1 Boring Old Man

Robert Spitzer was not remiss in rethinking the nosology of psychiatry. The two previous versions had been more testimonials to the our early thinkers than classifications of disease. And there’s no question that there would’ve been complaints no matter what direction he moved. I suppose that it must be true that any revolution is preoccupied with changing the old ways, whether government or science or philosophy. But "not that anymore" doesn’t always lead to the best "what now?" A pattern seen particularly in many patients with personality disorders comes to mind. The history has a monotonous story line – some problem leads to a dramatic solution which shortly becomes the next problem – and the pattern repeats. The narrative takes on a saw-toothed quality of a crisis driven life, rather than the expected growth through a series of crises and "lessons learned." Then there’s that awkward old saying that says "don’t throw out the baby with the bath water." Einstein made it very clear that "gravity" is simply a phenomenon limited to a specific set of circumstances, not a fundamental force in the universe. But if you’re a roofer, or a climber, or a builder – it’s a force to be reckoned with and counted on on a daily basis – the curvature of the space-time continuum is hardly a useful replacement. So the "old paradigm" persists along with the new. What needs to be kept from before in a time of change is a really essential question.

I’ve been thinking about my own experience in gravitating towards psychiatry as I’ve been reading about the birth of the DSM-III. The world of a practicing Internist wasn’t like the one of Internal Medicine Resident in a large charity hospital. In training, all the patients were desperately ill. It was an exciting battlefield filled with sound and fury every day [and most nights], signifying a lot. We suited up in white uniforms where lab-coat length measured "rank" and marched into life and death combat, hiding our fears behind a growing knowledge of medicine. I wouldn’t have missed it for the world, but it was time-limited. Routine practice was very different – at least for me. Most of the patients I saw didn’t have dire physical illnesses, and a surprising number were there with physical symptoms resulting from or masking mental problems. Primary Care Physicians spend a lot of their time doing negative work-ups, and for many patients, that’s all that’s required. Their anxiety is validated, and the negative evaluation is a relief. As my aging and impish dermatologist once said, "You think you shrinks are the only ones that can treat anxiety. Watch this!" He pointed to the lesion on my leg and said with a grin, "That ain’t cancer." Point taken.

But for a surprising number of the people I saw, that wasn’t enough. And I guess I was a curious person and started asking questions that lead me into the world of mental illness that had been off my radar in the combat zone of my residency training. And psychiatric referral isn’t easy in the best of circumstances because it can seem invalidating or even like an indictment. But where I was [the air force], it was even harder because it could really be invalidating for promotion or assignment, so I was on my own because most patients just wouldn’t accept referral. And I guess I was as good at mental illness as most doctors, but I felt clueless – to quote another old saying, "like a fish out of water." So that was the manifest reason for doing another residency [there were, of course, a thousand other reasons]. By the way, there’s a point to this story – coming in a paragraph not too far down this very page.

It was a right choice for me. Understanding mental illness requires learning to approach things in a different way, listen in a different way. If that weren’t true, there would never have been a psychiatry in the first place. It involved in part learning to listen to how I was feeling when I was with a person – metacommunication. It was like I was hearing music that had always been playing, but I hadn’t tuned to the right station. I learned about the "praecox" feeling, a feeling of craziness that one feels in the presence of a psychotic person. I learned how to read the guardedness and odd stare of paranoid people. I began to notice the internal sense of despair and hopelessness that comes when interviewing a person with Melancholia, or the infectious laughter that turns to irritation when you’re around Mania. I got where I could detect being put in a double bind by some seemingly benign question and how to respond instead of falling in a hole. I found out that scary people were actually frightened. It was slow, but it was the thing I’d come to learn. And there was so much to learn about how and where to listen – what wasn’t said, what was skipped over, when people changed the subject, when they got irritated, their strange thought patterns, the way they told their stories, the cognitive styles of Aaron Beck, etc.

Years later, when I was training residents, I remember being excited when they started hearing the music too. You could just tell. It’s not that it helped them at first, because hearing all the discordant tunes doesn’t necessarily tell you what to do. If anything, it makes you as confused as the afflicted person you’re dealing with. Dealing with that part is what they call life-long learning. But if you don’t hear it at all, you’re not really in the game. I used to tell the residents that when they finished their residencies, they wouldn’t feel like other doctors who finish filled with knowledge. In fact, the psychiatrists wouldn’t know they knew anything until they were interviewing a patient. It sounded kind of mystical, but it’s not at all. It’s the competence of experience and careful observation of things people don’t usually look at – a hard won intuition. That’s not psychoanalysis. That’s just Mental Illness 101. Those things are phenomenology, not theories. And they have a lot to do with diagnosis and the classification of disease, at least in psychiatry as I know it.

^{• 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.}
^{• 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.”}
^{• “He was famous for walking down a crowded hallway and not looking left or right or saying anything to anyone,” one colleague recalled. “He would never say hello. You could stand right next to him and be talking to him and he wouldn’t even hear you. He didn’t seem to recognize that anyone was there.”}
^{• 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?’ ”}
^{• After years of confrontations, Spitzer is now aware of this shortcoming, and says that he struggles with it in his everyday life. “I find it very hard to give presents,” he says. “I never know what to give. A lot of people, they can see something and say, ‘Oh, that person would like that.’ But that just doesn’t happen to me. It’s not that I’m stingy. I’m just not able to project what they would like.” Frances argues that Spitzer’s emotional myopia has benefitted him in his chosen career: “He doesn’t understand people’s emotions. He knows he doesn’t. But that’s actually helpful in labelling symptoms. It provides less noise.”}

^{• 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.}

Put simply, my complaint about the DSM-III is that it’s flat, sterile, missing the music and the soul of mental illness. Spitzer thought the basic observational field of psychiatry, those thing I talked about coming to psychiatry to learn, were theoretical, or non-objective, or psychoanalytic theories. Theories are hypothetical explanations of phenomena, not the phenomena themselves. My best guess is that he grew up blocking out the "noise," and got so good at it that he didn’t even hear it anymore. Maybe he never heard it in the first place. But that’s a speculation. What’s not speculation is that parts of the DSM-III [like the classification of depression] ignored the basic and time-proven methodology of psychiatry: the careful personal and family history gathering of Adolph Meyer; the attention Kraepelin, Bleuler, Freud, Meyer, and countless others paid to nuance and subtlety in emotional and cognitive presentations; the powerful evoked feelings communicated to the observer by disturbed people. While some of these things are difficult to objectify and describe, the difficulty doesn’t mean they’re not there. Spitzer’s class, Major Depression, is a testimonial to his failure to hear the music:

^{• Frances argues that Spitzer’s emotional myopia has benefitted him in his chosen career: “He doesn’t understand people’s emotions. He knows he doesn’t. But that’s actually helpful in labelling symptoms. It provides less noise.”}

^{• Bottom line: Major Depression doesn’t exist in Nature. A political process in psychiatry created it…}