By Eric Vandenbroeck and co-workers
The secrets behind the making of the Diagnostic and Statistical Manual of Mental Disorders(DSM)Part One
When the American Psychiatric Association released the fifth Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, Gary Greenberg, claimed the disorders listed aren't real -- they're invented. Author of Manufacturing Depression: The Secret History of a Modern Disease and contributor to The New Yorker, Mother Jones, The New York Times, and other publications, Greenberg is a practicing psychotherapist. The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry is his exposé of the business behind creating the new manual.
But there is more than that;
Dr. Robert L. Spitzer may not be well-known outside his field, but as the New Yorker put it in 2005, "he is, without question, one of the most influential psychiatrists of the twentieth century. "1
In 1974 Judd Marmor was asked to chair a strategic task force to update the profession's manual of disorders. The previous edition was a spiral-bound paperback costing just three dollars and fifty cents.2 It offered only cursory descriptions of almost two hundred illnesses.3 It was often derided as flawed and outdated.4 The entire field of psychiatry it represented badly needed a makeover.
American psychiatry was at the time in disarray. Several ‘scandals’ had battered its reputation. One of the best-known, appearing in Science, concerned eight ordinary citizens whom investigators had persuaded to tell 12 different hospitals they kept hearing voices saying "empty," "hollow," and "thud." All but one of the volunteers was hospitalized, then discharged with schizophrenia "in remission. "3
The implications of such carelessness were staggering, bearing an uncomfortable resemblance to the nightmare scenarios portrayed a decade earlier by Ken Kesey's One Flew over the Cuckoo’s Nest and other cautionary tales. Another study, revealing similar discrepancies in judgment among young psychiatrists of all stripes, found they "were no more likely to agree with an examiner's diagnosis than would be expected by chance.”4
These incidents were viewed as signs of something unsavory in the state of what, after all, was the leading influence on psychiatry for the rest of the world. In fact, we should emphasize that this is also why we choose in this case study primarily (although we also mention the UK) the American scene because it plays a leading role also elsewhere in the world, or for the other side of the spectrum see our case study about Indonesia earlier on this website.
The hundred-year war between neuropsychiatrists and psychoanalysts had reached a level of acrimony possible only when fundamental differences in approach and philosophy seem insurmountable. With each side hunkered down, the skirmishes had begun to fester, disabling the profession as a whole and damaging its reputation.
As if the situation weren't grim enough, healthcare costs were spiraling out of control, causing alarm, especially among managed-care companies. With its cautious, unhurried interest in mental conflicts and commitment to a treatment plan shared only by the analyst and patient, with loose empirical guidelines and no obvious end in sight-psychoanalysis seemed an increasingly costly and dispensable culprit to its opponents. 5
If something radical weren't done to stanch the discipline's internal problems and costs, many began to mutter; the entire field might collapse under the weight of its many conflicts. So Melvin Sabshin, then medical director of the APA and a man drawn to "evidence-based psychiatry," decided the DSM needed a fresh edition. "I wanted it to rely on data rather than opinion or ideology alone," he explained, so the field would be "better prepared to deal with the vicissitudes of economic pressures."6 Another key factor was that the World Health Organization in Geneva was due to update its own diagnostic manual, the International Classification of Diseases, and wanted the North American and European models better aligned.7
Hoping his suggestion would end the fights and scandals, Sabshin pressed for a standardized "classification system that would reflect our current state of knowledge regarding mental disorders."8 From the start, then, new disorders like social anxiety were seen as underreported maladies updating "our current state of knowledge," not strategic constructions that would end up completely redefining it.
Since any changes to the DSM were likely to favor the neuropsychiatrists, given their commitment to rapid, standardized results, Sabshin's decision was unavoidably political. So in hopes of placating the psychoanalytic group, he urged Marmor to appoint Spitzer, a friend, and charismatic professor with expertise in both camps and thus every appearance of neutrality.
Spitzer had trained as an analyst after undergoing psychoanalysis as a child and adolescent. "My mother sent me to a psychoanalyst when 1 was 9 or 10," he said, "because I'd slapped her when we were in an eye doctor's office, ... but I didn't really have therapy until I was 15."9 In light of this experience, it's curious that he then went on to train as a Reichian apparently in secret, as his parents opposed his plan.IO "I was intrigued by Wilhelm Reich's approach," he says, which at the time included way-out experiments with "orgastic potency" and a firm belief in extraterrestrials.11 But Spitzer's research, also adopting Reich's model, didn't work out well. In 1952, he laughs, he wrote to the guru, earnestly explaining that he'd not gotten satisfactory results from his experiments. Reich responded, assuring him that the cause was doubtless fallout from the atomic bomb! 12
Reich's was a truly esoteric form of pseudo-psychoanalysis, as many grasped at the time; Spitzer "never felt comfortable with what [he] was doing" when he saw patients.13 So, he kept his interest in quantifying psychological matters but did a 100-degree turn in how he viewed them and began honing an interest in diagnostic issues. Later still, after helping to update DSM-II in the late 1960s, he proved himself an able diplomat, negotiating a difficult truce over the fiercely contested status of homosexuality in the manual-a further reason Sabshin and Marmor wanted him leading the task force.14
Others were less kind about Spitzer's talent and the task that he was given. Allen Frances once said of his colleague, with a noticeable pat on the head, "He's kind of an idiot savant of diagnosis-in a good sense, in the sense that he never tires of it."15 Donald Klein adds dismissively, "When Bob was appointed to the DSM-III, the job was of no consequence. In fact, one of the reasons Bob got the job was that it wasn't considered that important."16
Nevertheless, Marmor picked him as the man who would restore scientific credibility to the study of mental disorders. Since his group redefined ordinary behaviors like shyness, whether or how Spitzer succeeded is a fascinating but largely untold story.
Over the next six years, the APA Task Force on Nomenclature and Statistics reviewed almost every tic and trait imaginable. The work was slow, difficult, and often contentious. Spitzer regularly labored 70 to 80 hours a week over the sprawling document, for his team of 15 set about codifying every aspect of phobia and anxiety, rendering them discrete illnesses.17 They discarded many current theories and mined large amounts of research for fresh insights.
Just keeping track of the many intricate debates that developed or stalled over each behavior was itself a formidable challenge, generating long before email hundreds of memos, notes, and letters. Given the nuggets of insight that had to be culled from six years of meetings, in ways that would do justice to the gravity of the work, it's a wonder the document was ever finished, much less published with one side's approval.
Embarrassed by DSM-II's diagnostic "holes," the task force tried to fill or replace them with numbered "axes" and "subcategories" in the parlance of the field. Yet each of these spawned so many inclusive criteria and symptoms that the terms frequently buckled and merged. Undeterred, the task force "discovered" II2 new disorders and disease categories. It also split anxiety neurosis into seven new parts:
So whereas DSM-II, the 1968 edition Spitzer helped update, had cited 180 categories of mental illness-including just one all-embracing form of "anxiety neurosis"-DSM-IIIR ("R" for "revision") eventually listed 292, and DSM-IV, appearing in 1994-, over 350.18 In just 26 years, that is, the total number of mental disorders the general population might exhibit almost doubled. As David Healy comments on this astonishing outcome, the revised parameters for depression alone resulted in "a thousandfold increase, despite the availability of treatments supposed to cure this terrible affliction."19
One could argue that psychiatry needed revamping and that only a fundamental shift in thinking would do. In fact, Spitzer's team and supporters proudly claim they were correcting a false medical picture in which certain maladies had escaped notice. Consequently, they pushed through reforms against substantial odds and with the highest standards of rigor and integrity that prevented thousands of people from suffering needlessly and the profession from languishing in confused mediocrity.
The story behind these changes is not as smooth as Spitzer, and other commentators suggest. Psychiatrists in the 1950s and 1960s were highly attuned to their patient's problems, and the media were not slow to report their discoveries. The escalation of illness categories was extreme, and even factoring in underreported problems couldn't account for it. Today Spitzer cheerfully concedes that younger colleagues tease him for someone who never saw a disorder he didn't like.20 But with the risk of mislabeling so high, many readers will not find that humor very reassuring.
While Spitzer and his allies prefer to cast their actions in a winning light, others feared the victors would soon repress this chapter of psychiatric history. As far back as June 1979, Roger Peele at the U.S. Department of Health, Education, and Welfare urged Spitzer, "Please write or have written a history of the development of DSM I, II, and III that will include all warts"-a request that Spitzer has so far answered selectively.21
Even so, Theodore Millon, a consultant to the DSM-III task force, broke rank in admitting: "There was very little systematic research, and much of the research that existed was really a hodgepodge-scattered, inconsistent, and ambiguous. We think most of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest."22
Given the DSM's global influence and psychiatrists' inability to agree on this key chapter of its history, it is time to present "all warts." As noted, the results were often chaotic. David Shaffer, a British psychiatrist who worked on DSM-III and DSM-IIIR, gives a memorable snapshot, conveying less the concentrated energies of brilliant minds than the raucous class of a teacher whose unruly pupils won't stay quiet: "There would be these meetings of the so-called experts or advisers, and people would be standing and talking. But Bob would be too busy typing notes to chair the meeting in an orderly way."23 Another participant called the chaos "disquieting." It didn't seem to be much of a basis for it except that someone just decided.
