DSM: A Common Language for Understanding Mental Illness

John McManamy Health Guide
  • In my previous blog, I recounted some of the history behind the modern DSM. Today’s DSM-IV-TR is the diagnostic bible used by psychiatry and related professions. A psychiatrist in New Jersey who diagnoses a patient with bipolar II rapid-cycling and co-occurring panic attacks can be reasonably confident that a consulting psychiatrist in New York will understand exactly what he or she is talking about. So will any nurses, therapists, medical doctors, pharmacists, HMO executives, corporate HR officers, teachers, parole officers, even Tom Cruise.

    So will the patient. No more Freudian muck; no more amorphous, impossible-to-define “neurosis” nonsense.
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    The architect of the modern DSM is Robert Spitzer, M.D., of Columbia University. He drew his inspiration from the pioneering German clinician Emil Kraepelin, who coined the term manic-depression. Robert Spitzer’s DSM dream team changed this to bipolar disorder, most likely so doctors wouldn’t think they were treating maniacs.

    The American Psychiatric Association gave Dr. Spitzer the brief to oversee the DSM-III in the 1970s. What the APA got was far more than they expected. The draft they received was no routine update. It was a direct challenge to the authority of Freud. A major showdown was brewing. The DSM-III was scheduled for publication in 1980, and the matter came up for approval in 1979. Some 350 psychiatrists were in attendance. “Spitzer got up onstage and reviewed the DSM process and what they were trying to accomplish, and there was a motion to pass it," an article in the Jan. 3, 2005, New Yorker describes.

    An eyewitness recalled: “People stood up and applauded. Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts, and instead he gets a standing ovation.”

    The DSM-III became an instant runaway success worldwide. Finally, psychiatry had a reasonably reliable method for diagnosing patients, with enormous treatment implications. Today’s DSM-IV-TR is largely derivative of the ground-breaking DSM-III. This is a tribute to Dr. Spitzer’s efforts, but also its greatest weakness. We have learned much about the brain and mood disorders since 1980, which is not reflected in today’s DSM. The one major change to the mood disorders section of the DSM was the addition in 1994 of the bipolar II diagnosis and its recognition of hypomania as the threshold criteria.

    Other than that, pretty much nada. Nothing to distinguish bipolar depression from unipolar depression, confusion about mixed states and rapid cycling, bias toward “female” symptoms, and so on.

    Some of these issues were already on my mind one fine evening in San Francisco three years ago when a man pulled up a seat next to me at a dinner symposium at the American Psychiatric Association’s annual meeting. His name tag read “Robert Spitzer.”

    To be continued …

Published On: January 20, 2006