Orderer of Disorders

The January 3 New Yorker includes a revealing profile of Robert Spitzer, the main driving force behind the landmark third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The article, by Alix Spiegel, makes clear that the DSM, widely viewed as a scientific taxonomy, is little more than a compilation of the conventional wisdom among the handful of psychiatrists who play an important role in shaping the text–or, in some cases, the whims of one guy with a typewriter:

In 1974, Roger Peele and Paul Luisada, psychiatrists at St. Elizabeths Hospital, in Washington, D.C., wrote a paper in which they used the term "hysterical psychoses" to describe the behavior of two kinds of patients they had observed: those who suffered from extremely short episodes of delusion and hallucination after a major traumatic event, and those who felt compelled to show up in an emergency room even though they had no genuine physical or psychological problems. Spitzer read the paper and asked Peele and Luisada if he could come to Washington to meet them. During a forty-minute conversation, the three decided that "hysterical psychoses" should really be divided into two disorders. Short episodes of delusion and hallucination would be labelled "brief reactive psychosis," and the tendency to show up in an emergency room without authentic cause would be called "factitious disorder." "Then Bob asked for a typewriter," Peele says. To Peele's surprise, Spitzer drafted the definitions on the spot. "He banged out criteria sets for factitious disorder and for brief reactive psychosis, and it struck me that this was a productive fellow! He comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders!" Both factitious disorder and brief reactive psychosis were included in the DSM-III with only minor adjustments.

DSM-III was supposed to make psychiatric diagnoses reliable–i.e., consistent from one practitioner to another. As Spitzer himself concedes, this goal remains elusive. Meanwhile, as Spiegel notes almost in passing, the more important question of validity–whether the "disorders" described in the manual correspond to real entities with similar causes and solutions–has been addressed hardly at all.

"One of the objections was that it appeared to be more authoritative than it was," a psychiatrist who worked on both DSM-III and its revision tells Spiegel. "The way it was laid out made it seem like a textbook, as if it was a depository of all known facts. The average reader would feel that it carried great authority and weight, which was not necessarily merited."