Many of the actual memos and letters combine carelessness and expediency. For starters, they hope that their own particular spin on anxiety, depression, or related illnesses might be accepted and thereafter invoked led some task force members to push too zealously for adoption. When Klein asked members of the Personality Disorders Subcommittee to review his proposal for "Emotionally Unstable Character Disorder," for example, he announced rather breezily, "You'll note that this syndrome has been repeatedly described by me," with drug and follow-up studies "attesting to the reality of this syndrome, which is more than can be said about a number of the syndromes in DSM III."25 Spitzer's exasperated reply, the following week, tried to head Klein off, amusingly, by invoking Kraepelin's description of an "irritable temperament."26
In other eruptions, the psychiatrists traded barbs over jargon and diagnostic precision. Asked Spitzer of Klein at one agitated moment over the criteria for avoidant personality disorder, "Does the reference to 'hypersensitivity to rejection' get too close to Hysteroid Dysphoria for your personal comfort?"27
Given the stakes, jockeying was probably inevitable; psychiatrists are as human as the patients they see. They may be adept at interpreting other people's behavior but sometimes are unaware of their own. Eliot Spitzer's difficulty in appeasing so many competing demands became immense, and the strain began to show. Jean Endicott, his collaborator, explains: "He got very involved with issues, with ideas, and with questions. He was unaware of how people were responding to him or the issue. He was surprised when he learned someone was annoyed. He'd say, 'Why was he annoyed? What'd I do?'28
And what about the psychiatrists' actual decisions? Shaffer is unusual in disputing their expertise; most would accept their track record in key areas. But perhaps owing to groupthink, inertia, or overreach, the results were often strikingly unimpressive and at times downright alarming. Renee Garfinkel, an administrative officer at the American Psychological Association, later observed, "The poverty of thought that went into the decision-making process was frightening." According to her, when one leading psychiatrist was asked to define how he was using the term masochistic during a meeting about its possible inclusion as a personality disorder, he replied: "Oh, you know what I mean, a whiny individual ... the Jewish-mother type."29
Leonore Walker, a Denver-based psychologist, remarked about a host of discussions. "Professional people were sitting around a computer, making decisions based on feelings or impressions, not facts." She added, "In some cases, the people revising DSM-III [were] making a mental illness out of adaptive behavior."30
Considering these objections, Irwin Marill and colleagues in Bethesda and the D.C. area seem justified in lamenting "glaring deficiencies inherent in the conceptualization of the manual," calling its quality "spotty" and its judgments "often internally contradictory."31 Of the proposed revisions to DSM-III, Robert Waugh declared: "I feel ashamed for psychiatry; I am fearful that we will be the laughing-stock of our scientific colleagues." Let's not invite ridicule."32 Brooklyn-based N. S. Lehrman went further, saying the "pseudo-scientific veneer" coating the group's work displayed so much "amateurishness" and "pretentiousness" that the manual might better be known as "The Emperor's New Jockstrap."33
As these examples underscore, the challenge of conveying unanimity to the public was becoming more difficult, with relations within the wider profession increasingly strained:
The fact that Spitzer had handpicked his team for its shared interest in diagnostic issues soon made abundantly clear to everyone else that it opposed all other schools of psychiatry, especially psychodynamic therapy and Freudian psychoanalysis.
Spitzer's earlier training as a psychoanalyst failed to mollify this group, which felt that key decisions about the profession were being made over its head. Further deals and compromises had to be struck, many at the eleventh hour, and few were satisfying to all parties.
There was the risk of error or simple inconsistency-no small or laughing matter when the new categories were so elaborate, and the diagnosis of millions of patients would soon be at stake.
Spitzer's daunting task spun out for six years. As he said, his marriage also collapsed. "A lot was going on."34
Spitzer argued strenuously that his task force was unbiased because it was merely cataloging symptoms and thus, in theory, steered clear of contentious questions about their cause and treatment. Accordingly, he argued that the DSM-III work was not skewed toward anyone's neuropsychiatric, psychoanalytic, or social and environmental approach. On the face of it, the DSM certainly does not favor neuropsychiatric over psychodynamic frameworks, a key point we have no wish to downplay. But Spitzer's argument, as will emerge, was also partly a ruse to mask that the task force was in fact extremely mindful of etiology; indeed, it tipped the scales in neuropsychiatry's favor by excluding conditions (including anxiety neurosis) that other psychological perspectives such as psychoanalysis had recognized for decades. Nor was the task force disinterested in assigning symptoms to newly christened disorders, for each decision (including those to rename) involved not only research whose conclusions were often open-ended but also acts of interpretation that drew heavily on the clinical trials of task force members and their friends.
In some cases, the trials involved but one patient whose behavior was reported by the member hoping to formalize their line of research. More often than not, however, the perspectives of several consultants had to align. Frequently they did not because of fundamental disagreements about the traits and their underlying significance. Spitzer's team then decided what was "right and true."
As these decisions tended to exclude terminology and treatments that their predecessors had used for generations, psychoanalysts perceived that the fate of their profession lay unfairly with a few colleagues committed to eliminating all trace of their work. As Paul Fink, Chair of Psychiatry and Human Behavior at Philadelphia's Thomas Jefferson University fumed in May 1978 to his colleague Lester Grinspoon: "I do not know who determined that this small group of people should try to reorganize psychiatric thinking in the United States, but I am somewhat concerned that they have such an arrogant view of their mission and are not willing to incorporate some of the things which we have learned over the past 70 years."35
"I think a lot of my success with DSM was able to negotiate with different groups," Spitzer told me, "which helped me deal with analytic people better. "36 Some would say the reason for these battles was that the task force derailed almost all psychodynamic arguments about the mind while shunting the profession to neurochemical arguments about the brain. In creating dozens of new illnesses and altering the wording of countless more, the updated manual certainly helped psychiatry to jump tracks. Almost overnight, shyness and many other routine moods and ailments became bona fide diseases.
Given the pressure on Spitzer to make the APA'S large membership (forty-one thousand) agree to his group's recommendations, it may be unsurprising that a man surviving such conflict-including trying committees, tense correspondence, and sometimes-rancorous conventions would, at moments of acute irony or stress, appreciate that he was presiding over a house of cards.
As he made clear, Bruce Rounsaville's drawing of DSM-III's creation is meant to "acknowledge its limitations," an admission that must sound astonishing to those once dazzled by Spitzer's interpretive confidence or infuriated by his railroading.37
Yet the third edition of DSM appeared in 1980, just a couple of years behind schedule. (One can also imagine the smile from this perspective as endorsing persistence and canny diplomacy.) It provided detailed descriptions of more than three hundred mental illnesses at five hundred pages, a third of which (including social phobia).
Several unflattering articles greeted its appearance, including a lampoon in Harper)s Magazine ("The Encyclopedia of Insanity: A Psychiatric Handbook Lists a Madness for Everyone") and a lament by Peter Janulis in the Archives of General Psychiatry on the consequences of deleting "neurosis" from the DSM-a reasonable problem to raise and, for the discipline, an equally significant problem to solve. 38 Spitzer was not in the mood for concessions, and with two colleagues, he responded with a poem that even The Lancet, supporting their approach, called "arrogant doggerel"39
Peter [T. Janulis], use DSM-III for a diagnostic description and neurosis to help you with your prescription.40
Spitzer and his colleagues clearly thought they were witty in mocking psychoanalysis while drawing attention to "bad cognitions" and "a transmitter lacking in your brain." Still, it would not be easy to find a more tone-deaf response to the widespread concerns of Janulis and others. Spitzer and the task force had purged, at a stroke, almost a century of thought.
Even so, the reply makes clear; Spitzer was blithe about consequences. Though the manual needed more tweaking and updating, Spitzer wanted new illnesses added, and his task force believed the DSM had transformed the profession. The psychiatrists attending the final key meeting gave Spitzer a standing ovation that left him speechless and teary-eyed. But the stampede toward neuropsychiatry had all but flattened the intense arguments over the truth and accuracy of the new categories.
