "atheoretical" unless you postulate that the ideas from St. Louis weren’t based on a theory. And it’s hard to say that "Washington University in St. Louis, with its genetically oriented Department of Psychiatry, was one of the birthing sites of biological psychiatry in the United States, The New York Psychiatric Institute was the other" doesn’t represent a theory – the theory that mental illness has to do with genetics and biology. And that is, indeed, exactly what they thought at Washington University. But is that what Robert Spitzer himself thought, or was he more "devoted contrarian" who had found a refuge for his anti-psychoanalytic attitude in the consort of the St. Louis group?