Dictionary of Disorder

9 / ANNALS OF MEDICINE THE DICTIONARY OF DISORDER

H crUJ one man revolutionizedpsychiatry .

BY ALIX SPIEGEL

n the mid-nineteen-forties, Robert established it as a scientific instrument met Spitzer in the lobby, a sparsely dec I Spitzer, a mathematically minded boy of enormous power. Because insurance orated and strangely silent place that of fifteen, began weekly sessions of companies now require a DSM diagno- doesn't seem to get much use. Spitzer, Reichian psychotherapy. Wilhelm Reich sis for reimbursement, the manual is a tall, thin man with well-cut clothes was an Austrian psychoanalyst and a mandatory for any mental-health pro- and a light step, was brought up on the student of Sigmund Freud who, among fessio nal seeking compensation. It's also Upper West Side. He is in his seventies other things, had marketed a device that used by the court system to help deter- but seems much younger; his graying he called the orgone accumulator--an mine insanity, by social-services agen- hair is dyed a deep shade of brown. He iron appliance, the size of a telephone cies, schools, prisons, governments, and, has worked at Columbia for more than booth, that he claimed could both en occasionally, as a plot device on "The forty years, and his office is filled with hance sexual pm-vers and cure cancer. Sopranos." This magnitude of cultural the debris of decades. Calligraphed cer Spitzer had asked his parents fo r per authority, however, is a relatively recent tificates with seals of red and gold cover mission to try Reichian analysis, but his phenomenon. Although the DSM was the walls, and his desk is overwheLned parents had refused-they thought it first published in 1952 and a second edi- by paper. was a sham--and so he decided to go to tion (DSM-If) came out in 1968, early Spitzer first came to the university as the sessions in secret. He paid five dollars Yersions of the document were largely a resident and student at the Columbia a week to a therapist on the Lower East ignored. Spitzer began work on the third Center for Psychoanalytic Training and Side of Manhattan, a young man willing \·ersion (DSM-Ill) in 197 4, when the Research, after graduating from N .Y.U. to talk frankly about the single most com manual was a spiral-bound paperback School of Medicine in 1957. He had had pelling issue Spitzer had yet encountered: of a hundred and fifty pages. It provided a brilliant medical-school career, pub women. Spitzer found this methodical cursory descriptions of about a hundred lishing in professional journals a series of approach to the enigma of attraction mental disorders, and was sold prima- well-received papers about childhood both soothing and invigorating. The real rily to large state mental institutions, for schizophrenia and reading disabilities. draw of the therapy, however, was that it three dollars and fifty cents. Under Spitz- He had also established himself outside greatly reduced Spitzer's anxieties about er's direction-which lasted through the the academy, by helping to discredit his his troubled family life: his mother was a DS!\1J-III, published in 1980, and the erstwhile hero Reich. In addition to his "professional patient" who cried continu DSM-111R ("R" for "revision"), published weekly sessions on the Lower East Side, ously; and his father was cold and remote. in 1987-both the girth of the DSM and the teen-age Spitzer had persuaded an Spitzer, unfortunately, had inherited his its stature substantially increased. It is other Reichian doctor to give him free mother's unruly inner life and his father's now nine hundred pages, defines close access to an orgone accumulator, and he repressed affect; though he often found to three hundred mental illnesses, and spent many hours sitting hopefully on himself overpowered by emotion, he was sells hundreds of thousands of copies, at the booth's tiny stool, absorbing healing somehow unable to express his feelings. eighty-three dollars each. But a mere de- orgone energy, to no obvious avail. In The sessions helped him, as he says, "be scription of the physical evolution of the time, he became disillusioned, and in come alive," and he always looked back on DSA1 doesn't fully capture what Spitzer college he >vrote a paper critical of the them with fondness. It was this experi was able to acco mplish. In the course therapy, which was consulted by the ence that confirmed what would become of defining more than a hundred mental Food and Drug Administration when his guiding principle: the best way to diseases, he not only revolutionized the they later prosecuted Reich for fraud. master the wilderness of emotion was practice of psychiatry but also gave peo- At Columbia Psychoanalytic, how through systematic study and analysis. ple all over the United States a new Ian- ever, Spitzer's career faltered. Psycho Robert Spitzer isn't widely known guage ·with which to interpret their daily analysis was too abstract, too theoretical, outside the field of mental health, but he experiences and tame the anarchy of . and somehow his patients rarely seemed is, without question, one of the most in their emotional lives. to improve. "I was always unsure that I fluential psychiatrists of the twentieth was being helpful, and I was uncomfort century. It was Spitzer who took the Di he Biometrics Department of the able with not knowing what to do with agnostic and Statistical Manual ojiv1mtaf T New York State Psychiatric Insti their messiness," he told me. 1 don't Disorders-the official listing of all men tute at Columbia Presbyterian Medical think I was uncomfortable listening and tal diseases recognized by the American Center is situated in an imposing neo empathizing--I just didn't know what Psychiatric Association (A.P.A.)--and Gothic building on West 168th Street. I the hell to do." Spitzer managed to grad-