The outcome was especially galling to them because the losses they endured-of authority, prestige, and power to determine the future of their field-did not feel like a fair defeat. Instead, the cards were stacked against them from the start. As Healy observes, "The creation of DSM-III was the Trojan horse by which they affected entry into the citadel of psychoanalysis."41 William Frosch, who later joined the task force, was even blunter: "Once people realized a lot of icons were being smashed, then everyone wanted a piece of the action."42
The fears psychoanalyst Otto Kernberg voiced at the time, therefore, seem justified. The neo- Kraepelinians was, he said, a group "whose ideas are obvious, very publicly known and [whose] guns are pointed at [psychoanalysis]."43 In light of such acrimony, it is all the more remarkable that Spitzer and his colleagues recall this episode as stringent and fair.
The analysts might have foiled him. They could have drawn comparisons between the DSM emphases his colleagues supplied and those already accepted by European psychiatry, which "uses the term neurosis." Spitzer backtracked quickly after realizing what he'd said. The key difficulty with neurosis) he added that "it would be hard to define what the boundaries of that category would be."44 What the term should include, in other words, is as fraught as what it must exclude.
The task force faced this problem all the time. For instance, Spitzer and his committee members openly lamented the number of "issues" they "wrestled with" when trying to nail down the major criteria of social phobia, even admitting that their definition of the disorder's cut-off point was "open to multiple interpretations."45 Supportive colleagues intent on retaining these and other terms in future issues of the DSM still fret that the disorders "appear not to have meaningful thresholds."46
Had a canny analyst asked Spitzer why the European model couldn't prevail, he admits it would've been a tough argument. "I suppose the reason they use" terms like neurosis, he muses, referring to the history of Freud. Freud developed those categories. " 47 Certainly, Freud did develop many new terms to describe his patients' behavior, and many of his followers applied the terms narrowly and reductively, especially in the 1940s and I950S, trying to fix the behavior as a component of the patient's identity, in ways that ended up pathologizing them.
Freud's work differs massively from the judgments of his midcentury practitioners. I doubt those arguing with Spitzer ever heard him say, "We've got to get rid of the word neurosis because it has psychoanalytic meaning." He joked about various psychoanalytic opponents and institutions, saying, "strategy of entrapment" was no longer possible. The games and strategies fall away at such moments, leaving the stakes for Spitzer and his opponents in plain sight.
The war over Freud was not the only controversy to emerge. Another was how the Task Force on Nomenclature and Statistics set about devising the new disorders. It sometimes pushed through reforms so hastily and vehemently that many observers found the process extremely disconcerting." During a forty-minute conversation" in Washington, Alix Spiegel observes, Spitzer and two other psychiatrists "decided that 'hysterical psychoses' should really be divided into two disorders. Short episodes of delusion and hallucination would be labeled 'brief reactive psychosis,' and the tendency to show up in an emergency room without authentic cause would be called 'factitious disorder.' 'Then Bob asked for a typewriter,' [Roger] Peele says. To Peele's surprise, Spitzer drafted the definitions on the spot. 'He banged out criteria sets for factitious disorder and brief reactive psychosis, and it struck me that this was a productive fellow! He comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders!"50
Not all maladies received such cursory attention; some generated much lengthier discussions. But Peele's retort about Spitzer's "productiveness" hints uneasily that the chairman's zeal could sometimes tip into unrestrained inventiveness. While meticulousness was hardly the group's forte, countless other procedural questions marred its work. Just as no firm guidelines established how long discussion about each illness should last, there were not enough people holding Spitzer accountable for the final wording. "He must have had some internal criteria," David Shaffer says. "But I don't always know what they were."51
Part of the problem, Paul Fink grasped, was that "all communications" concerning the task force and its working groups were "filtered through Bob Spitzer." By Fink's reckoning, Spitzer also scheduled too few meetings; by the time the annual ones came around, a lot of business and discussion "had been handled through correspondence which served to divide and conquer, leaving much of the final decision in Bob's hands, with the help of people like Don Klein who works in the same institution with him." A third and even more basic problem was that "the process by which the DSM III has been developed [was] highly prejudiced," since the task force was "from the very beginning, very much skewed toward a phenomenological and descriptive point of view, and [was] quite anti-psychodynamic.”52
Spitzer wouldn't characterize the problems or biases in this way. Still, he agrees he "picked everybody that [he] was comfortable with." They were drawn primarily to "diagnostic research and not to clinical practice." "53 By laying down, so few guidelines, Sabshin and Marmor seemed carefully neutral in 1974-when things were getting underway, but their hands-off approach gave Spitzer carte blanche to proceed. In selecting only "kindred spirits," then, he either forgot or tried to ignore the other side of the equation-the psychodynamic colleagues who had dominated the profession for decades and doubted Spitzer's emphasis on diagnostic reliability.
The net effect was that key debates got bogged down over first principles. While the task force redressed psychiatric terminology, much of the discussion and correspondence swirled around more elemental conflicts. According to Spitzer and his allies, the analysts feeling threatened and under attack became aggressive, envious, and obstructionist.54 When word reached them that the task force planned to eliminate neurosis from DSM-III, they were "aghast." But in a real sense, the neuropsychiatrists were doing just that. Moreover, to the analysts, neurosis wasn't just a "bread-and-butter term”55; its elimination, although needless, was slyly motivated to undercut their standing. When they tried to reason with Spitzer, they found him capricious and unyielding. He had responded to others and me that he proposed several compromises.
Spitzer became especially animated when revisiting this period with me, recalling the fight from almost three decades ago as if it had unfolded yesterday: You know, the analytic critique of DSM-III as it was developing was not, "We have another way of classifying." It's not like they said, "Here's our system for classifying." Their main complaint was that in the description of the disorders, we left out psychodynamic factors.
Now there's one interesting story about that. The American Psychoanalytic Association had a liaison committee that met with me. And the chair of their committee said, "You know, the problem is, we know so much more about these disorders than DSM-III puts in there." Well, what he meant was, we know the psychodynamic [side]. So I said, "Why don't you take one disorder and write it up the way you think, with the stuff we don't have in there?" So they gave it to Larry Rockland. He took OCD, and he wrote up the psychodynamics. And it was embarrassing. He had included "anal conflicts" and stuff. So we said, "This just won't fly. This is not something we can use."56
Spitzer, in fact, responded differently to his colleagues and opponents, 57, but he does have a point.58 psychodynamic approaches to diagnostics tend to flounder; they freight clinical treatment with a set of empirical expectations that psychoanalysis, in particular, sees as anathema. Freud explicitly refuted such expectations. So Spitzer's invitation raised a fundamental question about apples and oranges that he surely knew he could win. (That doesn't mean that apples-in this case, neuropsychiatry should prevail.)
Nor is Lawrence Rockland's correspondence with Spitzer at all "embarrassing"; on the contrary, it comes across as smart and reasonable. "It seems to be part of the general argument throughout DSM III," he observed in early 1978, "that lists of symptoms are somehow more scientific and 'harder' facts than muddle-headed psychodynamic theorizing and fantasizing. I think that this is a very unfair characterization of psychological thinking." Instead, he wanted more attention paid to "the particular shades and varieties of intrapsychic conflict," which, as he underscored, "exists in all psychopathology and all people." What this required, in practical terms, was "an attempt at a positive diagnosis of anxiety disorder based on a psychodynamic understanding of the patient, the patient's conflicts, and the psychosocial stresses operative which add up to a coherent picture of why the patient developed an anxiety neurosis at this time."59
Rockland's was far less of a cookie-cutter approach than Spitzer wanted and had taken it upon himself to mandate. Even so, it seemed unfair to dismiss Rockland's suggestions; and Leo Madow, chair of the liaison committee, wrote to say so, in a letter sufficiently important to reproduce it in full:
I am sure you can realize my deep concern when I spoke to you on the phone. You indicated that your Committee had met and apparently was rescinding the modifications we had recommended and that had been incorporated in the revision you sent me.
As you know, we have been trying for some time now to make changes in the DSM III that we felt were a contribution from our present state of knowledge of psychodynamics. As mentioned above, Larry Rockland, one of our Committee members, had submitted material that had been apparently rejected at first. Still, then some of the material was incorporated, particularly under the category of "predisposing factors."
When our Committee on DSM III met on Friday, December 16, 1977, in New York with Bill Frosch, this was reaffirmed. We were quite enthusiastic and made assignments for other categories to be re-written following the model of Larry Rockland. These included:
1. Disorders arising in childhood and adolescence;
2. Impulse disorders;
3. Personality disorders;
4. Psychosexual disorders; 5. Somatoform disorders.
When your phone call indicated another change, apparently following a Task Force meeting, I must confess I felt quite defeated and wondered what could have happened.
I gather that this meeting did not include Bill Frosch but that you had conveyed the information to him. One of my confusions, then, is that I had thought that Bill and Jack Frosch had been added as members of your Task Force. Was this action to rescind an action of the whole Task Force?
