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Robert L Spitzer
New York State Psychiatric Institute/Eve Vagg
Obituary
Robert L Spitzer Leading psychiatrist who developed strict standards for diagnosing mental disorders. Born on May 22, 1932, in White Plains, NY, USA, he died from complications of heart disease on Dec 25, 2015, in Seattle, WA, USA, aged 83 years. Psychiatry was in a crisis of credibility in the mid-1970s when Columbia University Professor Robert Spitzer was asked to oversee an update of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). “Spitzer pushed to get the DSM to adopt a more scientifically rigorous approach. It completely transformed the field and put psychiatry on firm scientific footing”, says Michael First, Professor of Clinical Psychiatry at Columbia University. Two studies published in the early 1970s shook the medical community’s confidence in psychiatric diagnoses. In 1972, researchers compared diagnostic practices of clinicians in New York and London and found that patients who would have been considered manic depressive or bipolar in London were determined to have schizophrenia in New York; Spitzer was a member of the steering committee for this study. The next year, Daniel Rosenhan published a controversial paper in Science describing how eight pseudopatients were admitted to psychiatric wards despite behaving as “normal” after a single, initial claim of hearing a voice. Spitzer wrote a scathing critique of Rosenhan’s experiment—“a careful examination of this study’s methods, results, and conclusions leads me to a diagnosis of ‘logic, in remission’”— but recognised that both the reliability and validity of psychiatric diagnosis was rightfully being questioned. Spitzer was developing psychiatric interview methods that focused on asking specific questions to extract information 428
needed for diagnosis when he became Chair of the DSM-III task force in 1974. These methods contrasted with the openended questioning of psychoanalysis, the predominant view of mental health at the time. Fascinated with data, measurement, and assessment from the beginning of his career, Spitzer and his colleagues got to work sorting symptoms and defining and naming disorders. When it was published in 1980, DSM-III listed 265 diagnostic categories and included for the first time bipolar disorder, post-traumatic stress disorder, and anorexia. “It re-shaped psychiatry”, says Allen Frances, Professor Emeritus of Psychiatry at Duke University and editor of the fourth edition of DSM. “In standardising, much was gained but something was also lost. More attention is paid to symptoms and less on the patients themselves, leading to reductionism in psychiatry. The biggest misuse is that pharmaceutical companies began selling diagnoses as all due to chemical imbalance that can be treated with a pill.” Spitzer himself later worried that standardisation was pathologising normal behaviours. He remained involved in updating later editions of DSM, advocating for the addition of premenstrual dysphoric disorder and binge eating disorder, which were added in 2013. He also helped to develop the Patient Health Questionnaire (PRIME-MD) that is now widely used in primary care medicine for screening and diagnosis of depression and for monitoring response to treatment. Stubborn, sometimes abrasive, and always eager, Spitzer’s work was guided by a strong sense of ethical fairness. ”He was an iconoclast and looked for injustice”, says First. Spitzer successfully fought to have homosexuality removed from the 1974 printing of DSM-II. “There was never a diagnostic question that he wouldn’t study from every perspective. Homosexuality presented an interesting intellectual question—what is normal? what is abnormal?—and had societal implications for how people live”, says Frances. “By withdrawing it from the manual, homosexuality was legitimised as a normal difference rather than a psychiatric behaviour. This early powerful statement by institutional psychiatry that this is normal sped up the confidence of people in the movement.” Spitzer received a bachelor’s degree in psychology from Cornell University in 1953 and a medical degree from New York University School of Medicine in 1957. He completed his psychiatric residency at New York State Psychiatric Institute in 1961 and graduated from Columbia University Center for Psychoanalytic Training and Research in 1966. He was a Professor of Psychiatry at the university until he retired in 2003. Spitzer’s first two marriages ended in divorce. He is survived by his wife and collaborator, Dr Janet Williams, five children, and four grandchildren. “No one in my experience has loved his work more than Bob Spitzer”, says Frances. “He couldn’t escape his fascination with psychiatric diagnoses.”
