Shrinks (18 page)

Only a handful of institutions had managed to resist the psychoanalytic invasion and maintain a balanced approach to psychiatric research. The most notable of these rare holdouts was appropriately located in the “Show-Me” State of Missouri. Three psychiatrists at Washington University in St. Louis—Eli Robins, Samuel Guze, and George Winokur—broke from their colleagues in academic psychiatry by taking a very different approach to diagnosis. They rested their iconoclastic sensibilities upon one indisputable fact: Nobody had ever demonstrated that unconscious conflicts (or anything else) actually caused mental illness. Without clear proof of a causal relationship, Robins, Guze, and Winokur insisted that diagnoses should not be contrived out of mere inference and speculation. The Freudians might have convinced themselves of the existence of neurosis, but it was not a scientific diagnosis. But if medicine lacked any concrete knowledge of what caused the various mental illnesses, then how did the Washington University trio believe they should be defined? By resurrecting the approach of Emil Kraepelin focused on symptoms and their course.

If a specific set of symptoms and their temporal course for each putative disorder could be agreed upon, then each physician would diagnose illnesses in the same way, no matter what her training background or theoretical orientation. This would finally ensure consistency and reliability in diagnosis, asserted the Washington University group—qualities that were egregiously absent in the
DSM-I
and
II
. The trio believed Kraepelin could save psychiatry.

Robins, Guze, and Winokur all came from eastern European families that had recently immigrated to the United States. They ate lunch together every day, brainstorming ideas, united by a sense of common purpose and by their isolation from the rest of psychiatry. (Their outcast status meant that the NIMH denied them funding for clinical studies from the 1950s until the late 1960s.) According to Guze, in the 1960s the Washington University psychiatrists gradually began to realize, “There were people around the country who wanted something different in psychiatry and were looking for someone or some place to take the lead. For many years that was a big advantage to us when it came to recruitment. Residents who were looking for something other than psychoanalytic training were always told to go out to St. Louis. We got a lot of interesting residents.” One of these interesting residents was John Feighner.

After graduating from medical school at the University of Kansas, Feighner initially planned to train in internal medicine, but he was drafted into military service. He served as an army physician caring for Vietnam veterans. The experience left him so shaken by the psychic devastation of the soldiers he treated that after he was discharged, he changed direction, and in 1966 he went to Washington University for training in psychiatry.

In his third year as a resident, Feighner was invited to attend meetings with Robins, Guze, and Winokur. He quickly absorbed their Kraepelinian perspective on diagnosis and decided to try to develop diagnostic criteria for depression based upon their ideas. He reviewed close to a thousand published articles about mood disorders and proposed specific symptoms for depression based upon the data in these papers. Impressed with their resident’s swift progress, the Washington University trinity formed a committee to help Feighner—and encouraged him to find criteria not just for depression but for all known mental illnesses.

The committee, which also included Washington University psychiatrists Robert Woodruff and Rod Munoz, met every week or two over a period of nine months. Feighner worked tirelessly, bringing every possible paper he could find on every disorder to the committee for review and using this research to propose criteria that were debated, refined, and endorsed by the group. In 1972, Feighner published their final system in the prestigious
Archives of General Psychiatry
as “Diagnostic criteria for use in psychiatric research,” though his system soon became immortalized as the Feighner Criteria. The paper concluded with a deliberate shot across the bow of psychoanalysis: “These symptoms represent a synthesis based on data, rather than opinion or tradition.”

The Feighner Criteria eventually became one of the most influential publications in the history of medicine and one of the most cited papers ever published in a psychiatric journal, receiving an average of 145 citations per year from the time of its publication through 1980; in contrast, the average article published in the
Archives of General Psychiatry
during the same period received only two citations per year. But when Feighner’s paper was first published, it had almost no meaningful impact on clinical practice. To most psychiatrists, the Washington University diagnostic system seemed like a pointless academic exercise, an esoteric research instrument with little relevance to treating the neurotics they saw in their clinical work. But a few psychiatrists did take notice. One was Robert Spitzer. Another was me.

Five years after the publication of his paper, John Feighner came to St. Vincent’s Hospital in New York where I was a second-year resident and gave a talk about his new diagnostic criteria. Feighner was physically unimpressive, but his brash manner and energetic intelligence made for a charismatic presence. His ideas resonated with my own growing disenchantment with psychoanalysis and spoke to the confusing clinical reality I was facing with my patients every day.

As was the custom, the St. Vincent’s residents had lunch with the speaker following his lecture. Over pizza and soda, we peppered Feighner with questions, and I recall being an overeager interrogator; I even followed him out of the building and all the way down the street while he hailed a taxi so I could continue talking to him as long as possible. He told me he had just moved to join the faculty of the newly established psychiatry department at the University of California in San Diego and opened a private psychiatric hospital in nearby Rancho Santa Fe that employed his new diagnostic methods, the first of its kind. This encounter with Feighner proved quite fortuitous for me.

A few months after I met Feighner, I received a call from an uncle who informed me that his daughter, my cousin Catherine, was having problems while attending a midwestern college. I was surprised, since I had grown up with her and knew her as intelligent, sensible, and grounded. But according to her father, she was out of control. She stayed out late partying, getting drunk, having risky sex, and engaging in numerous tumultuous relationships. But she would also tuck herself away in her room for days at a time, skipping classes and refusing to see anyone. My uncle didn’t know what to do.

