Imagine that it is 1974, and you are given the following task: Create a modern system of cataloguing and organizing the vast and dark chaos of psychological suffering. If done well, it will become the official diagnostic manual for millions of mental health clinicians in the United States and in the world, for decades to come.
Here are your tools: a 1962 spiral bound manual of 150 pages (DSM-II), a small cadre of experts to serve as colleagues and assistants, and a scientific understanding of neurobiology so slim that it had barely reached its infancy.
Courtesy Eve Vagg
Dr. Robert L. Spitzer
This was the job assigned to young Robert Spitzer, then a faculty member at Columbia University. Dr. Spitzer had been tangentially involved in the creation of the DSM-II, and was offered chairmanship of the DSM-III – a job that was at that time considered fairly insignificant. But Dr. Spitzer took it on with relish, and to the surprise of the profession, transformed the DSM into the defining document of modern psychiatry. Robert L. Spitzer died on Christmas Day this past year at the age of 83.
Over the years, Dr. Spitzer has become a household name in psychiatry, a larger-than-life figure. He is thought of by many as the architect of modern psychiatry, but also as a brilliant and brash disrupter who expunged the word “neurosis” from our diagnostic vocabulary, who persuaded organized psychiatry that homosexuality was not a disease, and who laid the groundwork for a system of thinking about mental illness that has guided the field for the past 36 years.
The Bob Spitzer I met was far more approachable than the myth suggests. Ten years ago, I emailed him out of the blue, to request an interview for a book I was writing about the state of psychiatry. To my surprise, not only did he respond positively, but a few weeks later, in December 2007, he had arranged a limo to drive me from La Guardia Airport to his house in a suburb of New York a block away from the Hudson River.
Butterflies in my stomach at the prospect of meeting a living legend, I wheeled my luggage from the limo and knocked on the door, and Dr. Spitzer himself opened it. He was wearing an apron, greeted me with a big smile, and asked me how I liked my eggs. We soon sat down at a kitchen table bathed in sunlight from the windows overlooking his back yard, and we ate cheese omelets and sausages, as we talked about the DSM and his career.
Dr. Daniel J. Carlat
Our conversation was wide ranging, but I’ll recount one interchange because it encapsulates Bob’s relentless honesty and thirst for the truth – both of which were key ingredients in his genius and his legacy.
I had always been curious about how the definition of depression was transformed from the vague “depressive neurosis” in the DSM-II (“This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession”) to the precisely defined “major depressive disorder” in the DSM-III.
Bob described the DSM committee process, the long hours of reviewing the literature, and the field trials in which psychiatrists were recruited to test drive the committee’s proposed criteria in their patients. Much of this I had read about, both in the various versions of DSM and in the many articles that Bob and his colleagues had published.
But I had more questions – especially about depression.
“I now understand the process of how you gathered the data,” I said. “But exactly how did you decide on five criteria as being your minimum threshold for depression?”
He took a sip of orange juice and thought for a second. “It was just a consensus. We would ask clinicians and researchers: ‘How many symptoms do you think patients ought to have before you would give the diagnosis of depression?’ And we came up with the arbitrary number of five.”
“But why did you choose five and not four? Or why didn’t you choose six?”
He smiled impishly, looking me directly in the eyes. “Because four just seemed like not enough. And six seemed like too much.”
Even with the benefit of the field trials, Bob pointed out to me, “there is no sharp dividing line where you can confidently say, ‘This is the perfect number of symptoms to make a diagnosis.”