Hannah S. Decker

This book feels like a jigsaw puzzle which didn't quite get assembled all the way.

Let's explain why this is important. By the 1970s, psychiatry was a discipline in real trouble. Although its practitioners were, theoretically, medical doctors, they didn't really do anything that resembled medicine -- no lab tests, no procedures, no pills. And, most important, no cures. Psychiatry, in America in particular, had been invaded by "psychoanalysis" -- Freudianism. Which had nothing to offer those with real mental illnesses (schizophrenia, bipolar disorder, severe depression; also neurodevelopmental conditions like autism). It was a treatment for the "worried well" -- but it claimed to be more.

This even though it didn't even know how to diagnose anything! Imagine a patient who came before two doctors, and one says, "He has heart disease" and the other says, "He has a broken leg." And then gave the patient the same treatment. At least one would be wrong, and how do you trust either one in that case? And, because they refused to do research to verify that their discipline worked (after all, it would have shown that, mostly, it didn't), they couldn't even know what did and did not work. Psychoanalysis wasn't science, it was fundamentally a religion -- and it was a religion that, by this time, people were starting to question.

The American Psychiatric Association couldn't, or at least wouldn't, do anything about psychoanalysis at that time -- too many of its members were analysts for them to stop and say, "This is bunk; let's get real." But they could at least produce a third edition of their Diagnostic and Statistical Manual that allowed repeatable diagnosis. And, because no psychoanalyst really wanted the job, the task of editing it went to Robert Spitzer, a man with a psychoanalytic background who disliked analysis, disliked dealing with patients, disliked ambiguity -- and loved organizing things.

The result was a revolution. The DSM-III, as the third edition of the Diagnostic and Statistical Manual was called, didn't actually get rid of the psychoanalysts. But it came at a time that a real form of therapy (Cognitive Behavioral Therapy) was being developed, and at the time when the first real psychotropic drugs were coming out (lithium for bipolar disorder, the tricyclics and later the SSRIs for depression, thorazine and the other antipsychotics for schizophrenia). All of them have combined to rehabilitate psychiatry. Not completely, of course -- from the days when there was too much analysis, we've now perhaps swung into an era of too many pills, and not all the definitions in DSM-III, or even its successor DSM-5, are right, and there are lots of things that can go wrong along the way. But things are much better. And Robert Spitzer's book was one of the most important elements of the change.

This volume describes the history of psychiatry up to the DSM-III, including how some psychiatrists, hidden from the glare of psychoanalysis, were trying to do real research; it also tells of the people who were to create the DSM-III. And it gives us an overview of the torturous process by which Spitzer fought the analysts at many points until -- perhaps to everyone's surprise -- the APA approved the DSM-III and opened the door for revolution.

It's an extremely complicated story, and the book reflects that; it's a big volume, in smallish print, with massive documentation. Unfortunately, it almost reads more like a series of separate essays than a whole. There are several ways you could do a book like this. You could do it topically: "Here is what a set of criteria for a diagnoses looks like." You could do it chronologically: "The most important meeting was in 1977; others followed in 1978 and 1979." You could do it by personalities: "Robert Spitzer during the process of writing the DSM-III would break up with his first wife and marry one of his co-workers." