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The Making of DSM-IIIŽReview - The Making of DSM-IIIŽ
A Diagnostic Manual's Conquest of American Psychiatry
by Hannah Decker
Oxford University Press, 2013
Review by Peter Zachar
Nov 10th 2015 (Volume 19, Issue 46)

Innovators are often made great, not by their contemporaries, but by subsequent generations. This process of ennoblement is analogous to how children and grandchildren become committed defenders of a sire's legacy, absent the personal gratification that offspring garner in identifying with family "eminence."  One of the goals of Hannah Decker's The Making of DSM-III is to elevate the psychiatrist Robert Spitzer by conferring upon him the eminence possessed by the 19th century German psychiatrist Emile Kraepelin.

I have met several people who have worked closely with Spitzer and view him as an important figure, but not quite a Kraepelin. For those just a generation younger, however, Spitzer's Kraepelinesque status seems almost self-evident. The parallel between the two men is easier to see if one mythologizes neither Kraepelin nor Spitzer.

          The book is divided into three sections. The first section is titled The History. Here Decker reconstructs the main events leading to the development of the DSM-III. She begins by describing the factors leading to the relatively short period of psychoanalytic dominance in American psychiatry. Having written favorably about psychoanalysis in the past, Decker does not deride the psychoanalytic perspective as some kind of misguided hiatus in the discipline's natural trajectory toward a biologically-based psychiatry. Instead she describes some key flaws by citing criticisms from within psychoanalysis itself.

Her explication of the anti-psychiatry movement is a strong feature of this section. Decker is neither contemptuous nor complimentary. Instead, she patiently describes and thoughtfully evaluates the various anti-psychiatric arguments that were used to cast doubt on the reality of mental illness. She also, revealingly, unifies this group by framing them as part of the anti-establishment Weltanschauung of the 1960s. Her larger purpose in this section is to explicate how the anti-psychiatry movement contributed to a crisis of confidence in psychiatric classification. A crisis of confidence, according to Thomas Kuhn, presages a revolution.

          Having established the crisis mindset, Decker turns to Emile Kraepelin in the late 19th century, arguing that he helped resolve another crisis of confidence. Kraepelin's famous distinction between dementia praecox and manic-depressive illness ushered in a medical approach to psychiatry emphasizing observable features such as course and outcome as opposed to inferences based upon romantic views about the nature of mind or upon speculative anatomy. This interpretation of Kraepelin's earlier views links him with Spitzer's own moment in history.

The concluding chapter of the first section further solidifies the historical link by describing how a small group of scientifically oriented psychiatrists at Washington University in St. Louis sought to undermine the institutional dominance of the psychoanalytic. As some readers may know, the Washington University psychiatrists were dubbed the neo-Kraepelinians. They were interested in classification and wanted it to be more scientific in nature. Classification, they believed, should be grounded in observable behavior and self-report rather than inferences about unconscious processes.  Spitzer became the conduit through which this group influenced all of American psychiatry.

          The second section of the book is titled The People. It contains two chapters composed of historical biographies. The most space is given to Spitzer himself. Decker describes Spitzer as from a young age rebellious, independently-minded, and attracted to leadership roles. He was more oriented to the ideas in a discussion than to people's reactions, which protected him from being discouraged by interpersonal conflict, or from burning his bridges with anyone in response to past conflict. More than once, she mentions that Spitzer enjoyed conflict. He was also charismatic and inspired loyalty. According to Decker, this unique combination of personality traits was an advantage in producing a DSM-III.

Spitzer's connection with Kraepelin is further reinforced by pointing out that, like Kraepelin, he had a background in psychology and was interested in measurement. Kraepelin studied with the psychologist Wilhelm Wundt and did research in experimental psychology throughout his entire working life. Spitzer was trained in psychoanalysis but never embraced it. Neither was he a biological psychiatrist; rather, he gravitated toward constructing schedules for diagnostic interviews and found a professional niche working under the psychologist Joseph Zubin. His interest in structured diagnostic interviews is why he was introduced to Washington University's Eli Robins, from whom Spitzer learned about descriptive psychopathology and the value of diagnostic criteria.

Through his connections at the New York State Psychiatric Institute and Columbia University Spitzer became involved in developing the DSM-II in the late 1960s. His position on this committee gave him an opportunity to enter the fray over the diagnostic status of homosexuality in 1973. At about the same time, Spitzer began working with Robins and the psychologist Jean Endicott to develop diagnostic criteria for use in research sponsored by the NIMH. Not surprisingly, in 1974 he was successful when seeking to be appointed to lead the DSM-III effort.  