56 THE NEW YOl\KER. JANUAl\Y 3, 2005 ---··-·--·-· ---·--'-- .. ~ · -· -----·· ·- .:...-~ - - -· ---· ·- - -- ~··· -··· --·-·- ··- -· ·- ·--·· ... _.,_ ....

1 [!]i • - Ix

Irz the nineteen-sixties, psychiatry was in a crisis: doctors couldn't seem to agree on v.:ho was sick and what ailed them.

uate, and secured a position as an in the still young field of psychiatry was instrument to be considered useful, it structor in the psychiatry department also in crisis. The central issue involved must have both. The S.A.T., for exam (he has held some version of the job ever the problem of diagnosis: psychiatrists ple, is viewed as reliable because a per since), but he is a man of tremendous couldn't seem to agree on who was sick son who takes the test on a Tuesday and drive and ambition--also a devoted con and what ailed them. A patient identi gets a score of 1200 will get a similar trarian---and he found teaching intel fied as a textbook hysteric by one psy score if he takes the test on a Thursday. lectually limiting. For satisfaction, he chiatrist might easily be classified as It is considered valid because scores are turned to research. He worked on de a hypochondriac depressive by another. believed to correlate with an external pression and on diagnostic interview Blame for this discrepancy was assigned realiry--"scholasti.c aptitude"---and the techniques, but neither line of inquiry to the DSM. Critics claimed that the test is seen as predictive of success in an produced the radical innovation or epic manual lacked what in the world of sci academic setting. Though validity is the discovery that he would need to make ence is known as "reliability"-the abil more important measure, it is imposs1~ his name. ity to produce a consistent, replicable ble to achieve validity without reliabil As Spitzer struggled to find his pro result---and therefore also lacked scien ity: if you take the S.A.T. on a Tues fessio nal footing in the nineteen-si_;,.Lies, tific validity. In order for any diagnostic day and get a 1200 and repeat it on a

