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Where is its mind? What the battle over the 'bible' says about psychiatry Add to ...

It's possible, looking back on Robert Spitzer's life as one of the most influential psychiatrists of the 20th century, to conclude that he had a genius for turning grudges into career moves.

As a teen in the 1940s, he tried Reichian therapy to calm his feelings about girls, and liked it. But as a grad student, after Wilhelm Reich's orgone accumulator didn't work as well as Dr. Spitzer hoped, he wrote a critical paper that contributed to Reich's prosecution by the U.S. Food and Drug Administration.

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He then became a psychoanalyst. And when talk therapy didn't cure his patients fast enough, he created the modern Diagnostic and Statistical Manual of Mental Disorders, the bulky tome that revolutionized psychiatry and drove the last nail into Sigmund Freud's coffin.

But revenge has a way of biting back. A new group of psychiatrists is now under fire as they try to prepare the latest edition of the DSM, the Sears Catalogue of mental illness, used by more than 28,000 psychiatrists to diagnose their patients' afflictions.

The controversy over the proposed DSM-5 is forcing psychiatry to analyze its own issues - its fervid embrace of drugs; its enthusiastic use of genetics and brain imaging to expand existing diagnostic categories, perhaps prematurely; and the limits of its ability to understand the human mind.

This may, in turn, open the door again, at least a little, to talk therapy and Dr. Spitzer's old enemy, the unconscious. For the failing notion that mental illness can be crisply categorized and fixed with drugs - an idea Dr. Spitzer helped to invent, and that then dominated mental health for 30 years - it seems the time, as the shrinks like to say, is up.

Nettling the narcissists

Every new version of the DSM has been controversial, but the groundbreaking fifth edition of the "dictionary of disorder," now scheduled for release in 2013, is showing symptoms of being the most contentious ever. The rough draft published on the American Psychiatric Association's DSM website has generated so much heat (50 million hits and more than 3,000 signed comments so far) that its release has been pushed back by a year.

The proposed new edition has created so many new categories of diagnosis, and widened the definitions of so many others, that the respected editor of the last edition, Allen Frances, has accused the new editors of reckless irresponsibility.

Meanwhile, entire disorders were to be excluded from the new edition - such as narcissistic disorder ("a grandiose sense of self-importance ... requires excessive admiration") - but the move aroused such indignation (imagine how the narcissists felt!) that the editors have had to re-include them.

The raft of proposed new disorders in DSM-5 has other people complaining in the opposite direction. Premenstrual dysphoric syndrome, a freshly minted slot ("marked lability of mood interspersed with frequent tearfulness … subjective feeling of being overwhelmed or out of control," to name two of five symptoms necessary to qualify), has produced persistent irritability and anger (symptom 4) on the DSM website.

"Some groups," the DSM's editors note, "have felt that a disorder that focuses on the perimen- strual phase of the menstrual cycle may 'pathologize' normal reproductive functioning in women."

The real surprise is that something as mundane as a diagnostic manual gets any attention at all. First published by the American Psychiatric Association in 1952, DSM-I and DSM-II were spiral-bound and 150 pages long. DSM-II listed 182 disorders, and sold for $3.50, mostly to intake departments at mental institutions.

But in 1974, Dr. Spitzer was given the task of renewing the manual. He'd previously spearheaded the APA's bitterly divisive 1973 decision to delist homosexuality as sexual deviancy in the DSM.

Having rejected Freudian therapy, and dissatisfied with teaching as a professional goal - according to some of his collaborators, he wasn't very good at reading people - Dr. Spitzer turned to rewriting the DSM.

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