“What did he say?,” Robert Spitzer asked me nervously as we sat in his home, midwinter 2006, reviewing changes to the third edition of the DSM. Years earlier, in the mid 1970s, he’d been handed the task of updating and improving the influential manual, and the interview had reached the crucial point when Spitzer and his supporters pressed for the inclusion of Panic Disorder as a stand-alone illness. The episode was charged with drama and historical significance. It took place against the expressed wishes of Isaac Marks, the world-renowned expert on panic, fear, and anxiety, whose work they were busy invoking.
As luck would have it, I had interviewed Marks at his home in south London just days before. Everything he said was still fresh and on tape. The argument between the two psychiatrists then played out again as if it had happened as recently. Though committed to treating and understanding panic, Marks was steadfastly opposed to its being represented as a stand-alone disorder. He was similarly opposed to the formal identification of Social Phobia/Social Anxiety Disorder as a separate disorder, not least after seeing his own research on the subject (pointing to a different conclusion) cited as a reason for the change. The evidence that Social Phobia should be separated off had not been overwhelming and little had been published since that implied otherwise. But on both counts, Marks was overruled. “The consensus was arranged by leaving out the dissenters,” he said to me ruefully, after Spitzer had told him in the men’s room at that key Boston conference that he “wasn’t going to win. Panic [disorder] is in. That’s it.” “Never mind about the pros and cons intellectually,” Marks continued, characterizing Spitzer’s apparently cavalier rejection of his expertise and objections. “Don’t confuse me with the data. It’s in.”
The Boston conference had been paid for by Upjohn Pharmaceuticals, maker of Xanax, a drug that became widely prescribed for Panic Disorder. As the CEO stood up to give his opening remarks, Marks recalled, he admitted quite openly: “There are three reasons why Upjohn is here taking an interest in these diagnoses. The first is money. The second is money. And the third is money.” Despite concern that his research was being misused, to ends he could not support, Marks was, he said, “disinvited” from subsequent discussions. Panic Disorder and Social Phobia/Social Anxiety Disorder weren't just included in DSM-III, but, as he feared, given such low diagnostic thresholds (including, in 1987, public-speaking anxiety for SAD) that millions of American adults and children became eligible for a diagnosis, with Xanax, Paxil, and other medication among the most frequently prescribed treatments.
It was a turning-point in our interview, too. Spitzer had agreed to it, at his home just north of New York City, after I’d pressed to see documents leading to the approval of Social Phobia and 111 other additions to DSM-III. I had recently been awarded a Guggenheim fellowship to write about such changes and their consequences, as I told him, and had a sizable but incomplete collection of DSM papers already. I wanted to see the complete record, to leave nothing relevant out. But the full archive, staff at the American Psychiatric Association advised, seemed to have been lost when the organization moved its headquarters and library from Washington D.C. to Arlington, Virginia. After the interview, the papers were quickly found and the APA opened its doors to me. Spitzer was instrumental in my getting permission not just to review and photocopy everything tied to DSM-III, with a particular emphasis on anxiety disorders, but also to reproduce key parts of those papers in book form.
In the days following Robert Spitzer’s untimely death last month, aged 83, the focus turned naturally to reviewing the many accomplishments of his long and influential career. Colleagues working on subsequent editions of the DSM, such as PT blogger Allen Frances, spoke warmly of his charm and charisma (very much in evidence to me that afternoon in February 2006), as well as his achievement in removing homosexuality from the DSM in 1973. As Frances reminded, Spitzer reached this difficult outcome in an altogether different climate, under hostile opposition from conservative colleagues who denounced him for heeding the objections of lesbians and gays themselves, much less for accepting that their concerns had any bearing on psychiatry itself.
Recent comparisons have also been made between DSM-III and its precursor, DSM-II, the edition from 1968 that, Spitzer admitted to me, had been edited by just one person, Sir Aubrey Lewis at the Maudsley Institute of Psychiatry in London. But such comparisons almost certainly put the bar too low, making everything else shine in comparison. According to Spitzer, it was Lewis who, without consultation and at a stroke of his pen, redefined multiple psychiatric conditions simply by striking the word “reaction” from them. “Schizophrenic reaction,” with its implied allusion to context, intensity, and frequency, suddenly became “Schizophrenia,” with suggested permanency and seemingly limitless recurrence. In turn, it was Spitzer who led the effort to add the word “disorder” to a large number of related conditions, effectively turning them into semi-permanent, even life-long biological states with an almost inevitable relation to pharmaceuticals.
Some will view that development as an improvement, in line with the narrative that the DSM improves with each new edition, even as its page-size and number of official conditions swell beyond recognition. But the move to heroize Robert Spitzer has an obvious downside, including to overlook well-documented and far-more complicated examples of his influence on the history of psychiatric diagnoses. Ironically, these include his indisputably signal achievements, such as removing homosexuality from the DSM in 1973, when he argued, quite rightly, that homophobia, rather than homoeroticism, tends to be psychiatrically charged. Yet it was Spitzer himself—apparently taking this regret to his grave—who, three decades later, openly conducted questionable and misleading research on so-called “reparative” therapy to alter homosexual attraction, in ways discredited by all reputable psychiatric and psychological organizations.