THE NEW YOl\lffR. JANUAl\Y 3, 2005 57 by the end of the meal Spitzer had bee offered the job of note-taker on th DSM-II committee. He accepted it, an, served ably. He was soon promoted, an, when gay activists began to protest th designation of homosexuality as a pa thology Spitzer brokered a compromis. that eventually resulted in the removal o homosexuality from the DSM. Giver the acrimony surrounding the subject I this was an i.mpressive feat of nosologi· I cal diplomacy, and in the early seventies when another revision of the DSA1 cam( I due, Spitzer was asked to be the chair· man of the task force. I Today, the chair of the DSM ras~ force is a coveted post-people work for I years to position themselves as candi dates--but in the early nineteen-seventies descriptive psychiatry was a backwater. [ IHE. RETURNS Donald Klein, a panic expert at Colum bia, who contributed to the DSJ\!I-m, says, "When Bob was appointed to the • • DSM-m, the job was of no consequence . In fact, one of the reasons Bob got the job was that it wasn't considered thar Thur:>day and get a 600, the test is clearly of the founders of cognitive beha' ioral important. The vast majority of psychi not able to gauge academic perfor therapy, published a similar paper on re atrists, or for that matter the A.P.A., mance. Reliability, therefore, is the thresh liability in 1962. His review of nine dif didn't expect anything to come from it." old standard. ferent studies found rates of agreement This attitude was particularly prevalent Problems with the reliability of psy between thirty-two and forty-two per among Freudian psychoanalysts, who chiatric diagnosis became evident dur cent. These were not encouraging num were the voice of the mental-health pro ing the Second World 'vVar, when the bers, given that di~onostic reliability isn't fession for much of the twentieth cen military noticed that medical boards in merely an academic issue: if psychiatrists tury. They saw descriptive psychiatry as different parts of the country had dra can't agree on a patient's condition, then narrow, bloodless, and without real sig matically different rejection rates for they can't agree on the treatment of that nificance. "Psychoanalysts dismiss symp men attempting to enlist. A draft board condition, and, essentially, there's no re toms as being unimportant, and they say in Wichita, say, might have a twenty lationship between diagnosis and cure. that the real thing is the internal con per-cent exclusion rate, while Baltimore In addition, research depends on doc flicts," Klein says. "So to be interested in might find si.xty per cent of its applicants tors' ability to form homogeneous subject descriptive diagnosis was to be superfi unfit for service. Much of the dispar groups. How can you test the effecti,·e cial and a little bit stupid." ity was on psychiatric grounds, and this ness of a new drug to treat depression if was puzzling. It seemed implausible that you can't-be sure that the person you're pitzer, however, managed to turn this the mental stability of potential recruits testing is suffering from that disorder? Sobscurity to his advantage. Given would vary so greatly from one area to Allen Frances, who worked under Spitzer unlimited administrative control, he es another. A close study of the boards on the DSM-ill and who, in 1987, \vas tablished twenty-five committees whose eventually determined that the psychia appointed the director of the DSiVI-JV, task it would be to come up with de trists responsible for making the deci says, "Without reliability the system is tailed descriptions of mental disorders, sions had widely divergent criteria. So a completely random, and the di~onoses and selected a group of psychiatrists who hypothesis emerged: perhaps it was not mean almost nothing--maybe \vorse saw themselves primarily as scientists to the young men but the doctors who were than nothing, because they're falsely la sit on those committees. These men and the problem. belling. You're better off not having a women came to be known in the halls of In 1949, the psychologist Philip Ash diagnostic system." Columbia as DOPs, for "data-oriented published a study showing that three Spitzer had no particular interest i.n people." They were deeply skeptical of psychiatrists faced with a single patient, psychiatric diagnosis, but in 1966 he psychiatry's unquestioning embrace of and given identical information at the happened to share a lunch table in the Freud. '.'Rather than just appealing to same moment, were able to reach the Columbia cafeteria with the chairman of authority, the authority of Freud, the ap same diagnostic conclusion only twenty the DSM-II task force. The two struck peal was: Are there studies? What evi per cent of the time. Aaron T. Beck, one up a conversation, got along well, and dence is there?" Spitzer says. "The peo- -

