Robert Spitzer (psychiatrist)

Robert Spitzer
Born	Robert Leopold Spitzer (1932-05-22)May 22, 1932 White Plains, New York, U.S.
Died	Seattle, Washington, U.S.
Nationality	American
Fields	psychiatry
Institutions	Columbia University
Alma mater	Cornell University (B.A.), New York University School of Medicine (M.D.)
Known for	his work on modernizing classification of mental disorders, recognizing homosexuality as a non-mental disorder
Influences	Wilhelm Reich
Spouse	Janet Williams (?-2015; his death)

Robert Leopold Spitzer (May 22, 1932 – December 25, 2015) was a psychiatrist and professor of psychiatry at Columbia University in New York City. He was a major force in the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

New York City

Spitzer spent most of his career at Columbia University in New York City, and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He is a major architect of the modern classification of mental disorders. He retired after 49 years in December 2010. He has been called one of the most influential psychiatrists of the 20th century.

Education and early years

Spitzer was born in White Plains, New York, in 1932. He received his bachelor's degree in psychology from Cornell University and his M.D. from New York University School of Medicine in 1957. Spitzer wrote an article on Wilhelm Reich's theories in 1953 which the American Journal of Psychiatry declined to publish.

Spitzer served on the four-person United States Steering Committee for the United States–United Kingdom Diagnostic Project, who published their results in 1972. (The most important difference between countries they found was that the concept of schizophrenia used in New York was much broader than the one used in London and included patients who would have been termed manic-depressive or bipolar.) Spitzer co-developed a computer program, Diagno I, in 1968, based on a logical decision tree, that could derive a diagnosis from the scores on a Psychiatric Status Schedule (which he co-published in 1970) and that the Project used to check the consistency of its results.

Screening and Diagnostic Tools

Spitzer codeveloped the Mood Disorder Questionnaire (MDQ), a screening technique used for diagnosing bipolar disorder. He also co-developed the Patient Health Questionnaire (PRIME-MD) which can be self-administered to find out if one has a mental illness. The portions of PRIME-MD directed at depression (PHQ2 and PHQ9) have since become accepted in primary care medicine for screening and diagnosis of major depression as well as for monitoring response to treatment.

Position on the DSM

Spitzer was chair of the task force of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) which was released in 1980. Spitzer is a major architect of the modern classification of mental disorders which involves classifying mental disorders in discrete categories with specified diagnostic criteria but later criticized what he saw as errors and excesses in the DSM's later versions, although he maintained his position that the DSM is still better than the alternatives.

Spitzer was briefly featured in the 2007 BBC TV series The Trap, in which he stated that the DSM, by operationalizing the definitions of mental disorders while paying little attention to the context in which the symptoms occur, may have medicalized the normal human experiences of a significant number of people.

Spitzer co-authored a position paper in 2003 with DSM-IV editor Michael First, stating that the "DSM is generally viewed as clinically useful." The position paper based this observation on data such as surveys from practicing professionals and feedback from medical students and residents. The authors added that primary care physicians find the DSM too complicated for their use. While agreeing that DSM is far from perfect, they reject the call for it to be abandoned. The authors emphasize that given then-current limitations in understanding psychiatric disorders, a multitude of DSM codes/dignoses might indeed apply to some patients but that it would be a "total speculation" to assign a single diagnosis to a patient.

The authors also acknowledged that the criteria for certain disorders are known to be poor but argue that it is one of the reasons why the Manual must undergo periodic revisions. Further, the authors rejected calls to adopt the ICD-9 because it lacks diagnostic criteria and would "[set] psychiatry back 30 years," while the ICD-10, they argue, closely resembles the DSM-III-R classification. In 2013, a definitive autobiography of Spitzer, "The Making of DSM-III®: A Diagnostic Manual's Conquest of American Psychiatry", was published by author and historian Hannah S. Decker.

Spitzer has criticized the revision process of the DSM-5 for lacking transparency. He has also criticized specific proposals, like the proposed introduction of the psychosis risk syndrome for people who have mild symptoms found in psychotic disorders.

Work on homosexuality

His most lasting legacy may have been his successful effort, in 1973, to stop treating homosexuality as an illness.

In 2001, Spitzer delivered a controversial paper, Can Some Gay Men and Lesbians Change Their Sexual Orientation? at the 2001 annual APA meeting; in that paper, Spitzer argued that it is possible that some highly motivated individuals could successfully change their sexual orientation from homosexual to heterosexual.

A Washington Post article indicates that Spitzer held 45-minute telephonic interviews with 200 people who claimed that their respective sexual orientations had changed from homosexual to heterosexual. Spitzer said he "began his study as a skeptic," but the study revealed that "66 percent of the men and 44 percent of the women had arrived at what [Spitzer] called good heterosexual functioning," defined as "being in a sustained, loving heterosexual relationship within the past year, getting enough satisfaction from the emotional relationship with their partner to rate at least seven on a 10-point scale, having satisfying heterosexual sex at least monthly and never or rarely thinking of somebody of the same sex during heterosexual sex."