A separate chapter features descriptions of the main members of Spitzer's DSM-III Task Force, which was the executive committee for the revision. Other than the psychologist Theodore Millon, everyone on Spitzer's original team had a professional connection to St. Louis or New York (where Spitzer resided). More so than Spitzer, the members on the Task Force were interested in ending the psychoanalytic dominance of American psychiatry 

          The scholarship of the first two sections is based largely on secondary sources and interviews. In many ways it is a long prologue to the beginning of the book. The third section (comprising over 60% of the volume) is titled The Making and is largely what has garnered the book such praise for its detailed and original scholarship. Here, Decker augments secondary sources and interviews with information drawn from the APA Archives.

          She begins by discussing how thoroughly the DSM consumed Spitzer. In fact, he began thinking about how to revise the manual several years before being awarded the task. Several important features of the current DSM revision process such as the committee structure and the field trials were his brainchildren. Decker describes how Spitzer was the dominant player in all aspects of the revision, but he also freely invited others to join his team's efforts and was open with the larger community about what they were planning. Much of this part of the book recounts how his openness led to conflict, and how Spitzer pushed on with a combination of determination, flexibility, and strategic placation.   

          In Decker's telling, Spitzer had three overriding goals for the DSM-III: a) to increase diagnostic reliability both to support research and to rehabilitate the tarnished reputation of psychiatry, b) to develop a definition of mental disorder that would undermine the attacks of the anti-psychiatrists, and c) to constrain the permissive diagnosis of schizophrenia in the U. S.

It is important to add that in response to feedback on the early drafts of the DSM-III, Spitzer sought to produce a system that was also clinically useful. This shift in his thinking led to a rift between him and the Washington University psychiatrists because Spitzer became quite liberal about including diagnostic categories in the manual if they might have clinical utility. The Washington University group believed in diagnosing only a small number of scientifically "valid" categories, and classifying the cases that did not fit these categories as undiagnosed psychiatric illness. Spitzer's desire to strike a practical balance between the diverse goals of researchers, clinicians, and administrators later became the guiding philosophy of the DSM-III-R and DSM-IV Task Forces.

          In the summer of 1976 an important midstream conference in St. Louis Missouri was attended by ninety-one prominent mental health professionals. Later that year a smaller, more elite conference was held in Toronto. After these meetings the direction that Spitzer and his team were heading had been made clear. So began two-and-a-half years of intense conflicts. In recounting these conflicts Decker dispassionately describes the various perspectives articulated and names the people who were the main antagonists. These conflicts include but are not limited to: clinical psychologists' opposition to defining mental disorders as a subset of medical disorders, arguments over the validity of borderline personality disorder, and a renewed battle over the diagnostic status of homosexuality.

The conflict given the most space in the book is the intense opposition of the psychoanalytic community to descriptive psychopathology and to the proposed deletion of the concept of neurosis from the DSM. Spitzer scrupulously worked on many compromises with the psychoanalysts, but they were usually rejected by his Task Force. Decker is sympathetic toward the psychoanalytic perspective and believes that eliminating it from the DSM-III was short-sighted. It is therefore telling that she places considerable blame for its absence on the political incompetence and lack of foresight within the segment of the analytic community that opposed the revisions.

 Because Decker digs down into the details, the book will hold the most appeal for readers who are interested in the history of psychiatric classification, but its value is not limited to them. For readers who are exposed primarily to various and sundry anti-psychiatric critiques, social-political critiques, or Whiggish histories that lionize biological psychiatry, this book presents an important alternative view. Decker offers a refreshing dose of realism about how these manuals have been developed, explaining why decisions were made, but presenting them forthrightly as decisions rather than discoveries.

In the past decade or so the scientific merits of the DSM categories have been increasingly called into question by many academic psychiatrists and psychologists, but the DSM-5 proposal to supplement diagnostic categories with cross-cutting dimensions was not successful. The APA Assembly, a group that rose to prominence in psychiatry through its support of the DSM-III played a large role in rejecting many changes envisioned for the DSM-5. How Spitzer persuaded the Assembly to side with him those many years ago is an important part of Decker's story. Despite recent predictions of another paradigm shift in psychiatric classification, Spitzer's and the DSM-III Task Force's achievement turned out to be still robust. For now, there does not appear to be another Spitzer or Kraepelin on the horizon, but no one saw them coming either.  


© 2015 Peter Zachar


Peter Zachar, Ph.D. is the author of A Metaphysics of Psychopathology (MIT Press, 2014) and the co-editor with D. Stoyanov, M. Aragona, and A. Jablensky of Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC and Beyond (Oxford University Press, 2015).


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