58 THE NEW YOflKER. JANUARY 3, 2005 ple I appointed had all made a commit group, as interpreted by Bob, with a lit rule, though, Spitzer was more inter ment to be guided by data." Like Spitzer, tle added weight to the people he re ested in including mental disorders than Jean Endicott, one of the original mem spected most, and a little bit to whoever in excluding them. "Bob never met a bers of the DS.. \J-fil task force, felt frus got there last." new diagnosis that he didn't at least get trated with the rigid dogmatism of psy Because there are very few records of interested in," Frances says. "Anything, choanalysis. She says, "For us DOPs, it the process, it's hard to pin down exactly however against his own leanings that was like, Come on- let's get out of the how Spitzer and his staff determined might be, was a new thing to play with, nineteenth century! Let's move into the which mental disorders to include in the a new toy." In 1974, Roger Peele and twentieth, maybe the twenty-first, and new manual and which to reject. Spitzer Paul Luisada, psychiatrists at St. Eliza apply what we've learned." seems to have made many of the final beths Hospital, in Washington, D.C., There was just one problem with decisions with minimal consultation. "He wrote a paper in which they used the this utopian \-ision of better psychia must have had some internal criteria," term "hys terical psychoses" to describe try through science: the "science" hadn't Shaffer says. "But I don't always know the behavior of two kinds of patients yet been done. "There was very little what they were." One afternoon in his they had observed: those who suffered systematic research, and much of the re office at Columbia, I asked Spitzer what from extremely short episodes of delu search that exi_c:red was really a hodge factors would lead him to add a new sion and hallucination after a major trau podge--scattered, inconsistent, and am disease. "How logical it was," he said, matic event, and those .who felt com biguous," Theodore Millon, one of the vaguely. "Whether it fit in. The main pelled to show up in an emergency room members of the DSM-ill task force, thing was that it had to make sense. It even though they had no genuine phys says. ''I thin1.z.. the majority of us recog had to be logical." H e went on, "For ical or psychological problems. Spitzer nized that the amount of good, solid sci most of the categories, it was just the read the paper and asked Peele and ence upon which we were making our best thinking of people who seemed to Luisada if he could come to Washington decisions wa; precry modest." Members have expertise in the area." to meet them. During a forty-minute of the various committees would regu Not every mental disorder made the conversation, the three decided that"hys larly meet and attempt to come up with final cut. For instance, a group of child terical psychoses" should really be di more specific and comprehensive de psychiatrists aspired to introduce a cat vided into two disorders. Short episodes scriptions oi mental disorders. David egory they called "atypical child"--an of delusion and hallucination would be Shaffer, a British J)>;.·chiatristwho worked idea that, according to Spitzer, didn't labelled "brief reactive psychosis," and the on the DS_\J-m and the DSM-filR, survive the first meeting. "I kept saying, tendency to show up in an emergency told me tb?:c the sessions were often 'O.K., how would you define "atypical room without authentic cause would be chaotic. "Tne~e would be these meet child"?' And the answer was 'Well, it's called "factitious disorder_" "Then Bob ings of the s o-c~ ll ed experts or advisers, very difficult to define, because these asked for a typewriter," Peele says. To and people would be standing and sit kids are all very different.' "As a general Peele's surprise, Spitzer drafted the def- ting and mo\"in.g around," he said. "Peo ple would talk on top of each other. But Bob would be too busy typing notes to chair the me~w.g in an orderly way." One participant said r.'iat the haphazardness of the meetr,gs he attended could be "disquieting.' H e went on, "Suddenly, these thing: ·sould happen and there didn't seem ro be much basis for it ex cept that so;::ieone just decided all of a sudden to run \v"ith it." Allen Fran ces agrees rha~ the loudest voices usually won out. Both he and Shaffer say, how ever, that the process designed by Spitzer was generall:• sotLT"1d. "There was not an other way of doing it, no extensive lit erature that one could tum to," Frances says. According to him, after the meet ings Spitzer would retreat to his office to make sense of the information he'd collected. "The way it worked was that after a period of erosion, with different opinions being condensed in his mind, a list of criteria would come up," Frances says. "It would usually be some combi "Hey, honey! I thought ofsomething else you nation of the accepted wisdom of the can put on your rest-raining order." .

