20

CRITERIONATING

In the back-and-forth between Rosenhan and Spitzer, Rosenhan seemed fixated on how Spitzer managed to get his hands on the records, focusing on this transgression to deflect from his own. Eventually, through sheer force of rage, Rosenhan learned that Spitzer received the records, secondhand, from Haverford State Hospital itself. Dr. Bartlett, feeling slighted by Rosenhan’s paper and its misleading portrayal of the care he received, sent Rosenhan’s medical records to a psychiatrist named Robert Woodruff, who would later join the DSM-III task force. Woodruff was vocal in his critiques of Rosenhan’s study and had written a fiery op-ed in the Medical World News, which Bartlett had seen. When Dr. Woodruff heard that Spitzer was organizing a conference on Rosenhan’s paper, he sent Rosenhan’s records to Spitzer. Spitzer knew everything that we know now—how far Rosenhan exaggerated his symptoms, how he unambiguously exaggerated some of the portrayals of his care—yet Spitzer never published these findings. If Spitzer, the “truth seeker,” had all the same information I had, why hadn’t he sounded the alarm about this popular study that was embarrassing his profession?

Once again, however, it was too late for me to find out. Woodruff took his own life in 1976, so I could not ask him why he remained silent. By the time I learned about the records, Spitzer was battling serious health problems that restrained him from sparring in the arena of academic controversy. The last time that the public heard from him was his 2012 denouncement of his prior research that supported the use of conversion therapy. And then the day after Christmas in 2015, the New York Times ran Spitzer’s obit: “Dr. Robert L. Spitzer, who gave psychiatry its first set of rigorous standards to describe mental disorders, providing a framework for diagnosis, research and legal judgments—as well as a lingua franca for the endless social debate over where to draw the line between normal and abnormal behavior—died on Friday in Seattle. He was 83.”

I’m left with the actions and words he left behind. Why had he said, once, that his critique of Rosenhan’s study was the paper he was most proud of, “the best thing I have ever written”? Spitzer had even returned to the Rosenhan well in 1976 by writing a follow-up on Rosenhan’s study called “More on Pseudoscience in Science and the Case for Psychiatric Diagnosis.” In it, Spitzer concluded that despite the paper’s glaring issues, Rosenhan got one thing right: his “recognition of the serious problems of the reliability of psychiatric diagnosis”—and Spitzer had a plan in place to solve it.

“For Spitzer, paradoxically, Rosenhan’s study and the extraordinary publicity it received was manna from Heaven. It provided the final impetus for a study he had been agitating to conduct for some time, to set up a task force of the American Psychiatric Association charged with revamping psychiatry’s approach to diagnosis,” wrote sociologist Andrew Scull.

In other words, the study was instrumental in achieving Spitzer’s goals: It gave him the grounds to move forward with the overhaul he knew the field needed to survive. So why deliver the fatal blow to something that could be so useful?

In the spring of 1974, APA medical director Melvin Sabshin tapped Spitzer to shepherd the creation of a new version of the DSM, setting in motion a “fateful point in the history of the American psychiatric profession.” The job was perfect for Spitzer, which worked for everyone because no one else wanted it. Most psychiatrists were far too enamored with sexier, Technicolor explorations of the motivations behind human behavior (with its mining of Greek myths like Oedipus and Electra for sources of interior conflict) to take on the drab black-and-white statistical backwater of diagnosis.

This new manual would be nothing like the DSM-I, a puny spiral-bound booklet created in 1952 after physicians witnessed the psychic horror that war wreaked; it would render the DSM-II, an analytically oriented text that used Freud-friendly terms like psychoneurotic and phobic neuroses, obsolete.

This third edition would highlight the teachings of psychiatrists reemerging at that time. “They were determined to create a psychiatry that looked more like the rest of medicine, in which patients were understood to have diseases and in which doctors identified the diseases and then targeted them by treating the body, just as medicine identified and treated cardiac illness, thyroiditis, and diabetes,” wrote Tanya Marie Luhrmann in Of Two Minds.

Spitzer recruited from the staunchly anti-Freudian, biologically focused constituency at Washington University in St. Louis a group of like-minded psychiatrists who called themselves neo-Kraepelinians, a direct callback to the German psychiatrist who proposed a new diagnostic language with dementia praecox. The Wash U group also referred to themselves as DOPs, or data-oriented persons, whose “guns [were] pointed” at psychoanalysis. Rumor was that they kept a picture of Freud above the urinal in their bathroom. In 1972 the Wash U contingent published the “Feighner Criteria,” one of the most cited papers in modern psychiatric history, which provided rigorous diagnostic criteria based off a descriptive approach—or the grouping symptoms that are common to diagnosis (again, much as Kraepelin did in the late 1800s)—and set the groundwork for Spitzer’s DSM-III.

In 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders roared to life. The big fat book (494 pages, compared with the DSM-II, which was 134 pages) offered up 265 disorders, more than double the number found in the first edition. The manual scrubbed most psychoanalytic references found in the previous DSMs and successfully ushered psychiatry back into the good graces of mainstream medicine. The DSM-III introduced “axes.” Axis I was devoted to disorders such as anxiety, anorexia, schizophrenia, and major depression. These were different from the personality disorders (like borderline, sociopathic, and narcissistic personality disorders) and developmental disorders in Axis II, described as “conditions and patterns of behavior that are defined as enduring, inflexible, and maladaptive.” The third axis was devoted to “physical” disorders, like cirrhosis of the liver, pneumonia, encephalitis, and brain tumors.

