Shrinks (19 page)

This was a definition of mental illness radically different from anything before. Not only was it far removed from the psychoanalytical view that a patient’s mental illness could be hidden from the patient herself, but it also amended Emil Kraepelin’s definition, which made no reference to subjective distress and considered short-lived conditions to be illnesses, too.

Spitzer laid down a two-step process for diagnosing patients that was as simple as it was shockingly new: first, determine the presence (or absence) of specific symptoms and for how long they had been active; then, compare these observed symptoms to the fixed set of criteria for each disorder. If the symptoms matched the criteria, then a diagnosis was justified. That’s it. No ferreting around in a patient’s unconscious for clues to a diagnosis, no interpreting the latent symbolism of dreams—just identifying concrete behaviors, thoughts, and physiological manifestations.

The
DSM-III
Task Force learned very quickly that in order to remain faithful to the published data, it was often necessary to create rather complex sets of criteria. In the
DSM-II
, for example, schizophrenia was dealt with in a series of impressionistic descriptions, including this definition of paranoid schizophrenia:

This type of schizophrenia is characterized primarily by the presence of persecutory or grandiose delusions, often associated with hallucinations. Excessive religiosity is sometimes seen. The patient’s attitude is frequently hostile and aggressive, and his behavior tends to be consistent with the delusions.

By contrast, the
DSM-III
provided several sets and subsets of conditions that were required for a diagnosis of schizophrenia. Here, for example, is condition C:

C. At least three of the following manifestations must be present for a diagnosis of “definite” schizophrenia, and two for a diagnosis of “probable” schizophrenia. (1) Single. (2) Poor premorbid social adjustment or work history. (3) Family history of schizophrenia. (4) Absence of alcoholism or drug abuse within one year of onset of psychosis. (5) Onset of illness prior to age 40.

Critics quickly sneered at the complicated “Select one from criteria set A, select two from criteria set B” instructions, calling it the “Chinese menu” approach to diagnosis, after the multitiered menus that were common in Chinese restaurants at the time. Spitzer and the Task Force countered that this increased complexity in the diagnostic criteria matched the evidence-based reality of mental disorders far better than the ambiguous generalities of the
DSM-II
.

But there was one notable problem with the Task Force’s utopian vision of better psychiatry through science: For many disorders, the science hadn’t actually been done yet. How could Spitzer determine which symptoms constituted a disorder when so few psychiatrists outside of Washington University and a handful of other institutions were conducting rigorous research on symptoms? What the Task Force needed were cross-sectional and longitudinal studies of patients’ symptoms and how these patterns of symptoms persisted over time, how they ran in families, how they responded to treatment, and how they reacted to life events. While Spitzer insisted that the diagnoses be based on published data, such data were often in very short supply.

If there was not an extensive body of literature on a particular diagnosis, then the Task Force followed an orderly procedure. First they reached out to researchers for unpublished data or gray literature (technical reports, white papers, or other research not published in a peer-reviewed format). Next, they reached out to experts with experience with the tentative diagnosis. Finally, the entire Task Force would debate the putative criteria until they reached consensus. Spitzer told me, “We tried to make the criteria represent the best thinking of people who had the most expertise in the area. The guiding principle was that the criteria needed to be logical and rational.” The
DSM-III
added many new disorders, including attention-deficit disorder, autism, anorexia nervosa, bulimia, panic disorder, and post-traumatic stress disorder.

There was one overt nonscientific factor that influenced the new diagnostic criteria: ensuring that insurance companies would pay for treatments. Spitzer knew that insurance companies were already cutting back on mental health care benefits as a result of the antipsychiatry movement. To combat this, the
DSM-III
stressed that its criteria were not the ultimate diagnostic word but that “clinical judgment is of paramount importance in making a diagnosis.” They believed that this disclaimer would give psychiatrists protection against an insurance company intent on showing that a patient did not exactly conform to the criteria listed. In actuality, time has shown that insurance companies do not tend to challenge psychiatrists’ diagnoses—instead, they often challenge the choice and duration of
treatment
for a diagnosis.

The
DSM-III
represented a revolutionary approach to mental illness, neither psychodynamic nor biological, but able to incorporate new research from any theoretical camp. By rejecting causes (including neurosis) as diagnostic criteria, the
DSM-III
also represented a complete repudiation of psychoanalytic theory. Before the
DSM-III
, the Feighner Criteria had almost exclusively been used for academic research, rather than clinical practice. Now the
DSM-III
would render the Feighner Criteria the clinical law of the land. But first, there was one major hurdle to surmount, and it was a doozy.

The
DSM-III
would only be published by the APA if its members voted to approve it. In 1979, a strong and vocal majority of these members were psychoanalysts. How could Spitzer persuade them to endorse a book that ran counter to their approach and might spell their own doom?

The Showdown

Throughout his tenure, Spitzer transparently and continuously communicated the Task Force’s progress on the
DSM-III
via a steady stream of personal letters, meeting minutes, reports, bulletins, publications, and talks. Each time he made a public presentation or published an update on the
DSM-III
, he encountered pushback. At first, the criticism was relatively mild, since most psychiatrists had no vested interest in a new diagnostic manual. Gradually, as more and more was revealed about the contents of the
DSM-III
, the blowback intensified.