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initions on the spot. "He banged out cri er's team reasoned that if a clear set of what to give. A lot of people, they can teria sets for factitious disorder and for criteria were provided, diagnostic relia see something and say, 'Oh, that person brief reactive psychosis, and it struck me bility would inevitably improve_ They would like that.' But that just doesn't that this was a productive fellow! H e also argued that the criteria would enable happen to me. It's not that I'm stingy. comes in to talk about an issue and walks mental-health professionals to commu I'm just not able to project what they away with diagnostic criteria for two nicate, and greatly facilitate psychiatric would like." Frances argues that Spitzer's different mental disorders!" Both facti research. But the real victory was that emotional myopia has benefitted him tious disorder and brief reactive psy each mental disorder could now be iden in his chosen career: "He doesn't un chosis were included in the DSA1-m tified by a foolproof little recipe. derstand people's emotions. He knows with only minor adjustments. he doesn't. But that's actually helpful The process of identifying new dis pitzer labored over the DSM-ill for in labelling symptoms. It provides less orders wasn't usually so improvisatory, Ssix years, often working seventy or noise." though, and it is certain that psychiatric eighty hours a week "He's kind of an What may have been a professional treatment was significantly improved idiot savant of diagnosis-in a good strength had disruptive consequences in by the designation of many of the new sense, in the sense that he never tires Spitzer's personal life. In 1958, he mar syndromes. Attention-deficit disorder, of it," Allen Frances says.John Talbott, ried a doctor, and they had two children. autism, anorexia nervosa, bulimia, panic a former president of the American & the demands of his project mounted, disorder, and post-traumatic stress dis Psychiatric Association, who has been he spent less and less time with his fam order are all examples of diseases added friends with Spitzer for years, says, "I re ily, and eventually fell in love with Janet during Spitzer's tenure which now re member the first time I saw him walk Williams, an attractive, outspoken social ceive specialized treatment. But by far into a breakfast at an APA meeting worker he had hired to help edit the the most radical innovation in the new in a jogging suit, sweating, and having manual. In 1979, he and his wife sepa DSM~d certainly the one that got exercised. I was taken aback The idea rated, and several years later Spitzer and the most attention in the psychiatric that I saw Bob Spitzer away from his Williams were married. Williams be community-was that, alongside the suit and computer was mind-shattering." came a professor at Columbia, and she greatly expanded prose descriptions for But Spitzer's dedication didn't always and Spitzer went on to have three chil each disorder, Spitzer added a checklist endear him to the people he worked dren. Spitzer remained close to his oldest of symptoms that should be present in with. "He was famous for walking down son, but his relationship with his daugh order to justify a diagnosis. For e.x.arnple, a crowded hallway and not looking left ter from his first marriage was initially the current DS1V1 describes a person vtith or right or saying anything to anyone," strained by the divorce. obsessive-compulsive personality disor one colleague recalled. "He would never The DSM was scheduled to be pub der as someone who: say hello. You could stand right next lished in 1980, which meant that Spitzer to him and be talking to him and he had to have a draft prepared in the spring -is preoccupied with de rails, rules, lists, order, organization, or schedules to the extent wouldn't even hear you. He didn't seem of 1979. Like any major American Psy that the major point of the acriviry is lost. ... to recognize that anyone was there." chiatric Association initiative, the DSl\11 -is unable ro discard worn-our or worth Despite Spitzer's genius at describ had to be ratified by the assembly of the less objects even when they have no senti mental value .. . . ing the particulars of emotional behav A.PA., a d ecision-making body com - adopts a miserly spending sryle towards ior, he didn't seem to grasp other people posed of elected officials from all over both self and others. very well.Jean Endicott, his collaborator the country. Spitz.er's anti-Freudian ideas Five other criteria are listed in a box be of many years, says, "He got very in had caused resentment throughout the neath the description of the disorder, volved with issues, with ideas, and with production process, and, as the date of and clinicians are cautioned that at least questions. At times he was unaware of the assembly approached, the opposi four of the eight must be present in how people were responding to him or tion gathered strength and narrowed its order for the label to be applied. to the issue. He was surprised when he focus to a single, crucial word-"neuro Finally, Spitzer and the DOPs argued, learned that someone was annoyed. He'd sis"-which Spitzer wanted stricken here was the answer to the problem of say, 'vVhy was he annoyed? What'd from the DSJ1.1. reliability, the issue that had bedevilled I do?' " After years of confrontations, The term "neurosis" has a very long psychiatry for years. As they understood Spitzer is now aware of this shortcom history, but over the course of the twen it, there were two reasons that doctors ing, and says that he struggles with it tieth century it became inseparable from couldn't agree on a diagnosis. The first in his everyday life_ "I find it very hard Freudian psychoanalytic philosophy. A was informational variance: because of to give presents," he says. "I never know neurosis, Freud believed, emerged from rapport or interview stjrle, different doc unconscious conflict. This was the bed tors get different information from the rock psychoanalytic concept at the height same patient. The second was interpre of the psychoanalytic era, and both the tive variance: each doctor carries in his DSM-I and the DSlvf-II made frequent mind his own definition of what a spe use of the term. Spitzer and the DOPs, cific disease looks like. One goal of the however, reasoned that, because a wide DSiW-lliwas to reduce interpretive vari range of mental-health professionals ance by standardizing definitions. Spitz- were going to use the manual in everyday