Diagnosing patients would never be the same, nor would interviewing them. Patients who expected open-ended psychoanalysis were surprised to find doctors boxed in by literal boxes—doctors were provided diagnostic criteria to tick off one by one, a process that some have called “the Chinese menu” approach. It may not have been creatively fulfilling, but now there were strict boundaries in place that kept psychiatrists from drawing outside the lines if they wanted reimbursement from insurance companies, who had fully embraced the manual. The goal was to make diagnosis standardized in such a way that someone in Maine who was diagnosed with schizophrenia would be diagnosed using the same criteria as someone in Arizona, ensuring that psychiatrists on either side of the country had a far greater chance of making the same diagnosis if they were faced with the same patient. Doctors now had a shared language. Reliability.

Like it or not, this is what a revolution looks like.

“It is as important to psychiatrists as the Constitution is to the US government or the Bible is to Christians,” wrote psychotherapist Gary Greenberg. All drug trials from the birth of the DSM-III forward were based on the manual’s criteria; insurance companies used it to decide how much coverage a person should receive; if a shrink or any kind of mental health professional wanted to get reimbursed for their time, they’d better know how to cite the DSM from memory. The DSM-III turned madness into different types of disorders that each responded to specific drug treatments, creating “rich pickings for the pharmaceutical industry.” And it didn’t stop with psychiatrists, extending to psychologists, social workers, and lawyers. It’s used in everything from criminal cases to custody battles, from courtrooms to the allocation of special needs resources in public schools.

One of Spitzer’s pet projects was to define mental disorder, a pursuit that he had been fixated on since the homosexuality debacle. The DSM-III laid that out at the very outset: A mental disorder “is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).” Not only did it associate mental illness with dysfunction, which was meant to protect us against making illnesses out of healthy eccentricity, but it also located the cause of mental illness inside the person (not with overbearing mothers or weak fathers, for example) in the same way that physical diseases, like cancer or heart disease, affect the body. So the manual used the term disorder—which implied a stronger biological connection—and threw away reaction, a relic of the psychodynamic era.

The DSM said outright that the continued distinction between physical and mental, between organic and functional, was “based on the tradition of separating these disorders,” while acknowledging that these distinctions were somewhat arbitrary. “Hence, this manual uses the term ‘physical disorder,’ recognizing that the boundaries for these two classes of disorders (‘mental’ and ‘physical’ disorders) change as our understanding of the pathophysiology of these disorders increases.”

To reflect this, the manual did not provide causes for the psychiatric disorders listed—the science just wasn’t there. The goal instead was to keep that part open-ended until the science caught up. It’s unclear if the clinicians who bought these books took note of these caveats, however, because everyone else saw the manual, combined with the promise of emerging neuroscience and genetics, as a recasting of psychoanalytically interpreted illnesses into full-blown brain illnesses.

No matter how little proof was there, psychiatry fully embraced the illness model—also known as the field’s remedicalization. Harvard psychiatrist Gerald Klerman called it “a victory” for science. It altered the way both doctors and patients saw the provenance of illness and their roles in it—instead of repressed egos and ids or frigid mothers, you had screwed-up brain chemicals or faulty (but not our fault) wiring. Psychiatrists like Nancy Andreasen saw this as a step forward for patients who “no longer must carry the burden of blame and guilt because they have become ill.” And that the world should “behave towards a patient just as they would if he had cancer or heart disease.”

All the while, the problem of Rosenhan and his pseudopatients nettled the manual’s creator. As Spitzer worked on drafts of the DSM, he often returned to Rosenhan’s study and asked himself: Would David Rosenhan and his pseudopatients get past this one?

“When we would write a criterion, for instance, we would often have the study in the back of our minds,” explained Spitzer’s wife, Janet Williams, who also worked on the DSM-III. “Criterionating, we used to call it. You had to write the criteria down and then think of every which way to question it, to improve it… We were always asking those things. This was when Rosenhan would inevitably come up.”

Spitzer was determined to make sure that the publicity nightmare that Rosenhan and his seven pseudopatients generated would never happen again. “Rosenhan’s pseudopatients would never have been diagnosed as schizophrenic if the interviewing psychiatrists had been using DSM-III,” wrote Tanya Marie Luhrmann.

“What Bob [Spitzer] did,” psychiatrist Allen Frances said in an interview, “was change the face of psychiatry, change the face of how people saw themselves. It wasn’t just a plus, but he did change the world, and that change was very much instigated by the Rosenhan project.” Without Rosenhan’s study, Frances told me, “Spitzer could never have done what he did with the DSM-III.”

It seemed to be a win for us all. Now we had a solid diagnostic system; we had medical language that replaced psychobabble; we had reliability so that doctors all over the world would make a consistent diagnosis.

It sounded, at least at first, like progress to me. I’ve met some of the holdover psychiatrists from the psychoanalytic era—one told me that he used to get an erection while standing at a podium in front of a new class of medical students and that he’d show it off by jutting out his hips and walking up and down the aisles. Another told me that I was fully healed from autoimmune encephalitis not because of advances in immunology or cutting-edge neuroscience, but because I “hadn’t experienced any real trauma before that moment.” As if a five-minute interaction can reveal something so deeply rooted.

If this arrogance is what the DSM-III replaced, good riddance.