How should we proceed? We are still eager to submit material for you. We indicated in the past that you would welcome this material and felt the lack of our participation. Now that we have evolved the machinery to develop contributions, it appears we are being blocked in our efforts to recommend these changes. Is there any appeal mechanism?
Leo Madow, M.D., Chairman Ad Hoc Committee on DSM III
The American Psychoanalytic Association 60
Whether Spitzer felt the lack of analysts' participation was "a lack of diplomatic intent" or Madow was saying so to be diplomatic must remain in doubt. There was no mechanism for appealing. So when the revised system collapsed, Spitzer explained, "the analytic group tried to defeat the whole thing."
The analysts wanted to hammer out the first principles. They pointed out that they were set to fail by false deadlines, inadequate lead time, lack of committee representation, and predetermined outcomes. As two other liaison committee members observed, when the analysts and their allies said, "Please let us have a sandbox to play in," the reply they most often received was, "Here we play baseball. "62
The analysts believed they were being treated with disdain. Small wonder they felt manipulated, sabotaged, and ultimately betrayed. Even Spitzer concedes, "I came up with all kinds of ways of muting their concerns. "63
Business wobbled along in this uneven way for months, with only the hardiest or most stubborn prepared to drag out the fight. As Spitzer pressed on with his mission, presumably taking minutes as he tapped away during meetings, discussion hovered over a topic that, in Spitzer's mind, was already settled: whether mental ailments were really medical disorders.
This issue dominated the arguments on and off the task force, all related questions, including how the psychiatrists should classify suffering-came back to this bedrock problem. As Spitzer admits, diagnosis is at the heart of psychiatry, and thus the source of so much acrimony, because it "defines what the reality is. "64
The first matter here is that the terms proposed, like avoidant personality disorder and social phobia, were not just descriptive. They were also prescriptive. Simply to include them in a "Diagnostic and Statistical Manual of Mental Disorders" was to convey that they are bona fide mental illnesses needing psychiatric attention. To rule out other terms, such as anxiety neurosis, was also to broadcast that these were outdated ways of labeling or thinking about illnesses.
To psychiatrists, the word disorder implies a stronger biological connection than neurosis. This last term recedes further into the eighteenth century while generally conveying nervous energy eruptions that would classify it as a psychological conflict.65
A second related matter concerns the parameters for each diagnosis, including when a psychiatrist should indicate that a patient is ill. The DSM-III task force stressed "nomenclature and statistics." While the guidelines were far from being so, one memo advised that a diagnosis should be made if the criteria for that diagnosis are met. 66
"The initial task force memorandum," comments Mitchell Wilson, "clearly stated a desire to erect a high threshold for making a psychiatric diagnosis, but with the addition of new diagnostic categories, the threshold for making a diagnosis was lowered. As DSM-III went through its various modifications," he explains, summarizing crucial letters and procedural turns, "it became more inclusive."67 To appalled onlookers promised scientific rigor; Spitzer set the bar for inclusion far too low.
"We didn't want anybody to feel that their diagnostic concepts were being excluded," Spitzer explained in another interview, magnificently ignoring the psychodynamic colleagues who felt exactly that. So "we took the attitude that we would include anything that seemed reasonable, that we could make some attempt to operationalize."68 Given the task force's low standards and vaulting ambition, it's difficult to say what would not be included.
What in theory constituted a new disease? Spitzer said, "How logical it was, whether it fits in. The main thing was that it had to make sense. It was just the best thinking of people who seemed to have expertise in most of the categories. "69 In other words, his friends would approach him and say they had conducted trials with promising results that fit his vision for the DSM. Bingo! Another disorder was added to the list.
But Spitzer wasn't giving the fullest account of his rationale, which was more elaborate and certainly more manipulative. To his allies, for instance, he would periodically explain, sotto voce, that "the only way to block" his enemies, and so win the "bloody battle" over terms like neurosis) "was to offer an alternative" that made him feel he was forging a "peace treaty" comparable to that emerging between Egypt and Israe.70
"I was convinced I was dynamite," he boasted, even if Northwestern University's Jules Masserman, less impressed, called his bragging "a self-righteous propaganda campaign."71 At other times, Spitzer appeared to be "a magician." At least that's what Allan Stone, then president of the APA, once said to him. "When I would appear in front of the committee, Spitzer proudly relays, "I could just get my way by talking and whatnot.”72
So politics sometimes clouded the science-in this case, the politics stemming from a hundred years' war-and overwhelmed the many improvements, big and small, that DSM-III made over DSM-II, including the later edition's greatly increased clinical reliability and more systematic research. Regrettably, the perspective offered by Spitzer veers disconcertingly from that of a faceless bureaucrat and impersonal scientist to that of a radiant prophet or entertaining maestro, presiding once more over a wobbly house of cards.
If all of these deliberations begin to seem inspired by Lewis Carroll's looking-glass world, we aren't alone in thinking so. After publishing three influential essays on psychiatric diagnosis in the mid-I970s, Alvan Feinstein, Yale Professor of Medicine and Epidemiology, presented a paper containing this intriguing hint: "Be sure to heed the Queen's advice to Alice in Wonderland: Consider everything." It wasn't by any means Feinstein's weightiest suggestion.
"Concentrate on raw evidence and [the] standardization of elements," he cautioned, and "avoid arbitrary demarcations." Yet "as you struggle with the magnitude and complexity of this enormous challenge," he couldn't resist adding, "don't get too depressed. "73
Appearing roughly midway through Spitzer's term as task force chair, when things were starting to slip, Feinstein's advice was so well-timed that when Jacques Quen recommended his work, after an evening's discussion with Spitzer, the chairman responded with alacrity, vowing to contact Feinstein immediately and adding, with almost a spring in his step, "Keep us on our toes."74
In Carroll's topsy-turvy world, the Queen is better known for ordering capricious executions than for promoting encyclopedic knowledge ("Off with their heads!" is doubtless more memorable than her peculiar variant of "Know thyself"). Yet if the Queen's advice seems a curious addition to Feinstein's otherwise sober analysis, Spitzer himself began a lengthy treatise on "Classification and Nosology in Psychiatry," two years earlier, with an epigraph from Carroll's sequel, Through the Looking Glass:
"What's the use of their having names?" asked the Gnat, "if they won't answer to you?" "No use to them);" said Alice, "but it's useful to the people that name them. If not, why do things have names at all?"
The following article is rather dry, making Carroll seem unworthy of our hunger for the stolid main course. But the epigraph is strangely apt. In all of Carroll's works, philosophical games about names, meaning, and nonsense play a significant role. Consider Masserman's jibe about its playing "antics with semantics" and Lehrman's crueler observations that its "pseudo-scientific veneer" led to such Carrollian wordplay as "continuingly unstable personality." Tongue in cheek, Lehrman called these personality disorders "stably unstable." I do not recall seeing a patient with a 'continuingly unstable personality.' I have seen many adolescents without goals."
When John Frosch, a late addition to the DSM-III task force, announced his resignation in 1978, moreover, he explained that all the bickering and guesswork had given him "an Alice in Wonderland feeling."77 And as one burrows through the group's vast correspondence, trying to make sense of its arcane, sometimes hilarious discussions, it's not difficult to see why. One can also share Frosch's disbelief and Lehrman's exasperation-indeed, feel that one is, like Alice, either tumbling down rabbit holes or hotly pursuing a mad hare that is about to dart into a new psychiatric Wonderland.
Frosch had reason to feel vertigo, for Spitzer encouraged him to join the task force at a particularly turbulent point in its history. In his and Ronald Bayer's "history of the controversy," Spitzer calls Frosch and his nephew "a perfect choice" for the group, as both were analysts who nonetheless "accepted the descriptive, criteria-based approach to diagnosis." For this very reason, though, they soon found themselves in "an unenviable position.”78
The analysts who observed such business with their faces pressed against the glass expected John Frosch to fight at least some of their battles, yet his heterodoxy on the task force was not, Spitzer concedes, "always a welcome addition." Indeed, "they themselves believed," he writes of both Frosches, in alternating amazement and stunningly evasive attribution, "that, at times, their suggestions met with an unreasonable animus."79 That is one way of explaining why John Frosch resigned after two fruitless years on the task force and why William, replacing him, called the pervasive anti-Freudian hostility tantamount to icon smashing.
John Frosch participated in several meetings and urged the task force to compromise on one symbolic matter not to delete Hintsis from DSM-III. But the proposal came to nothing and appeared to have been met with stony silence. After that, he rarely contributed and, in his resignation letter, calls himself a "faineant" (idling). The final sentence of his opening paragraph trails off into bewildered or frustrated silence: "I respect the efforts and the energy of the participants, but I cannot help wondering at times -"80ing at self-censorship, his dash makes it seem as if he's biting his knuckles to hold back a flood of irritation.