60 THE NEW YORKE!\, JA.~UARY 3, 2005 practice, the DSM could not be aligned with any single theory. They decided to restrict themselves simply to describing behaviors that were visible to the human eye: they couldn't tell you why someone developed obsessive-compulsive person ality disorder, but they were happy to observe that such a person is often "over conscientious, scrupulous, and inflexible about matters of morality." When word of Spitzer's intention to eliminate "neurosis" from the DSM got out, Donald Klein says, "people were aghast. 'Neurosis' was the bread-and butter term of psychiatry, and people thought that we were calling into ques tion their livelihood." Roger Peele, of St. Elizabeths, was sympathetic to Spitz er's work, but, as a representative of the Washington, D.C., branch of the A.PA, he felt a need to challenge Spitzer on behalf of his constituency. "The most common diagnosis in private practices in Washington, D.C., in the nineteen seventies was something called depres sive neurosis," Peele says. "That was what they were doing day after day" Psycho D..!tttE analysts bitterly denounced the early drafts. One psychiatrist, Howard Berk, "Put it under your pillow, and maybe you'll get a visitfrom the hairfairy." wrote a letter to Spitzer saying that "the DSM-m gets rid of the castle of neu • • rosis and replaces it with a diagnostic Levittown." Without the support of the psycho eyes got watery. Here was a group that after the publication of the DSlvl-III analysts, it was possible that the DSM-ill he was afraid would torpedo all his Spitzer embarked on a P.R. campaign, wouldn't pass the assembly and the en efforts, and instead he gets a standing touting its reliability as "far greater" and tire project would come to nothing. The ovation." "higher than previously achieved" and AP.A. leadership got involved, instruct "extremely good." "For the Mt time ... ing Spitzer and the DOPs to include psy he DSM-III and the DSM-IIIR to claims were made that the new manual choanalysts in their deliberations. After T gether sold more than a million was scientifically sound," they write in months of acrimonious debate, Spitzer copies. Sales of theDSM-JV(1994) also uMaking Us Crazy: DSM-The Psy and the psychoanalysts were able to reach exceeded a million, and the DSM-IV TR chiatric Bible and the Creation of Men a compromise: the word "neurosis" was (for "text revision"), the most recent iter tal Disorders" (1997). Gerald Klerman, retained in discreet parentheses in three ation of the DSA1, has sold four hundred a prominent psychiatrist, published an or four key categories. and twenty thousand copies since its influential book in 1986 that .tlatly an With this issue resolved, Spitzer pre publication, in 2000. Its success contin nounced, uThe reliability problem has sented the final draft of the DSM-m ues to grow. Today, there are forty DSM been solved." to the AP.A. assembly in May of 1979. related products available on the Web It was largely on the basis of state Roughly three hundred and fifty psy site of the American Psychiatric Asso ments like these that the new DS1V1was chiatrists gathered in a large auditorium ciation. Stuart Kirk, a professor of pub .embraced by psychiatrists and psychi in Chicago. Spitzer got up onstage and lic policy at U.C.LA, and Herb Kutch atric institutions all over the globe. uThe reviewed the DSM process and what ins, a professor emeritus of social work at DSM revolution in reliability is a revo they were trying to accomplish, and there California State University, Sacramento, lution in rhetoric, not in realin~" Kutch was a motion to pass it. "Then a rather have studied the creation of the mod ins and Kirk write. Kirk told me, "No remarkable thing happened," Peele says. ern DSlvl for more than seventeen years, one really scrutinized the science very "Something that you don't see in the as and they argue that its financial and carefully." This was owing, in part, to sembly very often. People stood up and academic success can be attributed to the manual's imposing physical appear applauded." Peele remembers watching Spitzer's skillful salesmanship. Accord ance. "One of the objections was that shock break over Spitzer's face. "Bob's ing to Kirk and Kutchins, immediately it appeared to be more authoritative