The turning point came in June 1976 at a special meeting in St. Louis (sponsored by the University of Missouri, not Washington University) with an audience of one hundred leaders in psychiatry and psychology. The
DSM-III
in Midstream, as the conference was called, marked the first time that many prominent psychoanalysts heard about Spitzer’s new vision for diagnosis. This was when the cat was finally let out of the bag. The meeting exploded in controversy. Attendees denounced what they viewed as a sterile system that purged the
DSM
of its intellectual substance, claiming Spitzer was turning the art of diagnosis into a mechanical exercise. Spitzer was frequently accosted in the corridors by psychoanalysts who demanded to know if he was intentionally setting out to destroy psychiatry, and by psychologists who demanded to know if he was deliberately attempting to marginalize their profession.

When it was over, influential groups mobilized to oppose Spitzer; he responded by throwing himself with redoubled energy into the task of responding to the opposition. Two of the most formidable opponents were the American Psychological Association, the largest professional organization of psychologists (sometimes referred to as “the big APA” since there are far more psychologists than psychiatrists in the U.S.), and the American Psychoanalytic Association (APsaA), still the largest professional organization of Freudian psychiatrists. One of the original goals of the
DSM-III
was to firmly establish that mental illness was a genuine medical condition in order to push back against the antipsychiatry movement’s contention that mental illness was merely a cultural label. But psychologists—therapists with a PhD instead of an MD—had benefited greatly from the antipsychiatry argument. If mental illness was a social phenomenon, as Szasz, Goffman, and Laing charged, then one didn’t need a medical degree to treat it: Anyone could justifiably use psychotherapy to guide a patient through her problems. If the American Psychiatric Association formally declared that mental illness was a medical disorder, psychologists stood to have their recent professional gains rolled back.

At first, the president of the big APA, Charles Kiesler, wrote to the American Psychiatric Association in diplomatic fashion: “I do not wish partisan conflict between our associations. In that spirit, the American Psychological Association wishes to offer its complete services to assist the American Psychiatric Association in the further development of the
DSM-III
.” Spitzer’s response was equally cordial: “We certainly believe that the American Psychological Association is in a unique position to help us in our work.” He included, with his reply, the latest draft of the
DSM-III
—which unambiguously asserted that mental illness was a medical condition. Now President Kiesler cut to the chase:

Since there is an implication that mental disorders are diseases, this suggests that social workers, psychologists, and educators lack the training and skills to diagnose, treat, or manage such disorders. If the current approach is not altered, then the American Psychological Association will embark on its own truly empirical venture in classification of behavioral disorders.

Kiesler’s thinly veiled threat to publish his own (nonmedical) version of the
DSM
had an effect other than the one intended: It provided Spitzer with an opening to retain his medical definition. Spitzer wrote back and politely encouraged him and the American Psychological Association to pursue their own classification system, suggesting that such a book might be a valuable contribution to mental health. In reality, Spitzer guessed (correctly) that the formidable demands of pursuing such an undertaking—which he was in the midst of himself—would ultimately prevent the big APA from pulling it off; at the same time, his endorsement of Kiesler’s project provided Spitzer with cover for the
DSM-III
’s medical definition—after all, the psychologists were free to put their own definition of mental illness in their own book.

But Spitzer’s biggest battle by far—truly a battle for the soul of psychiatry—was a winner-take-all clash with the psychoanalysts. Psychoanalytic institutions did not pay much attention to the
DSM-III
Task Force for the first two years of its existence, and not just because they didn’t care about the classification of mental disorders. They simply had little to fear from anyone: For four decades, the Freudians had ruled the profession unchecked. They controlled the academic departments, university hospitals, private practices, and even (so they assumed) the American Psychiatric Association; they were the face, voice, and pocketbook of psychiatry. It was simply inconceivable that something as insignificant as a classification manual would threaten their supreme authority. As Donald Klein, a member of the
DSM-III
Task Force, put it, “For the psychoanalysts, to be interested in descriptive diagnosis was to be superficial and a little bit stupid.”

The Midstream conference had roused the psychoanalysts from their apathy, though, forcing them to confront the possible effects of the
DSM-III
on the practice and public perception of psychoanalysis. Shortly after the conference, one prominent psychoanalyst wrote to Spitzer, “The
DSM-III
gets rid of the castle of neurosis and replaces it with a diagnostic Levittown,” comparing Spitzer’s
Manual
to a cookie-cutter housing development being built on Long Island. Two other prominent psychoanalysts charged that “the elimination of the psychiatric past by the
DSM-III
Task Force can be compared to the director of a national museum destroying his Rembrandts, Goyas, Utrillos, van Goghs, etc. because he believes his collection of Comic-Strip Type Warhols has greater relevance.”

But on the whole, since the psychoanalysts still had such a hard time believing that anything meaningful would come out of Spitzer’s project, there was never any great urgency behind their response. After all, the publication of the
DSM-I
and
DSM-II
had produced no noticeable impact on their profession. It took more than nine months after the Midstream conference for the first group of psychoanalysts to approach Spitzer with a formal request. The president and president-elect of the American Psychoanalytic Association sent a telegram to the APA asking that they postpone any more work on the
DMS-III
until the American Psychoanalytic Association had a chance to thoroughly evaluate its existing content and review the process by which any additional content would be approved. The APA refused.