Spitzer admitted that Bill was "pretty much a token figure."81 Although they were clearly unwanted guests, the Frosches were given a belated place at the table because the psychoanalytic community was up in arms about its lack of representation. It is not difficult to see why. The task force met and corresponded for almost four years before it even occurred to an onlooker, Herbert Pardes, that its membership and perspective were skewed entirely toward one approach: neuropsychiatry. "The resultant friction," Pardes warned, is "potentially divisive and likely to cause considerable strife within the psychiatric community. "82
Spitzer later characterized this moment as the psychoanalytic community's getting "very uptight." One might thus conclude that if Pardes had said nothing, even more than halfway through the task force's term, Spitzer would have carried on typing, keeping things just as they were.83
Although their invitations were clearly symbolic, the Frosches were meant to be cosmetic placaters, giving outraged analysts at least the illusion that things were fair and inclusive. Alice held the same illusion in Wonderland before realizing that the Queen's verdict was a foregone conclusion.
We have seen glaring discrepancies between how the task force was meant to work and how, in fact, its members tilted the issues to suit their perspective. But it's worth looking in more detail at the disparities between theory and practice because doing so gets us to the heart of a debate in psychiatry about how one defines-to say nothing of explains or endeavors to treat-mental illness.
"I don't subscribe to any particular etiology," Spitzer insisted, referring to different schools of thought on the causes of psychiatric illness. "As far as I'm concerned, I'm totally neutral. "84 But Spitzer's claim to disinterestedness looks almost comical beside correspondence explaining how he staged debates to predetermine their outcome, gloated over his obstructionist or "entrapment" strategies to allies, then torpedoed or sidelined countless other proposals, many of them psychodynamic, because they didn't fit his belief that DSM-III should be atheoretical-meaning that it should list only the symptoms of each illness and thus look agnostic about their probable causes.
Even without this contrary evidence, the phrase "truth and reliability in diagnosis," frequently ricocheting from one letter to the next, sounded increasingly like a call to arms.85 Certainly, it spurred a demand that the working groups under Spitzer's supervision standardize the traits and boundaries they gave each disorder, and thereby, in theory, stamp out awkward disparities in judgment.
Besides Emil Kraepelin, who gave it a model for classifying diseases from the nineteenth century, the task force had another, less distant precedent: colleagues in Washington University's psychiatry department who, under the guidance of Eli Robins and Samuel Guze, set out to define mental disorders in "descriptive, explicit, and rule-driven" ways.86 The St. Louis group wanted to devise firm criteria for each illness and undertook field trials that would measure, in strict, quantifiable ways, where the cutoff point for each disorder should fall.
It gives the impression of being very clear and exacting, describing every facet of an illness in rapid, surefire strokes. The overall medical picture seems so meticulously drawn as to be indisputable. One article on diagnostic criteria, coauthored in 1972 by John Feighner, Robins, Guze, and others, became so famous that it was soon known as listing simply the "Feighner criteria." However, its authors were adamant that every symptom had to be "chronic."
Consider Feighner's criteria for anxiety neurosis. "For a diagnosis" to be made, his team insisted, "A through D are required," and the symptoms of A alone are logged with striking precision: "A. The following manifestations must be present: (I) Age of onset before 4-0. (2) Chronic nervousness with recurrent anxiety attacks manifested by apprehension, fearfulness, or sense of impending doom, with at least four of the following symptoms present during the majority of attacks: (a) dyspnea [shortness of breath], (b) palpitations, (c) chest pain or discomfort, (d) choking or smothering sensation, (e) dizziness, and (f) paresthesias [tingling]." In specifYing how often these severe attacks must recur for a diagnosis to hold, paragraph B states unambiguously, "There must have been at least six anxiety attacks, each separated by at least a week from the others. "87
Feighner's team warned that its "criteria [were] not intended as final for any illness" and added, with refreshing candor, "Unfortunately, consistent and reliable laboratory findings have not yet been demonstrated in the more common psychiatric disorders," like anxiety neurosis.88 Even with this proviso, which Spitzer and many other psychiatrists conceded to be almost inevitable, the Feighner criteria became a beacon for one side of the profession. They set a new standard for measuring chronic maladies that patients and doctors once thought too subjective and unpredictable to bear such scrutiny.
The St. Louis group unnerved the wider psychodynamic community because its assessment of mental illness gave a rigid, one-dimensional account of symptoms. It amounted to a cookie-cutter approach to psychiatry. The notion that one could slot each person into diagnostic molds ruled out other factors, such as the dynamic nature of the illness. For psychodynamic clinicians, illnesses are not uniform because their symptoms are inherently unreliable guides to patient distress. The point is to unearth what is behind the symptom, not to take the latter as an end or a complete picture in itself.
Still, Bayer and Spitzer were right to observe that "with its intellectual roots in St. Louis instead of Vienna, and with its intellectual inspiration derived from Kraepelin, not Freud, the task force was viewed from the outset as unsympathetic to the interests of those whose theory and practice derived from the psychoanalytic tradition.”89 Kraepelin's doctrinaire approach to mental illness greatly influenced those at Washington University. Though Spitzer has played down his debt to the German, his colleague Gerald Klerman not only christened the task force "neo- Kraepelinian" but also later caused a ruckus when declaring, during a major debate about DSM-III, "The problem of [diagnostic] reliability [has] been solved. "90 Even Spitzer now winces at this unfortunate boast, telling me it was "regretful because the problem of reliability hasn't been solved at all."91 Nevertheless, concerning German psychiatry, Spitzer hoped to substitute reliability for validity and repeated Griesinger (Kraepelin's forebear) almost verbatim when asserting another crucial, polarizing statement: "A mental (psychiatric) disorder is a medical disorder."92
Of course, phrasing so provocative and tendentious failed to settle this crucial debate, and Spitzer's colleagues balked. While his definition extended a much longer one harking back to the nineteenth century, his allies actually found Spitzer's revisions too open-ended.
According to Klein, for instance, the idea that a "disorder or illness" might somehow "reflect social deviance or discomfort" wrongly eclipsed "that subclass of biological dysfunction that in a given society entitles the person to the exemptions inherent in the sick role." The enormity of Klein's intervention isn't difficult to grasp. If psychiatrists didn't specify whether an illness is chiefly biological or psychological, society might discount the symptoms, and patients couldn't say the impairment stemmed from factors beyond their control-for instance, chemical imbalances in the brain. As Klein declared starkly, "If a dysfunction produces minimal manifest disability, then society is less likely to award the sick role since the person should be capable of carrying out the usual social demands."93
Put another way, unless one says that anxiety and depression are chronic afflictions deriving entirely from biological problems, various subcategories in the DSM(such as "social phobia") might be dismissed as trifling problems that don't belong there. For one thing, medical insurance wouldn't cover them.
When word got out that Spitzer's team was redefining mental disorders, angry letters denounced the move. Howard Berk and Hector Jason, members of the liaison committee, resorted to sarcasm: "In the process of simplification and restriction, we see that the proposed nomenclature displays a generous measure of linguistic and conceptual sterility."94 Even a few of Spitzer's allies pleaded for restraint. Paul Chodoff called the definition needlessly "complicated and cumbersome" and added, weakly, "I wonder if we have to say that everything we are classifying is a mental illness."95
Of all the skeptics, Richard Schwartz at the Cleveland Clinic put the issue best: "My quarrel with DSM-III," he declared, "is that for many of the disorders listed therein, the social consensus that they are true diseases and should be managed by the psychiatric profession is lacking." The task force had resorted to classifying as illnesses "abnormalities of thought, emotion, or behavior" that" lie outside the domain of psychiatry. "96
Spitzer's allies were upset because they had tried to dance around this particular minefield, opting for a less contentious model of mental illness. As Henry Pinsker stated in an early memo from June 1975, "Our Task Force has been unanimous that mental disorder should be defined narrowly, and that people should not be called mentally ill simply because they are different or unhappy. "97 To credit every psychological disorder with an underlying medical origin struck the Spitzer group as not only a massive and unnecessary shift in thinking but also a betrayal of first principles.