THE NEW YORKER. JANUARY 3, 2005 61 gave the chairmanship of the DSM-1 task force to Allen Frances. "The Ame ican Psychiatric Association decided th: they had had enough of Spitzer, and can understand that," Spitzer says wit a note of regret in his voice. "I tllln that there was a feeling that if the DS1l was going to represent the entire pro fession-which obviously it has to--i would be good to have someone else. This certainly was part of the reason But Spitzer's colleagues believe that th1 single-mindedness with which he trans formed the DSM also contributed to hi eclipse. "I think that Spitzer looked bet ter in illthan he did in filR," Peele says "filR, for one reason or another, cam< across as more heavy-handed-'Spitzei wants it this way!'" As chair of the DSM-JV, France~ quickly set about constructing a more transparent process. Power was decen tralized, there were systematic literature reviews, and the committees were put on notice that, as Frances says, "the wild "/lnd, what's worse, this has cost me some Iraqi contracts." growth and casual addition" of new men tal disorders were to be avoided. Spitzer • • was made special adviser to the DSM-JV task force, but his power was dramati cally reduced. He found the whole ex than it was. The way it was laid out A year and a half after the publi perience profoundly distressing. "I had made it seem like a te.xtbook, as if it cation of the DSM-m, Spitzer began the feeling that this wonderful thing that was a depository of all known facts," work on its revision. Emboldened by his I created was going to be destroyed," David Shaffer says. "The average reader success, he became still more adamant he says. would feel that it carried great author about his opinions, and made enemies of ity and weight, which was not necessar a variety of groups. "I lo\·e controversy," he official position of the American ily merited." Spitzer admits, "so if there was some T Psychiatric Association is that the Almost immediately, the book started thing that I thought needed to be added reliability of the DSM is sound. Darrel to turn up everywhere. It was translated that was controversial, so much the bet Regier, the director of research at the into thirteen languages. Insurance com - ter." H e enraged feminists when he tried AP.A, says, "Reliability is, of course, panies, which expanded their coverage as to include a diagnosis termed "masochis improved. Because you have the crite psychotherapy became more widespread tic personality disorder," a no nsexual ria, you're not depending on untestable in the nineteen-seventies, welcomed the form of masochism which critics claimed theories of the cause of a diagnosis." He DSM-ill as a standard. But it was more implied that some abused \vives might says that psychiatric practice was so rad than that: the DSM had become a cul be responsible for their own mistreat ically changed by Spitzer's DSM-it tural phenomenon. There were splashy ment. He angered women's groups again was, for the first time, at least nominally stories in the press, and TV news mag when he attempted to designate PMS as evidence-based-that it's impossible to azines showcased several of the newly a mental disorder ("pre-menstrual dys compare reliability before and after. One identified disorders. "It was a runaway phoric disorder"). "A lot of what's in consequence of the addition of diagnos success in terms of publicity," Allen Fran the DSA1 represents what Bob thinks tic criteria was the creation of long, ces says. Spitzer, Williams, and the rest is right," Michael First, a psychiatrist structured interviews, which have al of the DOPs were surprised and pleased at Columbia who worked on both the lowed psychiatrists successfully to as by the reception. "For us it was kind DSM-IIIR and DSM-IV, says. "He re semble homogeneous research popula of like being rock stars," Williams says. ally saw this as his book, and if he tions for clinical trials. In this context, "Because everyone saw that it was the thought it was right he would push very the DSM diagnoses have been found to next big thing, everyone knew us and hard to get it in that way." Thus, despite be reliable. wanted to talk to us. It was like sud the success of Spitzer's two editions, and But structured interviews don't al denly being the most popular kid on despite e.xtensive lobbying on his part, ways have much in common with the the block." the American Psychiatric Association conversations that take place in thera-

