Robert Spitzer, Psychiatrist Who Set Rigorous Standards for Diagnosis, Dies at 83
By BENEDICT CAREY

Dr. Robert L. Spitzer, who gave psychiatry its first set of rigorous standards to describe mental disorders, providing a framework for diagnosis, research and legal judgments — as well as a lingua franca for the endless social debate over where to draw the line between normal and abnormal behavior — died on Friday in Seattle. He was 83.

Dr. Spitzer died from complications of heart disease at the assisted living facility where he lived, his wife, Janet Williams, said. The couple had moved to Seattle from Princeton, N.J., this year.

Dr. Spitzer’s remaking of psychiatry began with an early interest in one of the least glamorous and, historically, most ignored corners of the field: measurement.

In the early 1960s, the field was fighting to sustain its credibility, in large part because diagnoses varied widely from doctor to doctor. For instance, a patient told he was depressed by one doctor might be called anxious or neurotic by another. The field’s diagnostic manual, at the time a pamphletlike document rooted in Freudian ideas, left wide latitude for the therapist’s judgment. Dr. Spitzer, a rising star at Columbia University, was himself looking for direction, increasingly frustrated with Freudian analysis.

A chance meeting with a colleague working on a new edition of the manual — the Diagnostic and Statistical Manual of Mental Disorders, or the D.S.M. for short — led to a job taking notes for the committee debating revisions. There he became fascinated with reliable means for measuring symptoms and behavior — i.e., assessment.

“At the time, there was zero interest in assessment,” said Dr. Michael First, a professor of clinical psychiatry at Columbia University. “He saw how important it was, and his whole career led to assessment being taken seriously.”

One of the first behaviors Dr. Spitzer scrutinized was homosexuality, which at the time was listed in the manual as a mental disorder. Dr. Spitzer, after meeting with gay advocates, began re-examining homosexuality based on whether it caused any measurable distress.

The issue was extremely contentious, but in 1973, Dr. Spitzer engineered a deal by which the diagnosis was replaced by “sexual orientation disturbance,” to describe people whose sexual orientation, gay or straight, caused them distress.

Gay groups immediately recognized the change as a historic one, and Dr. Spitzer’s skill in orchestrating it helped him take charge of the third update of the manual, known as DSM3. “The fact that gay marriage is allowed today is in part owed to Bob Spitzer,” said Dr. Jack Drescher, a psychoanalyst in private practice in New York who is gay.

To some extent, the central question Dr. Spitzer applied to homosexuality — does it cause distress? — was the same one he used to conduct a broad re-examination of all behaviors listed as disorders. In a series of meetings, many in New York, he convened experts in each diagnostic category and sat in a corner, typing notes as they debated. Working with another researcher, Dr. Williams, who would become his wife, he produced the DSM3, which became an unlikely best seller in 1980 in the United States and abroad.

It immediately set the blueprint for future manuals, using rigorously tested checklists to categorize mental problems. It also elevated its principal architect to the top of his field, where he reigned as keeper of the book for more than two decades.

Dr. Spitzer wore the position as if he had been born to it, exuberantly courting controversy. He clashed with Freudian analysts, researchers, journalists and, late in his career, gay advocates and psychiatrists, who helped discredit a study he had done purporting to support “reparative” therapy to alter homosexual behavior.

Dr. Spitzer publicly apologized for that study in 2012, calling it the only thing in his career that he regretted.

“Bob Spitzer was by far the most influential psychiatrist of his time,” Dr. Allen Frances, a professor emeritus of psychiatry at Duke University and editor of a later edition of the manual, said in an email. “He saved the field and its millions of patients from a crisis of credibility, raising its scientific standards and rescuing it from the arbitrariness of warring and unsupported opinions.”

Robert Leopold Spitzer was born on May 22, 1932, in White Plains, N.Y., the youngest of three children of Benjamin and Esther Spitzer. His father was an engineer who invented dental materials, among other things; his mother was an accomplished pianist. The family soon moved to Manhattan, and Dr. Spitzer grew up on the Upper West Side, where he attended the Walden School.

