Robert Spitzer, M.D., Dies at Age 83, Hailed as Pioneering Diagnostician
Abstract
He is credited with leading a movement that placed psychiatry within the larger house of medicine by introducing a system of nosology based on evidence.
Robert Spitzer, M.D., a towering figure in contemporary American psychiatry and a leading architect of APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM), died on December 25, 2015, at the age of 83.
Robert Spitzer, M.D., was known as the psychiatrist most responsible for the removal of homosexuality from the list of disorders in DSM.
He is widely known outside the profession as the individual responsible for leading a movement to have homosexuality removed from the list of disorders in DSM in 1973. Within the profession, he is also known as the pioneer of a system of measurement and assessment for diagnosing mental illnesses that helped to move American psychiatry toward a more evidence-based nosology. He chaired the task force that produced DSM-III in 1980, and though the manual has evolved, the essential elements of classifying mental disorders in discrete categories with specific diagnostic criteria are retained in today’s DSM-5.
APA leaders and those who worked closely with Spitzer over many years hailed a psychiatrist who was forceful, opinionated, and sometimes combative but deeply committed to improving the diagnosis and care of people with mental illness.
“Robert Spitzer was a hero of modern psychiatry whose work will have a lasting impact,” said APA President Renȳe Binder, M.D. “His pioneering work in measurement and assessment has informed successive editions of DSM, creating a reliable diagnostic system that is recognized throughout the world. His leadership in removing homosexuality from the manual more than 40 years ago was a landmark achievement for the LGBT community, our profession, and our patients. We are deeply saddened by his loss.”
“Robert Spitzer, M.D., was a major force in advancing psychiatric diagnosis,” agreed APA CEO and Medical Director Saul Levin, M.D., M.P.A. “I admire him not only for his contribution, but also his integrity.”
Establishing Psychiatric Bona Fides
“I think Bob Spitzer is a classic example of the right person at the right place at the right time,” former APA President Jeffrey Lieberman, M.D., told Psychiatric News. Lieberman is chair of the Department of Psychiatry at Columbia University, where Spitzer spent his career. He is also chair of psychiatry at New York Presbyterian Hospital, director of the New York State Psychiatric Institute, and author of Shrinks: The Untold Story of Psychiatry.
“He had an incredibly active and intelligent mind, and he was brimming with self-confidence. He could be outspoken and assertive to the point of being overbearing, and he never shrank from confrontation. He was fundamentally a seeker of the truth,” said Lieberman. “He was appointed by APA leadership to head the process of re-establishing the profession’s bona fides with a more evidence-based, scientifically justified diagnostic nosology. Spitzer was charged with this responsibility, and he succeeded brilliantly. He ruffled some feathers in the process and dealt with a lot of challenges, conflicts, and controversies, but he was successful.”
DSM-III introduced the use of categories of mental illness with specific diagnostic criteria, as well as the multi-axial system, which was eliminated from DSM for the fifth edition.
Lieberman was echoed by Michael First, M.D., editorial and coding consultant for DSM-5. He also was editor of the DSM-IV-TR, editor of text and criteria for DSM-IV, and editor of the Handbook on Psychiatric Measures.
“The anti-psychiatry movement was flourishing,” First said of the time prior to DSM-III. “Psychiatric diagnosis was widely assumed to be so unreliable that the odds of two psychiatrists agreeing on a diagnosis was like flipping a coin. By capitalizing on scientific work and coming up with a method for making diagnosis more reliable, DSM-III was a huge step toward putting psychiatry on the map as a legitimate medical specialty. It was Bob Spitzer’s vision to create diagnostic criteria that could be used by clinicians everywhere and that could be the lingua franca of the entire field.”
First did a fellowship in biometrics research under the direction of Spitzer, whom he credits as his mentor. “My entire career was shaped by my decision to come to Columbia to work with Bob,” First told Psychiatric News.
Lieberman pointed out that among Spitzer’s lesser-known accomplishments (at least among the general public) was his work in establishing a diagnosis for posttraumatic stress disorder (PTSD). Working with psychiatrists Chaim Shatan, M.D., Robert Lifton, M.D., and others, Spitzer listened to the stories of veterans returning from Vietnam and appointed Nancy Andreasen, M.D., later editor of the American Journal of Psychiatry, to head a work group on developing criteria for what would be called PTSD in DSM-III.
David Kupfer, M.D., chair of the DSM-5 Task Force, said the inclusion of criteria for sleep disorders in the new manual owes much to Spitzer’s early work.
At the Center of Debates About Homosexuality
It was around the issue of homosexuality that Spitzer’s passion for evidence—as well as his deft political skills—became evident to the APA leadership. In the early 1970s, gay activists, including gay psychiatrists within the APA membership, began to advocate for the elimination of homosexuality as a mental disorder in DSM.
Spitzer had become convinced that gay men and women, on the basis of their homosexuality alone, could not be determined to be mentally ill. In part because of his leadership, homosexuality was removed from the diagnostic list in 1973—after extraordinarily heated debate—and replaced with a new category proposed by Spitzer called “sexual orientation disturbance.” This designation could be used for individuals who were unhappy or distressed because of their sexual orientation. It was later termed “ego dystonic homosexuality” in DSM-III, a category that was dropped for DSM-III-R.
Jack Drescher, M.D., said Spitzer’s leadership on the issue, by focusing on subjective distress experienced by the patient, provided a template, of sorts, for how to approach mental illness generally.
“If gay people were not distressed or unhappy with their orientation, how could we categorize homosexuality as a disorder if we were not simply moralizing?” said Drescher, training and supervising analyst at the William Alanson White Institute and past chair of the APA Committee on Gay, Lesbian, and Bisexual Concerns.
Years later, Spitzer, perhaps reflecting a penchant for controversy, surprised many people when he presented a paper at APA’s 2001 annual meeting that attracted enormous media attention based on a study purporting to show that some gay individuals could change their orientation through “reparative therapy.”
A decade later, Spitzer recanted the study. In a letter to the editor of the Archives of Sexual Behavior, where the study appeared in 2003, Spitzer issued a mea culpa. “I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy,” he wrote. “I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some ‘highly motivated’ individuals” (Psychiatric News, June 15, 2012).
Drescher, who came to know Spitzer personally, said he believes Spitzer was genuinely surprised and aggrieved that his study had become a flash point in the “culture wars.”
Spitzer also drew attention for his criticism of the process used in the development of DSM-5. But even as an adversary he was regarded by all as a worthy one who sought the truth.
“I think he had one of the most original minds I have ever met,” Drescher said. “Were it not for what Bob Spitzer accomplished, it would not have been possible for someone like me to have a profession in psychoanalysis, and even though he made some errors along the way, the good he did easily outweighed the bad.” ■