In 2001, when he might have settled for a different legacy, Spitzer published an article in Archives of Sexual Behavior claiming that, for highly motivated individuals, ex-gay therapy worked. A decade later still, after it came to light that the article’s research had relied entirely on the testimony of patients he had personally “recruited,” who were already identified with prominent ex-gay groups such as Exodus and NARTH (short for the National Association for Research and Therapy of Homosexuality), so making his research both deceptive and a self-fulfilling prophecy, Spitzer issued a statement of regret and recanted his conclusions. The outcome was immediate and dramatic, including across American psychiatry; we shouldn't underestimate the courage needed to make such a public disclosure, especially given the number of lives affected. Yet in light of Spitzer’s high standing in psychiatry and strong influence on it when he published the article (2001), his decision to conduct, publish, and for a decade stand behind such research needs assessing alongside his accomplishment in removing homosexuality from the DSM. Like it or not (and many of his admirers will not), it’s part of the same historical record.
During our interview, Spitzer mentioned openly, almost proudly, that one of the reasons he pushed for adoption of the term “disorder” for conditions such as anxiety was that it eliminated psychotherapy and psychoanalysis as treatment options. He added that opponents of the change could have mounted a legitimate defense if they’d spotted a key discrepancy with the ICD system, where the term “anxiety neurosis” was still included, in ways that made the DSM change look arbitrary and loaded. And he openly acknowledged that the addition of new conditions to the DSM was in part “a function of ‘Do you have a treatment’? If you have a treatment, you’re more interested in getting the category in” (qtd. in Shyness 75). Such pressure from drug-makers and their academic sponsors highlights a cart-before-the-horse dynamic often borne out by the DSM-III papers, as in the above linking of Panic Disorder to Upjohn Pharmaceuticals.
Spitzer advised me that afternoon that DSM-III had made only “a modest improvement” to diagnostic reliability and he openly acknowledged in the interview the risks of overstating the manual’s efficacy, noting that such improvements, as for the conditions themselves, “depend on the settings.” He also worried greatly about “false positives” (interrater reliability), even as he packed his DSM task forces with “kindred spirits” and determined publicly that the strongest criteria for whether to add a new condition to the DSM was, in his words, “how logical it was … whether it fit in. The main thing was that it had to make sense. It had to be logical” (qtd. in Shyness 57).
Of the actual discussions about content and criteria that took place among the psychiatrists, which are reproduced faithfully in Shyness with APA permission, several commentators complained at the time: “The poverty of thought that went into the decision-making was frightening… In some cases, the people revising DSM-III [were] making a mental illness out of adaptive behavior.” A consultant to the edition’s task force later conceded to the New Yorker magazine, “There was very little systematic research [involved], and much of the research that existed was really a hodgepodge—scattered, inconsistent, and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest” (qtd. in Shyness 45, 41-42). It may not surprise, then, to read that in 1984, in a forum on DSM published in the American Journal of Psychiatry, psychiatrist George Vaillant warned that the “disadvantages of DSM-III outweigh its advantages," as in his estimation the edition “represents a bold series of choices based on guess, taste, prejudice, and hope” (qtd. 66).
A full reckoning of Spitzer’s legacy—far beyond the scope of this post—will need to revisit his responsibility for the inclusion, in the appendix to DSM-IIIR, of what became Premenstrual Dysphoric Disorder (PMDD), on the basis of what he insisted, to me and others, was a printing error. Introduced after the resignation from DSM committees of expert researchers, again following the type of scenario Isaac Marks had experienced and earlier described, the “printing error” in DSM-IIIR oddly came with its own diagnostic code, almost in anticipation of the promotional campaigns that drug-makers would run in the 1990s, to extend the patent life of blockbuster antidepressants by giving their makers a license to treat PMDD.
Many such examples of Spitzer’s diagnostic emphases and overreach are documented in my book. I allude here to this complex, unsettled history not to diminish the achievements and effects of this influential psychiatrist, but to ensure that all of them stay part of the historical record. Doing so is the only way to gauge their consequences, and—given our ongoing problems with overdiagnosis and overmedicating—to assess where they leave us today.
References and Further Reading
Bayer, Ronald. Homosexuality and American Psychiatry: The Politics of Diagnosis. New York: Basic Books, 1981.
Carey, Ben. “Robert Spitzer, 83, Dies; Psychiatrist Set Rigorous Standards for Diagnosis.” New York Times, December 26, 2015.
Crignon, Anne. “Robert Spitzer, le psychiatre le plus influent du XXe siècle.” Nouvel observateur, January 10, 2016.
Frances, Allen. “A Tribute to Robert Spitzer: The Most Influential Psychiatrist of His Time.” Psychology Today, January 8, 2016. (Culled from a longer version in The Lancet.)
Lane, Christopher. Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press, 2007.
Spiegel, Alix. “The Dictionary of Disorder: How One Man Revolutionized Psychiatry.” New Yorker, January 3, 2005.