Unsurprisingly, qualms began to crystallize around the increasingly rigid use of Kraepelin. As Madow muttered semi-privately to Lester Grinspoon, "I hope that we were able to indicate our feelings that this document will not enhance the image of American psychiatry but rather appears to be a neo- Kraepelinian approach which indicates the level of our knowledge of the field to be at a point much less developed than it really is.”98
In his defense, Spitzer was concerned that diagnostic terms such as neurosis would be "used in two very different ways by different groups within our profession. "99 This worry sounds quite reasonable until you consider that similar ambiguities riddled DSM-III. As Spitzer wanted the manual to list only symptoms, the conflict over neurosis should never have arisen. But since he had sided with the neuropsychiatrists over the fate of this term, reminding his task force members of "our long-standing opposition to the inclusion of neurosis in the DSM-III classification," he could hardly claim to be impartial.lOO Transparently, his task force was trying to ban terminology associated with psychoanalysis, as Spitzer admitted to me. Jaso and Berk pointed this fact out to him at the time when lambasting the group's "large-scale, arbitrary extirpation of established concepts." They complained, "The DSM-III gets rid of the castles of Neurosis and replaces it with a diagnostic Levittown."101
Once again, advancing a theory of mental illness and trying to crush one's enemies became inseparable. Each theoretical claim also spawned many conceptual and procedural questions that beset the task force for years. Even among Spitzer's "kindred spirits," no one could guarantee that psychiatrists would interpret every sign of illness the same way ("interrater reliability," in the lingo of the field). Spitzer's group could list all the telltale signs of a particular disorder and hope these were sufficiently complete to rule out misdiagnoses ("false positives").102 But there was still the thorny issue of who would assess a patient's distress and dysfunction and stipulate that they were suffering from generalized anxiety, say, rather than an avoidant personality disorder.
In practice, DSM - III made it unnecessary to choose. When in doubt, psychiatrists could simply list both. Still, as the task force had staked its reputation on diagnostic clarity and reliability, it needed to set a clear example. And as these judgments varied wildly among the field's leading experts, what hope was there of producing flawless consensus in the wider culture?
After completing the field trials, the psychiatrists would shrink the patient responses to fit an abstract concept like "social phobia." Devising the criteria for such terms was a major act of interpretation, involving clinical and sometimes moral judgment and speculation. As George Vaillant put it, "DSM- III represents a bold series of choices based on guess, taste, prejudice, and hope."103 Once the diagnostic term appeared with its associated criteria in the DSM, psychiatrists would ideally interpret signs of it in just the same way by focusing on how many criteria a patient met.
In practice, however, the examining psychiatrist would seek only corroborating signs of pre-described traits and syndromes. Why? The committee's criteria for selecting and recording behavioral traits became so important and politicized. Irwin Marill and his Bethesda colleagues observed that the idea that "persons could 'objectively' be classified as 'average' [or not] by some 'average' ... psychiatrist promulgates a pseudo-objectivity which simply substitutes the subjectivity of the observer for the subjectivity of the patient."104
Spitzer's colleagues countered that they would only diagnose disorders causing patients acute distress, dysfunction, deviance, and danger (the so-called 4-DS characterizing abnormal behavior).105 But DSM-III flouted this principle repeatedly, partly because it lowered their diagnostic threshold and ignored the extent to which its procedures still relied on subjective interpretation and bias. As Marill and his coworkers insisted, the manual "ignores what we all know: namely, that a stimulus which is exciting and pleasurable for one person, maybe indifferent to a second, and horrifying or depressing to a third." 106
To put it differently, the attempt to bypass human judgment and produce a rule-driven account of a disorder's effects would almost certainly overlook profound differences in not an only degree but also kind. It would likely run together disparate kinds of behavior that only the psychiatrist naming the disorder would recognize. "That's a big problem," Spitzer acknowledged, and "it still is a big problem."
Beyond bias and interpretation, when the task force tried to apportion symptoms to each disorder, it found an illness like introverted personality disorder initially aligned with Axis II personality disorders. As the debate intensified, however, the same trait acquired the qualities of an anxiety disorder, which the task force had resolved should appear in Axis I, and so on.
Other protracted discussions spun out for months over ambiguous and dubious terms, such as oppositional defiant disorder, psychosexual relationship capacity disorder, labile personality, malingering, chronic undifferentiated unhappiness, chronic complaint disorder, and, most relevant here, withdrawn, sensitive, and introverted personality disorder, which will be part of the focus of P.2 of this 3 part expose.108
Among the "associated features" of chronic undifferentiated unhappiness, according to Steven E. Hyler, is that "the person with this disorder will often present a somber face. The corners of his mouth will usually be lower than the center; the shoulders are usually hunched, [and] the gait is slow." But it was in describing the signs of chronic complaint disorder that Hyler really found his stride: The essential feature [of] this disorder is the person's persistent and consistent complaining in such a manner that it is obvious to even the unskilled observer. To be included in this category are persons who heretofore were known by the synonyms: "kvetch," "scootch," "noodge," and just plain "neurotic."
An episode of acute complaining is usually elicited by the question: "How are you?" The pathognomonic response is, "Don't ask." The response complaints are of a general nature and include such diverse topics as the weather, the energy crisis, taxes, or the previous evening's track results .... Associated features in this disorder include an outlook on life characterized as pessimistic... The complaints themself [sic] are usually presented in a high-pitched whining fashion which is especially noxious to the listener. ... There also appears to be an ethnic association with this disorder in that it is found predominantly in persons Eastern-European ancestry. In these cases, the pathognomonic expression becomes, "Oy vay, don't ask." 109
Perhaps unsurprisingly, the task force rejected these and related proposals because it could not decide on their validity or distinct criteria. Often it simply adopted new categories to accommodate them, like "V: Codes for Conditions Not Attributable to a Mental Disorder That Is a Focus of Attention or Treatment." (Three examples: "V62.30: Academic Problem," "V61.10 Marital Problem," and "V62.81: Other Interpersonal Problem," whose symptoms include "difficulties with co-workers, or with romantic partners.")110 Perhaps it shouldn't surprise us, then, that one member joked that serving on the task force had been enough to induce the very pathologies it sought to classifY: "I have had a 309.28 [adjustment disorder ]," he declared, "over DSM III."111
The task force also made it possible for a patient's symptoms to count several times and thus qualify as multiple, simultaneous illnesses ("comorbid factors" in the new lingo), something "that happens nowhere else in medicine" (distinct illnesses may occur of course overlap). Earlier editions of the DSM had ruled out double jeopardy.112 Even so, when diagnosing patients, psychiatrists generally stick with the terms and criteria they memorized in medical school. 113 How likely was it then that they would monitor the appendix and disease criteria of each DSM edition in hopes of keeping up with the task forces' increasingly arcane distinctions?
One thing is clear: The proliferation of categories between DSM-II and DSM-III should have raised eyebrows among mathematical purists and even diehard neuropsychiatrists. The latter's response seems, in hindsight, almost supine. It was left to two professors of social work, Stuart Kirk and Herb Kutchins, to show that Spitzer and his colleagues offered only "the illusory precision of statistical accuracy." DSM- III) they wrote, had set the range of kappas too high (above 0.7 or even 0.8, rather than, as would be normal, a range from 0.4 to 0.6). Kappas are "an index of reliability that corrects for chance agreement" and thus a major factor in all DSM calculations. Spitzer's setting them too high skewed the math by greatly increasing the number of patients meeting the new criteria.1l4 When one adds such statistical problems to the conceptual ones here detailed, the results become chaotic. As Kutchins and Kirk put it in their follow-up study, Making Us Crazy) "By simply altering slightly the wording of a criterion, the duration for which a symptom must be experienced to satisfy a criterion, or the number of criteria used to establish a diagnosis, the prevalence rates will rise and fall as erratically as the stock market."115
Spitzer's rejoinder is in some respects surprising, given his ardent defense of DSM-III: "We've been accused of exaggerating how much reliability improved [in the third edition], which I think is not true .... If you ask clinicians now how reliable is the DSM or how much it's improved, I don't know what they'd say, but it's a modest improvement. It depends on the settings." These are best, he concedes, when the population of those afflicted is high, as in Anxiety Disorders clinics, but "it's very modest" if one tries calculating prevalence among even related groups, such as those attending outpatient clinics. 116
David Barlow, codirector of SUNY-Albany's Center for Stress and Anxiety Disorders, in fact, alerted Spitzer to this general problem in July 1985, warning: "The other difficulty we see with returning GAD [Generalized Anxiety Disorder] to the type of broad residual category that it occupies in DSM-III was the extremely low KAPPA that we achieved with that definition."117 The admission is very significant because it indicates the prevalence rates were low even among Barlow's clinical patients, a population that by Spitzer's reckoning should yield higher-than-average results.
Many would therefore discount the inclusion of that population, insisting they are not statistically representative. Barlow's statement also makes clear that the diagnostic criteria in DSM-III were at odds with the clinical reality and needed to be fixed, either by reducing the numbers said to suffer from GAD, which would shrink the magnitude of the disorder, or by relaxing the criteria used to gauge the suffering associated with it, which would maintain or even increase the disorder's apparent severity. With the solution pointing logically to the need to lower the disorder's prevalence, as the clinical population should always drive the criteria (not the reverse), one wonders with Kutchins and Kirk why Spitzer, already warned about the "extremely low KAPPA" result, ended up setting the range too high.