Alison Snyder www.thelancet.com Vol 387 January 30, 2016
Obituary
Robert L Spitzer Leading psychiatrist who developed strict standards for diagnosing mental disorders. Born on May 22, 1932, in White Plains, NY, USA, he died from complications of heart disease on Dec 25, 2015, in Seattle, WA, USA, aged 83 years. Psychiatry was in a crisis of credibility in the mid-1970s when Columbia University Professor Robert Spitzer was asked to oversee an update of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). “Spitzer pushed to get the DSM to adopt a more scientifically rigorous approach. It completely transformed the field and put psychiatry on firm scientific footing”, says Michael First, Professor of Clinical Psychiatry at Columbia University. Two studies published in the early 1970s shook the medical community’s confidence in psychiatric diagnoses. In 1972, researchers compared diagnostic practices of clinicians in New York and London and found that patients who would have been considered manic depressive or bipolar in London were determined to have schizophrenia in New York; Spitzer was a member of the steering committee for this study. The next year, Daniel Rosenhan published a controversial paper in Science describing how eight pseudopatients were admitted to psychiatric wards despite behaving as “normal” after a single, initial claim of hearing a voice. Spitzer wrote a scathing critique of Rosenhan’s experiment—“a careful examination of this study’s methods, results, and conclusions leads me to a diagnosis of ‘logic, in remission’”— but recognised that both the reliability and validity of psychiatric diagnosis was rightfully being questioned. Spitzer was developing psychiatric interview methods that focused on asking specific questions to extract information 428
needed for diagnosis when he became Chair of the DSM-III task force in 1974. These methods contrasted with the openended questioning of psychoanalysis, the predominant view of mental health at the time. Fascinated with data, measurement, and assessment from the beginning of his career, Spitzer and his colleagues got to work sorting symptoms and defining and naming disorders. When it was published in 1980, DSM-III listed 265 diagnostic categories and included for the first time bipolar disorder, post-traumatic stress disorder, and anorexia. “It re-shaped psychiatry”, says Allen Frances, Professor Emeritus of Psychiatry at Duke University and editor of the fourth edition of DSM. “In standardising, much was gained but something was also lost. More attention is paid to symptoms and less on the patients themselves, leading to reductionism in psychiatry. The biggest misuse is that pharmaceutical companies began selling diagnoses as all due to chemical imbalance that can be treated with a pill.” Spitzer himself later worried that standardisation was pathologising normal behaviours. He remained involved in updating later editions of DSM, advocating for the addition of premenstrual dysphoric disorder and binge eating disorder, which were added in 2013. He also helped to develop the Patient Health Questionnaire (PRIME-MD) that is now widely used in primary care medicine for screening and diagnosis of depression and for monitoring response to treatment. Stubborn, sometimes abrasive, and always eager, Spitzer’s work was guided by a strong sense of ethical fairness. ”He was an iconoclast and looked for injustice”, says First. Spitzer successfully fought to have homosexuality removed from the 1974 printing of DSM-II. “There was never a diagnostic question that he wouldn’t study from every perspective. Homosexuality presented an interesting intellectual question—what is normal? what is abnormal?—and had societal implications for how people live”, says Frances. “By withdrawing it from the manual, homosexuality was legitimised as a normal difference rather than a psychiatric behaviour. This early powerful statement by institutional psychiatry that this is normal sped up the confidence of people in the movement.” Spitzer received a bachelor’s degree in psychology from Cornell University in 1953 and a medical degree from New York University School of Medicine in 1957. He completed his psychiatric residency at New York State Psychiatric Institute in 1961 and graduated from Columbia University Center for Psychoanalytic Training and Research in 1966. He was a Professor of Psychiatry at the university until he retired in 2003. Spitzer’s first two marriages ended in divorce. He is survived by his wife and collaborator, Dr Janet Williams, five children, and four grandchildren. “No one in my experience has loved his work more than Bob Spitzer”, says Frances. “He couldn’t escape his fascination with psychiatric diagnoses.”
Alison Snyder www.thelancet.com Vol 387 January 30, 2016