62 THE NEW YOl\K:ER. JANUAR.Y 3, 2005 pists' offices, and since the publication of priately given the label of attention for patients. Good for everyone at that the DSM-ill, in 1980, no major study deficit/hyperactivity disorder can come point in time to have someone whose has been able to demonstrate a substan to see himself as broken or limited, and view may have been more simpleminded tive improvement in reliability in those act accordingly. And there are other than the world really is. A more complex less formal settings. During the produc problems with the DSM. Critics com view of life at that point would have re tion of the DSM-IV, the American Psy plain that it often characterizes everyday sulted in a ho-hum 'We have this book chiatric Association received funding behaviors as abnormal, and that it con and maybe it will be useful in our field.' from the MacArthur Foundation to un tinues to lack validity, whether or not The revolution came not just from the dertake a broad reliability study, and al the issue of reliability has been defi material itself, from the substance of it, though the research phase of the project nitely resolved. but from the passion with which it was was completed, the findings were never Even some ~f the manual's early ad introduced." published. The director of the project, vocates now think that the broad claims Spitzer, too, has grown more circum Jim Thompson, says that the AP.A ran of reliability were exaggerated. "To my spect. "To say that we've solved the reli out of money. Another study, whose pri way of thinking, the reliability of the ability problem is just not true," he told mary author was Spitzer's wife, Janet DSM-although improved-has been me one afternoon in his office at Co Williams, took place at six sites in the oversold by some people," Allen Frances lumbia. ''It's been improved. But if you're United States and one in Germany. Su says. "From a cultural standpoint, relia in a situation '"vith a general clinician pervised by Williams and some of the bility was a way of authenticating the it's certainly not very good. There's still most experienced diagnostic profession DSA1 as a radical innovation." He adds, a real problem, and it's not clear how als in the world, the participating clini "In a vacuum, to create criteria that were to solve the problem." His personal in cians were given extensive special train based on accepted wisdom as a first vestment in the DSM remains intense. ing before being split into pairs and stab was fine, as long as you didn't take it During one of our conversations, I asked asked to interview nearly six hundred too seriously. The processes that hap Spitzer if he ever feels a sense of own prospective patients. The idea was to de pened were very limited, but they were ership when troubled friends speak to termine whether clinicians faced with valuable in their context." And Frances him of their new diagnoses, or perhaps the same client could agree on a diagno believes that both psychiatry and the when he comes across a newspaper ac sis using the DSM. Although Williams public have benefi.tted in a less tangi count that features one of the disor claims that the study supported the reli ble way from the collective fantasy that ders to which he gave so much of his ability of the DSM, when the investiga the DSM was a genuine scier:.tific tool. life. He admitted that he does on occa tors wrote up their results they admitted "In my view, if I had been doing the sion feel a small surge of pride. "My fin that they "had expected higher reliabil DSM-ill it would never haw been as gers were on the typewriter that typed ity values." In fact, Kutchins and Kirk famous a document, because I'm a skep those. They might have been changed point out, the results were "not that dif tic," he says. "But it was good for the somewhat, but they all went through ferent from those statistics achieved in world at large. Good for psychiatry, good my fingers," he said. "Every word." • the 1950s and 1960s--and in some cases were worse." Reliability is probably lowest in the place where the most diagnoses are made: the therapist's office. As Tom Widiger, who served as head of research for the DSM-JV, points out, "There are lots of studies which show that clini cians diagnose most of their patients with one particular disorder and really don't systematically assess for other dis orders. They have a bias in reference to the disorder that they are especially interested in treating and believe that most of their patients have." Unfortu nately, because psychiatry and its sister disciplines stand under the authorita tive banner of science, consumers are often reluctant to challenge the labels they are given. Diagnoses are frequently liberating, helping a person to under stand that what he views as a personal failing is actually a medical problem, but they can in certain cases become self fulfilling prophecies. A child inappro- "How's everything?"

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