I called Cathy’s roommate and the resident counselor in her dorm. From their concerned descriptions it seemed that she was probably suffering from some form of manic-depressive illness, today called bipolar disorder. Though her university offered mental health services, the staff consisted of psychologists and social workers who mainly provided counseling. The psychiatry department at the university, meanwhile, was run by psychoanalysts, as were all of the eminent psychiatric centers at the time (including the Menninger Clinic, Austen Riggs, Chestnut Lodge, Sheppard Pratt, and the Payne Whitney Clinic). I had begun to question the effectiveness of psychoanalytical treatments, and didn’t want to consign my cousin to misguided care at any of these Freudian institutions. But, then, how to help Cathy? An inspired idea suddenly occurred to me: I would call John Feighner.

I explained Cathy’s situation and worked out a plan for her admission to his new hospital halfway across the country, arranging for her to be directly under his care. Following her arrival, Feighner confirmed my provisional diagnosis of manic-depressive illness using his Feighner Criteria, treated her with lithium (a new and highly controversial drug), and within weeks had stabilized her condition. Cathy was discharged, resumed her classes, and graduated on time.

Today I argue against sending patients out of state for psychiatric treatment, since it’s usually possible to find competent care locally. But in 1977, at that early stage in my career, I did not have sufficient confidence in my own profession to risk the health of someone dear to me to psychiatry’s existing standard of care.

While Feighner made a big impression on me, his criteria were mostly greeted with yawns. According to historian Hannah Decker, the Kraepelinians at Washington University were not surprised by their lack of impact, believing they would be “lucky” to make “a dent” in a field ruled by psychoanalysis.

They turned out to be very lucky indeed.

A Book That Changed Everything

“The Washington University people were absolutely delighted I got the job because they were completely outside of the mainstream, but now I was going to use their diagnostic system for the
DSM
,” Spitzer says, smiling. Spitzer had been introduced to the Washington University group in 1971, two years before he was appointed chair of the
DSM-III
, while working on an NIMH study of depression. The head of the project suggested that Spitzer visit Washington University to check out the Kraepelin-influenced ideas about diagnosing depression that originated with Feighner and the Robins, Guze, Winokur triad. “When I got there and discovered they were actually establishing menus of symptoms for each disorder based on data from published research,” Spitzer recounts with obvious pleasure, “it was like I had finally awoken from a spell. Finally, a rational way to approach diagnosis other than the nebulous psychoanalytical definitions in the
DSM-II
.”

Armed with the Feighner Criteria and determined to counteract the claims of the antipsychiatry movement by establishing rock-solid reliability in diagnosis, Spitzer’s first job as chairman was to appoint the other members of the
DSM-III
Task Force. “Outside of the APA Board, nobody really cared much about the new
DSM
, so it was totally under my control,” Spitzer explains. “I didn’t have to clear my appointments with anyone—so about half my appointees were Feighner types.”

When the seven Task Force members assembled for the first time, each expected to be the odd person out, believing their desire for increased objectivity and precision in diagnosis would represent the minority view. To their surprise, they discovered that, as a group, they unanimously favored the “dust bowl empiricism” of Washington University: There was universal consensus that the
DSM-II
should be unabashedly jettisoned, while the
DSM-III
should use specifically defined, symptoms-based criteria instead of general descriptions. Task Force member Nancy Andreasen of the University of Iowa recalls, “We shared the feeling we were creating a small revolution in American psychiatry.”

Spitzer established twenty-five separate
DSM-III
subcommittees, each asked to produce detailed descriptions for one domain of mental illness, such as anxiety disorders, mood disorders, or sexual disorders. To fill these committees, Spitzer appointed psychiatrists who saw themselves primarily as scientists rather than clinicians and instructed them to scour published data relative to the establishment of possible diagnostic criteria—regardless of whether these data-based criteria aligned with the traditional understanding of a disorder.

Spitzer threw himself into the creation of a new
DSM
with a fierce and focused energy. “I was working seven days a week, sometimes twelve hours a day,” he recollects. “Sometimes I would wake up Janet in the middle of the night asking for her opinion on a point, and then she’d get up and we’d work together.” Spitzer’s wife, Janet Williams, who has a doctorate in social work and is a leading expert in diagnostic assessment, confirms that the
DSM-III
was an all-consuming project for them both. “He answered every letter the Task Force received while he was working on the
DSM-III
, and responded to every critical article about it, no matter how obscure the journal—and remember, this was before computers,” Janet recounts. “Fortunately, we were very fast typists.” Jean Endicott, a psychologist who worked closely with Spitzer, remembers, “He would come in on Mondays having clearly worked on the
DSM
all weekend. If you sat by him on the plane, there was no question what you were going to be talking about.”

Spitzer soon proposed an idea that—if adopted—would fundamentally and irrevocably alter the medical definition of mental illness. He suggested dropping the one criterion that psychoanalysts had long considered essential when diagnosing a patient’s illness: the
cause
of the illness, or what physicians term
etiology
. Ever since Freud, psychoanalysts believed that mental illness was caused by unconscious conflicts. Identify the conflicts and you would identify the illness, ran the venerable Freudian doctrine. Spitzer rejected this approach. He shared the Washington University group’s view that there was no evidence to support the cause of
any
mental illness (other than addictions). He wanted to expunge all references to etiology that weren’t backed up by hard data. The rest of the Task Force unanimously agreed.

To replace causes, Spitzer laid down two new essential criteria for any diagnosis: (1) the symptoms must be distressing to the individual
or
the symptoms must impair the individual’s ability to function (this was the “subjective distress” criteria he had first proposed while fighting to depathologize homosexuality), and (2) the symptoms must be enduring (so if you were gloomy for a day after your pet hamster died, this would not constitute depression).