Robert Spitzer: Psychiatrist who revolutionised his profession and led the campaign to stop regarding homosexuality as a disorder

In the tumult of the 1960s, psychiatry was under siege. Critics said it lacked scientific standards, failing many truly troubled people while medicating or institutionalising others who suffered from nothing more serious than non-conformity. As he listened to his patients talk through their problems, a fledgling Columbia University psychiatrist, Robert Spitzer, was nagged by doubts. “I was always unsure that I was being helpful,” he recalled, “and I was uncomfortable with not knowing what to do with their messiness.” Struggling to find a place in his profession, he ended up transforming it.

He dived headfirst into one of the era's most heated debates, brokering the American Psychiatric Association's landmark 1973 vote to stop treating homosexuality as an illness. Taking the helm at the APA's Diagnostic and Statistical Manual of Mental Disorders, regarded as the profession's bible, he led a push for uniform standards in an often ambiguous discipline. He added dozens of mental disorders to the psychiatric lexicon, such as anorexia, bipolar disorder, panic disorder and PTSD, and the DSM tripled in size and at least as much in influence under his leadership.

Spitzer was born in 1932 in White Plains, New York to the children of Eastern European immigrants. His engineer father was cold and distant, he recalled his mother in chronic grief over his older sister's death from meningitis. But he took a briskly rational approach to his complicated childhood and adolescence. He drew graphs to chart his fluctuating feelings about the girls in his life, and during high school sneaked out for $5 analysis sessions.

He enjoyed the talking part but grew sceptical about the “orgone accumulator” his therapist had him sit in – an iron box devised by the psychoanalyst Wilhelm Reich that could supposedly cure various mental disorders. As a Cornell undergraduate, Spitzer wrote a paper debunking “orgone energy” theory, and the US Food and Drugs Administration asked him to serve as an expert witness in a fraud case against Reich. It was an experience that would serve him well for later battles.

The traits that made Spitzer attract controversy were the same that fuelled his psychiatric revolution: a desire to challenge the establishment, a mania for data and order and a curious mind. As a student at New York University he published a paper challenging a major study by a prominent faculty member. His career was somewhat aimless, though, until 1966, when a colleague at Columbia mentioned that he was on a committee for the DSM-II, the first major revision of the APA's 1952 directory of disorders, and asked if Spitzer would help. His initial role was modest, but it gave him a front-row seat to the debates in his profession.

After the 1969 Stonewall riots, gay activists were agitating for more rights, and in the early 1970s they invaded APA conferences to protest against homosexuality's classification as a mental illness. It wasn't just a paper stigma: some gay people couldn't get treated for depression or anxiety because doctors focused on their orientation; others were pressured into therapies involving hormones or electric shocks.

After a clash at a 1972 meeting of behavioural therapists in New York, Spitzer decided to hear the protesters out. Personally, he believed then that homosexuality was an illness but, forever the devil's advocate, he organised a panel for both sides to air their arguments at the 1973 APA conference in Honolulu. There, an activist took Spitzer to a secret gathering of closeted gay psychiatrists. Many had prestigious credentials, which convinced him that homosexuality was not some crippling condition.

Ultimately, his was the loudest voice arguing to drop homosexuality from the DSM. If gays were happy being gay, where was the disorder? But he offered a deft compromise: in subsequent printings of the DSM-II, homosexuality was replaced with “ego-dystonic homosexuality,” the condition of gays or lesbians unhappy with their orientation.

What psychiatry needed, he believed, was a common language to describe mental illnesses. He filled the DSM-III committees with psychiatrists who shared his fervour for data and description. In chaotic meetings, they would shout suggestions for new disorders, which often went straight into Spitzer's typewriter.

Old, broadly defined conditions were broken into more specific ones. “Anxiety neurosis” was replaced by panic disorder, social phobia and generalised anxiety disorder. Judgemental terms such as “frigidity” were swapped for clinical ones such as “inhibited sexual desire.”

Spitzer waded into the fights that erupted over his new classifications, such as tobacco dependence. At the time, nearly 40 per cent of adults smoked, but many doctors were wary of linking the habit to mental illness, and the industry was fighting back. But Spitzer unveiled a shocking photograph of a throat cancer victim smoking a cigarette through his tracheotomy hole. Tobacco dependence made the cut.

The DSM-III was a sensation on its 1980 release; along with a 1987 revision that Spitzer also oversaw, it sold 1m copies. But as the APA prepared for the fourth edition, the leadership replaced Spitzer, regarded by some as too dominant and heavy-handed.

But Spitzer's work changed the treatment of many mental illnesses and opened the door to new epidemiological research: once doctors had a common understanding of which symptoms defined which illnesses, they could track their prevalence across large populations.

Spitzer liked to provoke. He sparred with Freudians when he banned their cherished word “neurosis” – fixated on tangible symptoms, he had no truck with unconscious conflict. He enraged feminists when he tried to classify pre-menstrual syndrome as a mental illness, and nearly undermined his social-justice legacy when, late in his career, he championed therapies to “cure” homosexuals. His 2001 study was pilloried by colleagues and activists for shoddy methodology, and in 2012 he retracted it.

Robert Leopold Spitzer, psychiatrist: born White Plains, New York 22 May 1932; married firstly (marriage dissolved), secondly Judith Berg (marriage dissolved; two children), thirdly Janet Williams (three children); died Seattle 25 December 2015.

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