He received a bachelor’s degree in psychology from Cornell University in 1953 and an M.D. in 1957 from New York University School of Medicine. He completed a psychiatric residence at the New York State Psychiatric Institute in 1961, and in 1966 he graduated from Columbia’s Center for Psychoanalytic Training and Research. From 1980 to 2001, he won many of the field’s most prestigious awards, including one for patient care and one for teaching.

A tall, lean, restless presence, he freely admitted to craving controversy and attention, and to forging relationships through debate and disagreement. “Maybe it was a New York thing, growing up here, I don’t know,” he said in an interview with The New York Times in 2012. “I was just always like that, contrary and confident.”

Those qualities, combined with his outsize influence, did not sit well with many colleagues, some of whom said the DSM3 and its successors delivered standardization at the expense of humane interviewing and intuition.

“DSM has had a dehumanizing impact on the practice of psychiatry,” Dr. Nancy Andreasen, a prominent psychiatrist at the University of Iowa, wrote in 2007. “History taking — the central evaluation tool in psychiatry — has frequently been reduced to the use of DSM checklists.”

Dr. Spitzer’s first two marriages ended in divorce. In addition to Dr. Williams, he is survived by five children — Laura Spitzer and Daniel Spitzer, by his second marriage, and Noah, Ezra and Gideon Spitzer-Williams by his third — and four grandchildren.

Not long before retiring from Columbia in 2003, Dr. Spitzer developed Parkinson’s disease, which progressively limited his mobility. It had no measurable effect on any other quality. During subsequent major revisions of the psychiatric manual — particularly DSM5, published in 2013 — he loomed on the sidelines like an exacting parent, issuing advice, commentary and punishing critiques.

“For DSM3, he was in every work group. He ran the entire show; he virtually wrote the thing himself” with Dr. Williams, said Dr. First, who edited DSM4 and consulted on DSM5. “Since then, the process has become decentralized, and people have come to realize how extremely difficult it is to get experts in this field to agree on anything.”

同性戀去病化推手 美醫師史畢哲逝世

當代最具影響力的美國精神科醫師史畢哲（Robert Spitzer）廿五日因心臟疾病併發症逝世，享壽八十三歲。史畢哲多次參與編纂「精神疾病診斷與統計手冊（DSM）」，根據數據和證據訂定診斷框架，並於1973年將同性戀從DSM病理學名單中去除。

史畢哲當年接下編纂「美國精神病學會」第三版DSM編纂工作後，與各診斷領域專家會面記錄觀察結果，彙整為大家都認同的精神疾病定義，成精神科醫師診斷精神疾患的依據。

史畢哲與妻子珍妮特．威廉斯均為美國哥倫比亞大學精神病學教授，兩人共同參與第三版DSM編寫過程。威廉斯說，DSM定義了所有主要病症，成為精神科醫師診斷精神疾患的參考依據。第三版DSM 1980年出版，成為全球暢銷書。

在那之前的1960年初期，精神科醫師診斷手冊以心理學家佛洛伊德的多個概念為基礎，留給醫生廣闊的個人評斷空間。意即，一名病患可能被這位醫生診斷為憂鬱症，被另一位醫生診斷為焦慮症。

史畢哲2005年受訪時說，他不只是訪問那些佛洛依德專家，而更注重研究數據和證據。第四版DSM編者、美國杜克大學榮譽退休精神病學教授法藍西斯說，史畢哲「是他的時代最具影響力的精神學家，他拯救了這個領域和數百萬病患」。

1973年，史畢哲會晤多名同志運動人士後，決定將同性戀從心理疾病名單中去除。他說，「心理疾病必須與痛苦等主觀不愉快或社會功能障礙相關」，但同性戀者對自己的性傾向感到自在，就不能算是疾病。紐約精神分析學家德瑞雪說：「同性婚姻如今被允許，部分應歸功於史畢哲。」

史畢哲2012年曾為他2001年出版的研究道歉，該研究發現同性戀者經過「性傾向修復治療」後可恢復異性戀傾向，但研究調查對象只詢問做過這項治療的人。史畢哲自稱這是他職業生涯中唯一後悔的事，他說：「你怎能知道一個人的性向真的轉變了呢？」

原文參照：
http://www.nytimes.com/2015/12/27/us/robert-spitzer-psychiatrist-who-set-rigorous-standards-for-diagnosis-dies-at-83.html

2015-12-28．聯合報．A13．國際．編譯陳韻涵