Healy writes: "Today's classification systems make it possible to have many different illnesses at the same time, something that happens nowhere else in medicine. It would seem inevitable that there must be a collapse back toward larger categories at some point." 118 Neuropsychiatrists today fiercely defend them by pointing to the vast numbers of North Americans they have identified as suffering from the afflictions cataloged. In light of this and other documented sleights of hand, David Faust and Richard Miner seem justified in asking whether DSM-III shouldn't be dubbed "the empiricist's new clothes." 119
"To be meaningful," Marill and his colleagues aptly forewarned in June 1977, psychiatric terminology "should not be changed casually or capriciously ...; otherwise fads of conceptualization may seriously interfere with the steady evolution of our science. We cannot be sure what we are talking about," they cautioned, "if someone is constantly pulling the words out from under us. "120
With one exception, all unpublished documents and correspondence quoted in this case study and part appearing on this page appear courtesy of the American Psychiatric Association.
1. Alix Spiegel, "The Dictionary of Disorder: How One Man Revolutionized Psychiatry," New Yorker(January 3, 2005), 56.
2. Herb Kutchins and Stuart A. Kirk, Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders (New York: Free Press, 1997),4-0.
3. D. L. Rosenhan, "On Being Sane in Insane Places," Science 179 (n.s.; January 19, 1973), 251, 252.
4. T. M. Luhrmann, Of Two Minds: An Anthropologist Looks at American Psychiatry (New York: Vintage, 2000), 224-.
See Joel Paris, The Fall of an Icon: Psychoanalysis and Academic Psychiatry (Toronto: University of Toronto Press, 2005). Blue Cross reduced its psychiatric coverage in the mid-1970s to 20 outpatient visits and 4-5 inpatient hospital days per year because it clearly favored neuropsychiatry over psychoanalysis. As its vice president explained, "Compared to other types of [mental health] services [the psychotherapeutic model] offers less clarity and uniformity of terminology concerning mental diagnosis, treatment modalities, and types of facilities providing care." This problem arises from the latent or private nature of many services; only the patient and the therapist have direct knowledge of what services were provided. "Blue Cross VP [Robert J. Laur] Says MH Prospects Cloudy, Psychiatric News (August 6, 1975), I, 6,7.
6. Melvin Sabshin, as quoted in Leslie Knowlton, "Melvin Sabshin: A Profile," Psychiatric Times 15.5 (May 1998). The point here is not that psychoanalytic practice had no interest in the description, simply that neuropsychiatrists and managed-care companies viewed it as operating according to loose empirical guidelines. For elaboration on matters of psychiatric description and diagnosis, see Karl Jaspers, General Psychopathology, trans. J. Hoenig and Marian W. Hamilton (194-8; Chicago: University of Chicago Press, 1963).
7. ICD-9 was published in May 1978, two years before DSM-III.
8. Although the phrase mirrors Sabshin's approach, it is actually that of Robert L. Spitzer and his co-authors in Spitzer, Michael Sheehy, and Jean Endicott, "DSM-III: Guiding Principles," Psychiatric Diagnosis, ed. I AM Vivian M. Rakoff, Harvey C. Stancer, and Henry B. Kedward (New York: Brunner/Mazel, 1977). See also Allen Frances and Arnold M. Cooper, "Descriptive and Dynamic Psychiatry: A Perspective on DSM-III," American Journal of Psychiatry 138.9 (1981), 1198 -202.
9. Robert L. Spitzer interview.
10. Spiegel, "Dictionary of Disorder."
11. Wilhelm Reich, Character Analysis, 3rd ed., trans. Theodore P. Wolfe (1933; New York: Orgone Institute, 194-9), 165.
12. Spitzer interview.
14. Some psychiatrists (including Spitzer) had sided with gay rights groups in arguing that homosexuality should no longer be considered a mental illness. Disagreeing vehemently, other psychiatrists resisted this move. As neither side would back down, the wrangle dragged on for several years, spilling into DSM-III discussions. Although the conservative psychiatrists ended up losing that battle, Spitzer came up with a compromise term ("Sexual Orientation Disturbance");. However, imperfect to both sides, it nonetheless paved the way for a more constructive dialogue. Indeed, by 1977 the discussion had shifted to ego-dystonic homosexuality, the term finally appearing in DSM-III. Even so, a large number of psychiatrists petitioned for its removal because it appeared to pathologize "homosexual arousal." See "Ego-dystonic Homosexuality," DSM-III (302.00), 281; and Ronald Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis (New York: Basic Books, 1981).
15. Allen Frances, as quoted in Spiegel, "Dictionary of Disorder," 60.
16. Donald F. Klein, as quoted in ibid., 58.
17. All but two of the task force were male, though Jean Endicott and Rachel Gittelman joined four outside consultants. The principal members ultimately were Robert L. Spitzer (chair), Nancy Andreasen, Robert L. Arnstein, Dennis Cantwell, Paula J. Clayton, William A. Frosch, Donald W. Goodwin, Donald F. Klein, Z. J. Lipowski, Michael L. Mavroidis, Henry Pinsker, George Saslow, Michael Sheehy, Robert Woodruff, and Lyman C. Wynne. Consultants in addition to Endicott and Gittelman were Morton Kramer and Theodore Millon. Woodruff died before DSM-III appeared.
18. David Healy, The Antidepressant Era (Cambridge, Mass.: Harvard University Press, 1997), 237.
19. David Healy, Let Them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry and Depression (New York: New York University Press, 2004-), 2; emphasis in original.
20. Spitzer interview by Ray Moynihan, quoted in Moynihan and Alan Cassels, Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All into Patients (New York: Nation Books, 2005), 108.
21. From the highly condensed and rather self-flattering version of events that Spitzer co-authored with Ronald Bayer, "Neurosis, Psychodynamics, and DSM-III: A History of the Controversy," Archives of General Psychiatry 4-2.2 (1985), 187-96, one would know only a fraction of the arguments documented by the unpublished correspondence.
22. Theodore Millon, as quoted in Spiegel, "Dictionary of Disorder," 59.
23. David Shaffer, as quoted in ibid.
24. An unidentified participant quoted in ibid.
25. Klein to Spitzer, March 29, 1978, entitled "Emotionally Unstable Character Disorder."
26. Spitzer to Klein, April 5, 1978. The letter is entitled "Emotionally Unstable Character Disorder-Revisited Once Again."
27. Spitzer to Klein, February 27, 1978.
28. Jean Endicott, as quoted in Spiegel, "Dictionary of Disorder," 60.
29. Renee Garfinkel, as quoted in Jamie Talan, "Diagnosis by the Book: Controversy over Revisions of the Manual Psychiatrists Use," Newsday (March II, 1986).
30. Leonore Walker, as quoted in ibid.
31. Irwin H. Marill et al. to Peele, June 6, 1977.
32. Waugh to Spitzer, July II, 1975.
33. N. S. Lehrman, "'Borderline Personality Disorders' Should Be Discarded (The Emperor's New Jockstrap )," unpublished, 9, 10.
34. Spitzer interview.
35. Fink to Grinspoon, May 15, 1978.
36. Spitzer, interview.
38. L. J. Davis, "The Encyclopedia of Insanity: A Psychiatric Handbook lists a Madness for Everyone," Harper's Magazine (February 1997), 61-66; and Peter T. Janulis, "Tribute to a Word: Neurosis," Archives of General Psychiatry 39.5 (1982), 623. See David Gelman, "Beyond Neurosis," Newsweek (January 8, 1979),68.
39. Editorial, "Goodbye Neurosis?" The Lancet 2.8288 (July 3, 1982), 29.
40. Robert L. Spitzer, Andrew E. Skodol, and Miriam Gibbon, "Reply," Archives of GeneralPsychiatry39.5 (1982), 623-24.
41. Healy, Antidepressant Era, 233.
42. William A. Frosch, telephone interview, August 18, 1989, as quoted in Mitchell Wilson, "DSM-III and the Transformation of American Psychiatry: A History," American Journal of Psychiatry 150.3 (March 1993), 407.
43. Otto Kernberg, as quoted in Healy, Antidepressant Era, 234.
44. Spitzer interview.
45. Richard G. Heimberg et al., "The Issue of Subtypes in the Diagnosis of Social Phobia," Journal of Anxiety Disorders 7.3 (1993), 263, 265.
46. Ronald C. Kessler et al., "Mild Disorders Should Not Be Eliminated from the DSM-V," Archives of General Psychiatry 60.II (2003), III8.
47. Spitzer interview.
49. Spitzer to Sachar and Klein, July 12, 1977. The one-sentence letter, prefacing Spitzer's July 8 "invitation" to Thomas Lynch, president of the Baltimore District of Columbia Society of Psychoanalysis, for "input into the further development of DSM-III," reads: "You may enjoy the enclosed as an example of my strategy of entrapment."
