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Robert Spitzer: the most influential psychiatrist of his time

2016; Elsevier BV; Volume: 3; Issue: 2 Linguagem: Inglês

10.1016/s2215-0366(16)00007-9

2215-0374

Allen Frances,

Child and Adolescent Health

Debate is ongoing about whether the flow of history is pushed forward more by ineluctable forces or by the prominent people who represent them. I usually subscribe to the former opinion, but must admit the relevance of the latter in the one small piece of history that I got to watch from the ringside. Bob Spitzer, who died at 83 years of age on Christmas Day 2015, shaped psychiatry far more than anyone else in the past half century. Rarely have so many owed so much to just one individual. Bob was a great force of nature, able to turn improbable ambitions into standard psychiatric practice. His impact was wide, deep, pervasive, and enduring, guiding the work of millions of mental health practitioners and improving the lives of hundreds of millions of patients all over the world. Had Bob never existed, psychiatry would have meandered gradually toward its present course but much more slowly and indirectly, cutting channels with very different depths and directions. Bob entered world history before his 40th birthday, accomplishing a feat whose scope went far beyond psychiatry to influence religious, legal, societal, and popular attitudes and practices. Homosexuality had previously been vilified by religions as sin; by legal systems as crime; by society as deviation; by the average person as weakness; and by the diagnostic system in psychiatry as a mental disorder. Bob led a courageous and difficult struggle to recognise that different sexual preferences were normal variants of human potential, not manifestations of depravity, deviance, impairment, or psychiatric illness. The removal of “homosexuality” from DSM II in 1973 was engineered by Bob—the result of his single-minded and almost single-handed crusade to eliminate the psychiatric stigmatisation of difference. Without Bob, such liberation and validation would have taken additional decades. No one else in the specialty combined his package of passionate fairness, knowledge of science, stubborn determination, political acumen, debating skills, and pure delight in heated controversy. Bob was the irresistible force that was eventually able to remove the immovable object. This first step turned out to be a tipping point, leading to a cascade of more general destigmatisation. Once the error of mislabelling homosexuality as illness was accepted, why not reconsider the legitimacy of labelling it as crime or as sin? Bob opened the door that led 40 years later to Supreme Court decisions that legalised gay marriage and criminalised descrimination against homosexual people. Without Bob, homosexuality might still be viewed as a mental disorder and society might not be granting full marital status and child custody rights. Bob's other major accomplishment was to save psychiatry from a crisis of credibility. Two widely publicised studies in the early 1970s made it clear that psychiatrists could not agree on diagnosis and were keeping patients in hospital who didn't need to be there. It looked like psychiatrists didn't know what they were doing. Bob happened to be working on a criteria-based method for assessing and sorting psychiatric symptoms. The American Psychiatric Association turned to Bob and gave him power and discretion to accomplish a radical task. Could he adapt his method to achieve reliability—intended originally for use only in research settings—to the needs of everyday clinical practice? This would aim to achieve diagnostic agreement among clinicians, improve clinical communication, facilitate research and education, and provide more accurate statistics. However, the risk would be the creation of a cumbersome system that no one would use. Only a master psychometrician could create DSM III and only a master salesman could convince clinicians of the need to accept and use it. It had many limitations and caused its own set of problems, but DSM III had the great virtue of raising the scientific standards of psychiatry and rescued it from the arbitrariness and lack of credibility of warring and unsupported opinions. When Bob began work on DSM III in the mid-1970s, precious little scientific evidence was available to guide how the different disorders should be defined. So Bob created working groups on the various disorders and invited the experts to numerous meetings that all followed the same pattern. He would let us rant and rave in the mornings, blowing off steam promoting competing concepts. Bob would type at blazing speed and was like a magician who seemed to pull DSM III out of a hat—or rather, his computer. A giant deli lunch would eventually arrive that made everyone drowsy and less argumentative. Bob would then present a beautifully worded criteria set that captured the best of the morning's suggestions and pacified most disagreements. Thus, DSM III was born. Unexpectedly, DSM became a cultural phenomenon and has been among the best-selling books every year for the past 35 years. The explicit diagnostic criteria sparked great (perhaps too much) public interest and self-diagnosis. Psychiatric research flourished. DSM was (perhaps too) influential in education and the courts. The advantages of the DSM system must be balanced by its disadvantages. Meant as a mere clinical guide, it has been worshipped as a “bible”. Diagnostic criteria have been misused by the pharmaceutical industry in disease-mongering campaigns. Clinical interviewing and education is too often reduced to a checklist approach that ignores what is special and individual about the patient. Bob had his limitations and inevitably they are also part of the DSM legacy. Because his career didn't include much patient contact, I felt that he tended to imagine mental disorders as pure Platonic ideal types, conforming to the packages contained in the criteria sets he was so skillful in writing. In day to day clinical life, patients are much more heterogeneous in their presentation, and the boundaries between disorders are rather fuzzy. Bob seemed to have a naive belief that he was describing illnesses that actually existed in nature, rather than merely creating convenient, but necessarily arbitrary, constructs. Bob was too optimistic about the potential benefits of new diagnoses and relatively blind to their risks. The addition in DSM of many new diagnostic categories and loose definitions of old ones has led to diagnostic inflation and the misuse of medication. Bob's lifelong grudge against psychoanalysis trapped him in the box of descriptive and biological reductionism, paying too little attention to the psychological, interpersonal, social, and cultural factors that affect psychiatric presentations and their treatment. Moreover, Bob had little knowledge of, or concern about, the historical traditions and philosophical complexities that caution against the unintended consequences of radical change. But Bob's limitations were also keys to his great strength. More a doer than a theoretician, unencumbered by the doubts and scepticism of others, not chained by tradition, he was a confident and undaunted innovator pulling a reluctant field forward. In my experience, no-one has ever been more passionately focused on his work than Bob Spitzer. He literally lived DSM 24/7 for more than 50 years. The thousands of hours I spent with Bob at work, meetings, meals, on planes and car rides, at parties, and while walking or jogging were rarely quiet and almost always devoted to his curious, restless, and incessant probing of diagnostic questions. Bob and I often disagreed, on rare occasions heatedly, but I always felt love, respect, and admiration for the man and for his accomplishments. On a personal level, Bob was an unpredictable mixture of great charm, infectious gaiety, saturnine moods, and abrasiveness. He treated everyone equally, without respect to rank or previous accomplishment. He would give his highest attention and respect to a smart, if lowly, student, but could be dismissively arrogant with senior professors if he believed them to be ignorant or wrong. To the end, Bob retained an appealing boyishness, an impish sense of humour, a winning smile, and an intense joy in living. All the more sad that Bob suffered from Parkinson's disease during the final decade of his life. Bob had always been a puritanical health nut who never smoked, never ate a forbidden food, and ran religiously every day for most of his life. It is ironic and in its way unfair that he fell ill when he always tried so hard to stay well. Thank you Bob for the memories. I smile as I complete this tribute to you and also shed a tear. You are missed.