Spitzer also found that "89 percent of men and 95 percent of women said they were bothered only slightly, or not at all, by unwanted homosexual feelings" but that "only 11 percent of the men and 37 percent of the women reported a complete absence of homosexual indicators, including same-sex attraction." The Post reported, "Some 43 percent of the sample had been referred to Spitzer by 'ex-gay ministries,'" while "an additional 23 percent were referred by the National Association for Research and Therapy of Homosexuality." Spitzer has stated that his research "shows some people can change from gay to straight, and we ought to acknowledge that." Considering how difficult it had been to find 100 participants, and that they were considered the best cases of conversion therapy, Spitzer concluded that although change could occur, it was probably very rare.

The APA issued an official disavowal of Spitzer's paper, noting that it had not been peer reviewed and stating that "[t]here is no published scientific evidence supporting the efficacy of reparative therapy as a treatment to change one's sexual orientation." Two years later, the paper was peer reviewed and published in the Archives of Sexual Behavior.

Two-thirds of the reviews were critical, and the publication decision sparked controversy, with one member of the publication's supporting organization resigning in protest. The paper has been criticized for its sampling methods and criteria for success.

In a 2005 interview, Spitzer stated, "Many colleagues were outraged" following the publication of the study. Spitzer added, "Within the gay community, there was initially tremendous anger and feeling that I had betrayed them." When asked whether he would consider a follow-up study, Spitzer said no and added that he felt "a little battle fatigue." While Spitzer has said that he has no way of knowing whether the study participants were being honest, he has also indicated that he believed that the interviewees were being candid with him.

In a 2012 interview, Spitzer said he asked to retract the study, stating that he agreed with its critics:

"In retrospect, I have to admit I think the critiques are largely correct," he said. "The findings can be considered evidence for what those who have undergone ex-gay therapy say about it, but nothing more." He said he spoke with the editor of the Archives of Sexual Behavior about writing a retraction, but the editor declined. (Repeated attempts to contact the journal went unanswered.)

In a letter to Kenneth J Zucker, editor of Journal of Sexual Behavior, Spitzer wrote:

"Several months ago I told you that because of my revised view of my 2001 study of reparative therapy changing sexual orientation, I was considering writing something that would acknowledge that I now judged the major critiques of the study as largely correct. After discussing my revised view of the study with Gabriel Arana, a reporter for American Prospect', and with Malcolm Ritter, an Associated Press science writer, I decided that I had to make public my current thinking about the study. Here it is.

"Basic Research Question. From the beginning it was: “can some version of reparative therapy enable individuals to change their sexual orientation from homosexual to heterosexual?” Realizing that the study design made it impossible to answer this question, I suggested that the study could be viewed as answering the question, “how do individuals undergoing reparative therapy describe changes in sexual orientation?” – a not very interesting question.

"The Fatal Flaw in the Study – There was no way to judge the credibility of subject reports of change in sexual orientation. I offered several (unconvincing) reasons why it was reasonable to assume that the subject’s reports of change were credible and not self-deception or outright lying. But the simple fact is that there was no way to determine if the subject’s accounts of change were valid.
I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. 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."

Awards and prizes

Spitzer received the Thomas William Salmon Medal from the New York Academy of Medicine for his contributions to psychiatry.

Death

Spitzer died on December 25, 2015 in Seattle, having recently moved there from New Jersey. His wife stated his death was due to heart problems.

Books

• Critical Issues in Psychiatric Diagnosis (with Donald F. Klein), Raven, 1978. ISBN 0-89004-213-6
• DSM III Casebook, American Psychiatric Publications, 1981. ISBN 0-89042-051-3
• Treatment of Mental Disorders (with James W. Jefferson), Oxford University Press, 1982. ISBN 0-19-503107-5
• Psychopathology, a Case Book (with Janet B. W. Williams and Andrew E. Skodol), McGraw-Hill, 1983. ISBN 0-07-060350-2
• DSM-III Case Book (Diagnostic), Cambridge University Press, 1985. ISBN 0-521-31530-1
• APA: Desk Reference to DSM-III R (Diagnostic), Cambridge University Press, 1987. ISBN 0-521-34693-2
• An Annotated Bibliography of DSM-III, 1987. ISBN 0-88048-257-5
• Structured Clinical Interview for DSM-III Axis I Disorders, Research Version, Patient Edition (SCID-I/P), 1990. ISBN 0-88048-411-X
• DSM-IV Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, 1994. ISBN 0-88048-675-9
• Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), 1997. ISBN 0-88048-931-6
• International Perspectives on DSM-III, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, 1998. ISBN 0-88048-017-3
• DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, 2002. ISBN 1-58562-058-0
• Treatment Companion to the DSM-IV-TR Casebook, American Psychiatric Association, 2004. ISBN 1-58562-139-0
• DSM-IV-TR Casebook, Volume 2, American Psychiatric Association, 2006. ISBN 1-58562-219-2