The American psychiatrist Robert Spitzer, who has died aged 83, took a homegrown system for classifying psychiatric disorders to world prominence. In 1974, the American Psychiatric Association (APA) asked Spitzer to take responsibility for a new edition of its Diagnostic and Statistical Manual of Mental Disorders, which had begun in 1952. This new edition, the third, known as DSM-3, was published in 1980 and quickly became the “world bible” of psychiatric diagnosis.
The DSM acquired increasing importance in those years because of the new prominence of drugs in treating psychiatric patients. Before the 1950s, psychiatry had few effective drugs. Yet with the opening of the vast new cornucopia of psychopharmacology, it did make a difference what agent was prescribed: different disorders responded to different treatments. Accordingly, which diagnoses were included or excluded in the classification had great financial consequences. Billions of dollars in pharmaceutical profits were at stake, and some of the diagnoses, such as “major depression”, could be profitable indeed.
The third edition of the DSM completely revised the standard diagnoses of psychiatry, hitherto dominated by the partisans of psychoanalysis with such terms as “psychoneurosis,” “hysteria” and “depressive neurosis”. Although Spitzer had undergone psychoanalytic training, based on the principles of Freud’s teaching, he had a deep loathing for it and was keen on abolishing its influence in American psychiatry. So as he took the helm of the DSM-3 taskforce, he was determined that psychoanalytic principles be driven out of psychiatric diagnoses, and that presumably evidence-based concepts be installed in their place.
Spitzer came to this assignment as a member of the biometrics division of the New York State Psychiatric Institute, based at Columbia University in Manhattan. Born and raised in White Plains, New York, son of Benjamin and Esther Spitzer, he graduated in medicine from New York University in 1957, and began a career at PI, as the Psychiatric Institute was called, the following year. He quickly became an insider in this strategic institution, and was called upon to function as a consultant to DSM-2, published in 1968.
However, what the APA had not counted on was that, as head of the DSM-3 taskforce, Spitzer would preside over the complete recasting of psychiatric diagnoses, rather than merely adjusting the semicolons, which is what it had in mind in commissioning the third edition: it wanted to bring American diagnostics into conformity with a revised system of the World Health Organisation. The document the taskforce brought forth, very much a product of Spitzer’s driving, authoritarian personality, meant a real turning of the page in the history of psychiatry. It was the beginning of the end of the primacy of psychoanalysis. The DSM-3 diagnostic register recognised virtually none of the Freudian illness concepts.
As for the rest, Spitzer and his colleagues behaved as though they were starting at ground zero, as if there were no previous diagnostic traditions in psychiatry to build on. Spitzer decreed that the classic two depressions that psychiatry had always known – melancholic depression and a mixture of lesser complaints known as “nerves” – be condensed into a single depressive illness: “major depression”. Until DSM-3, psychiatry had recognised a single form of anxiety; after DSM-3, there were eight.
Invented from whole cloth were such new diagnostic concepts as attention deficit disorder, then known as ADD, later as attention deficit hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD). These have become hugely popular diagnoses; before 1980 they were virtually unknown.
Spitzer did, however, ensure schizophrenia remained a single disorder, and the taskforce made no effort to disaggregate chronic psychotic illness into different components. He solidified the tradition, begun by the German psychiatrist Karl Leonhard in 1957, of treating manic-depressive illness as entirely different from unipolar depression (in DSM-3, “major depression”). Some have argued that it makes little sense to classify depressive illnesses on the basis of polarity, but Spitzer was not really a clinician, and did not have the gut sense of a senior psychiatrist that mania, unipolar depression and bipolar depression were all pretty well melded together in the same ball of wax.
The legacy of DSM-3 has proved to be highly controversial, and Spitzer’s historical reputation depends on whether one views the influence of DSM as mainly positive or negative. The pharmaceutical industry found the specific new diagnoses highly positive, as drugs could be developed for “major depression” or “generalised anxiety disorder”. Many clinicians accepted the authority of the APA as conclusive, and brought their own diagnostic patterns into accordance with DSM-3, though fewer in the UK have fallen into line.
Yet nagging doubts remained. Collapsing all depressive illnesses into a single pot called “major depression” has struck many as reckless, given the clear differences in responsiveness to treatment between melancholic depression and non-melancholic depression. The continuing subdivision of anxiety into microfragments has seemed to some observers absurd, given that all these anxieties seem to respond to the same treatments. And lumping the variegated world of military post-deployment syndromes into PTSD has been criticised as unscientific and unhelpful in finding differentiated treatments.
In 1973 Spitzer led a movement within the APA to remove homosexuality from the list of diagnoses. Yet DSM-3 did retain “ego-dystonic homosexuality” – being gay but unhappy – as a disease.
If the successive editions of DSM initiated by DSM-3 turn out to be scientifically valueless (DSM-5 was launched in 2013), Spitzer’s importance may be reduced to having begun the final chapter in the history of psychoanalysis. If, on the other hand, they prove to be of enduring value, future generations will laud Spitzer as a great psychiatric figure of the late 20th century.
Spitzer’s first two marriages ended in divorce. He is survived by his third wife, Janet Williams, and their three children, Noah, Ezra and Gideon; by two children, Laura and Daniel, from his second marriage; and by four grandchildren.
• Robert Leopold Spitzer, psychiatrist, born 22 May 1932; died 25 December 2015