50. Spiegel, "Dictionary of Disorder," 59-60.
51. Shaffer, as quoted in ibid., 59.
52. Fink to Grinspoon, May 15, 1978.
53. Robert L. Spitzer, "A Manual for Diagnosis and Statistics," 53.Psychopharmacologists III: Interviews with Dr. David Healy (London: Arnold, 2000),418; Spitzer, interview by Mitchell Wilson, September 17, 1989, as quoted in Wilson, "DSM-III and the Transformation," 404; and Bayer and Spitzer, "Neurosis, Psychodynamics, and DSM-III," 188.
54. Spitzer, "Manual for Diagnosis and Statistics," 4-24-.
55. Klein, as quoted in Spiegel, "Dictionary of Disorder," 61.
56. Spitzer interview.
57. See his reply to Leo Madow, January 30, 1978, which unfortunately is much too long to reproduce, but which outlines several responses to Rockland's work and its implications for the task force.
58. See Benedict Carey, "For Therapy, A New Guide With a Touch of Personality," New York Times (January 24-,2006), on the Alliance of Psychoanalytic Organizations' recently published Psychodynamic Diagnostic Manual (Silver Spring, Md.: Psychodynamic Diagnostic Manual, 2006).
59. Lawrence Rockland, "Some Thoughts on the Subject: Should Psychodynamics Be Included in the DSM III?" (January 1978).
60. Madow to Spitzer, January 4-,1978.
61. Spitzer interview.
62. Hector Jasa and Howard E. Berk, Memo to the Task Force, June II, 1976.
63. Spitzer, "Manual for Diagnosis and Statistics," 4-24-.
64. Ibid., 4-27.
65. See the memo from Millon to Spitzer, "On Neuroses," September 18, 1974-. Also, Millais Culpin, "The Conception of Nervous Disorder," British Journal of Medical PsychologY35 (1962),73-80.
66. Minutes of the September 4-,1974-, meeting of the Task Force on Nomenclature and Statistics, as quoted in Wilson, "DSM-III and the Transformation," 4-05.
67. Wilson, "DSM-III and the Transformation," 4-06. See also Stuart A. Kirk and Herb Kutchins, The Selling Of DSM: The Rhetoric of Science in Psychiatry (New York: de Gruyter, 1992), 103 - 5.
68. Spitzer, "Manual for Diagnosis and Statistics," 4-24--25.
69. Spitzer, as quoted in Spiegel, "Dictionary of Disorder," 59.
70. Spitzer, Memo to Task Force Members, April 2, 1979, entitled "The Beginning of the End, Neurotic Disorders and My Neurotic Behavior"; Spitzer, Memo to Task Force Members, April 25, 1979, entitled "Our Travails Never Seem to End"; and Spitzer, Memo to the Assembly Liaison, Joint American Psychoanalytic Association, and American Academy of Psychoanalysis Committees, March 27, 1979, entitled "April 7th Meeting and Possible Neurotic Peace Treaty."
71. Spitzer to Task Force Members, April 25, 1979; Masserman to H. Keith Brodie, April 24-, 1979.
72. Spitzer, "Manual for Diagnosis and Statistics," 4-24-.
73. Alvan R. Feinstein, "A Critical Overview of Diagnosis in Psychiatry," paper presented at the Fourth C. M. Hincks Memorial Lectures, Toronto, November 19, 1976.
74. Spitzer to Quen, February 19, 1976.
75. Robert L. Spitzer and Paul T. Wilson, "Classification and Nosology in Psychiatry and the Diagnostic and Statistical Manual of the American Psychiatric Association," published as "Nosology and the Official Psychiatric Nomenclature," Comprehensive Textbook of Psychiatry, 2nd Edition, ed. Alfred M. Freedman, Harold 1. Kaplan, and Benjamin J. Sadock (Baltimore: Williams and Wilkins, 1975), 1:826-45.
76. Jules H. Masserman, "On Indefinite Definitions," The Proposed DSM-III: Critiques by Participants of the Conference on Improvements in Psychiatric Classification and Terminology: A Working Conference to Critically Examine DSM-III in Midstream" (St. Louis, June 1976), 7d; and Lehrman, '''Borderline Personality Disorders,'" 9-10, 4-5.
77. John Frosch to Spitzer, December 4-,1978.
78. Bayer and Spitzer, "Neurosis, Psychodynamics, and DSM-III,"190.
79. Ibid. The authors' own footnotes refer to two unpublished interviews with the Frosches in May and June 1982.
80. John Frosch to Spitzer, December 4-,1978.
81. Spitzer interview.
82. Pardes to Grinspoon, May 19, 1978.
83. Spitzer, "Manual for Diagnosis and Statistics," 419.
84. Ibid., 4-21.
85. David Dorosin to Spitzer, May 17,1976.
86. Wilson, "DSM-III and the Transformation," 404.
87. John P. Feighner et al., "Diagnostic Criteria for Use in Psychiatric Research," Archives of General Psychiatry 26.1 (1972), 59. Robert A. Woodruff, one of the authors, later served on the DSM-III task force.
88. Ibid., 57.
89. Bayer and Spitzer, "Neurosis, Psychodynamics, and DSM-III,"188.
90. Gerald L. Klerman, "The Advantages of DSM-III," in "A Debate on DSM-III" with George E. Vaillant, Robert L. Spitzer, and Robert Michels, American Journal of Psychiatry 141.4 (1984), 541.
91. Spitzer interview.
92. Spitzer to Professor Sir Martin Roth, June 3, 1976.
93. Donald F. Klein, "Definition of Disorder, " The Proposed DSM-III: Critiques, Id.
94. Jaso and Berk, Memo to the Task Force, June II, 1976.
95.Chodoffto Spitzer, June 16, 1976.
96. Richard A. Schwartz, "Personality Disorders," The Proposed DSM- III: Critiques, 8d.
97. Pinsker to Members of the Task Force on Nomenclature and Statistics, June 4, 1975.
98. Madow to Grinspoon, September 14-, 1978. Stanford's David Dorosin also concluded to Spitzer, "In our search for a 'truth and reliability in diagnosis' nosology, I'm still not convinced that we have to go back as far as Kraepelin to maintain the integrity of a profession with our range and depth of responsibilities in contemporary society" (Dorosin to Spitzer, May 17, 1976).
99. Spitzer to Offenkrantz and Jasa, March 19, 1979.
100. Spitzer to Task Force Members, April 2, 1979.
101. Jaso and Berk, Memo to the Task Force, June II, 1976.
102. See, in particular, Robert L. Spitzer and Jerome C. Wakefield, "DSM-IV Diagnostic Criterion for Clinical Significance: Does It Help Solve the False Positives Problem?" American Journal of Psychiatry 156.12 (1999),1856-64.
103. George E. Vaillant, "The Disadvantages of DSM- III Outweigh Its Advantages," American Journal of Psychiatry 141.4 (1984), 545.
104. Marill et al. to Peele, June 6, 1977; emphasis in original.
105. Klein, "Definition of Disorder," Id.
106. Marill et al. to Peele, June 6, 1977.
107. Spitzer, interview by author.
Concerning the term labile personality, Arthur Rifkin wrote to Spitzer, June 30, 1978: "Should this be considered for personality disorder or affective illness?" For discussion of the proposed term "malingering," see Steven E. Hyler to Spitzer, May 17, 1978.
109. Steven E. Hyler, "Chronic Undifferentiated Unhappiness" (CUU) and "Chronic Complaint Disorder" (CCD), which Spitzer forwarded to the task force for consideration on May 1O, 1977. His cover letter reads, doubtless with some irony, "Enclosed are draft versions of two new disorders for possible inclusion in DSM-1I1 ... It is gratifying to see that the methodology that we have so painstakingly developed for the 'traditional' disorders applies equally well to disorders yet awaiting discovery."
110. "Academic Problem," "Marital Problem," and "Other Interpersonal Problem," DSM-III(V62.30, V6I.Io, V62.81), respectively 332, 333, and 334.
111. Jules H. Masserman, "A Critique of the Current Version of DSM-III," unpublished paper appended to his April II, 1979, letter to Boyd L. Burris.
112. Healy, Antidepressant Era, 175.
113. Luhrmann, Of Two Minds, 54.
114. Ibid., 229. See also Kirk and Kutchins, Selling of DSM, esp. 56 - 63.
115. Kutchins and Kirk, Making Us Crazy, 24-4-.
116. Spitzer interview.
117. Barlow to Spitzer, July 26, 1985.
118. Healy, Antidepressant Era, 175.
119. David Faust and Richard A. Miner, "The Empiricist and His New Clothes: DSM-IIIin Perspective," American Journal of Psychiatry 143.8 (1986): 962- 67.
120. Marill et al. to Peele, June 6, 1977.