The Most Important Psychiatrist of our Time

December 17, 2010 was a special day in the history of psychiatric diagnosis. Bob Spitzer retired after a remarkable 52 year career. The event was celebrated in a warm and wonderful conference held in his honor at Columbia University-- where Bob has worked for the past 52 years. Dozens of Bob's colleagues and students gave speeches describing his powerful influence on our field and his personal impact on our lives. 

Without doubt or peer, Bob has been the most important  psychiatrist of our time. Freud and Adolph Meyer were the greatest influences on American psychiatry during the first part of the twentieth century. But Spitzer replaced them in 1980 with the publication of DSM-III. And he will remain the central figure until we can eventually go beyond his method of descriptive diagnosis with biological tests and a deeper understanding of the manifold causes of psychopathology.

Unfortunately, this will be  a painstakingly gradual process lasting many decades. Certainly, the remarkable neuroscience revolution is revealing the secrets of our nature, but it has at the same time taught us how complicated and heterogeneous are the causes of mental illness. There is no one schizophrenia-- the clinical picture we describe with this term may be caused by hundreds of different underlying causes. Describing psychiatric disorders clearly is a blunt but useful instrument in diagnosis and treatment- - the best we can do until we understand them on a much deeper and more detailed level. And Bob has been and will remain our master describer.

Before DSM-III, psychiatric diagnosis was in a sad state, and with it psychiatry. Two clinicians seeing the same patient often did not agree on the diagnosis. This embedded a kind of randomness in treatment selection and was an insurmountable obstacle to meaningful research. Bob had the vision, technical know-how, diplomatic skill, energy,and stubbornness to single-handedly turn an entire profession around on a dime. He replaced idiosyncratic, impressionistic, unreliable psychiatric diagnosis with precise, systematic criteria sets that (at least under optimal conditions) could produce high levels of diagnostic agreement. This facilitated clinical work, was essential for research, improved education, and brought some sense to forensics.

Perhaps even more significant, Bob and DSM-III helped to save psychiatry as a medical specialty. The previous lack of a proper diagnostic system had set psychiatry adrift-- lurching toward hermeneutics and away from healing. DSM-III anchored psychiatry back to medicine and science. Before it,  psychiatric diagnosis was  ignored and virtually useless. Now it was the center of every clinical, research, teaching, forensic conversation. Psychiatric research had lagged medicine-- now it is the second best funded (after internal medicine) in most medical schools.

DSM-III was also a surprise runaway best seller and an unexpected cultural phenomenon. Millions of copies of DSM have been sold--far more than the total number of clinicians. The DSM's became a useful vehicle of self-diagnosis (and perhaps a not so useful topic of cocktail party patter and of name calling in family squabbles). DSM-III also changed the way we see ourselves--many people previously preoccupied with understanding their unconscious motivations now focused on understanding their psychiatric disorder.

Not all of the impacts have been positive. As with every revolution, there has been an unfortunate overshoot. In the hands of naive biological reductionists, the DSM categories have sometimes been oversold as diseases and worshiped as false icons. The availability of a clear diagnostic system has furthered the massive marketing efforts of drug companies to "sell the ill" in order to "peddle the pill." Often, we have lost sight of psychological meanings, of the importance of the doctor/patient relationship, of the enormous beneficial power of tincture of time and placebo. But most of the blame comes from how DSM is used, not how it is written. Overall DSM-III was the single most useful,influential, and progressive step forward in psychiatric diagnosis since the first modern system developed by Pinel 200 years ago.

Bob has had another lesser known, but no less important, impact on our society. In the early 1970's, he was instrumental in eliminating homosexuality from DSM-II, refuting the notion that sexual orientation is a concern of psychiatry. Psychiatry's recognition that homosexuality is not illness played a key role in the subsequent expansion of societal respect and civil rights. Bob's efforts were fundamental to the process leading to the recent landmark repeal of the military's discriminatory "don't ask/don't tell" policy. 

Bob has retired from Columbia, but not from his tireless, and often lonely efforts, to preserve the integrity of our diagnostic system. He was the first to realize that DSM-5 was badly launched with unnecessary confidentiality agreements and stealth minutes. He asked me to join his protest to pry open the process before it clammed shut. To my shame, I refused to help and left Bob to stand alone as the sole voice of reason and experience as the disaster began to unfold. Why the cold shoulder? I was simply too lazy, too disengaged, too wary of controversy. Sorry, Bob. Perhaps a more concerted early joint effort could have helped. But we now are in it for the duration and will both keep trying to bring common sense to process that has so far been remarkably insulated from it.   

In closing, let's take a look at who are the great names in psychiatric diagnosis during the past 2500 years. The short list would indisputably have to include  Hippocrates, Galen, Sydenham, Pinel, Kraepelin, Freud, and Spitzer. Not bad company. Way to go, Bob.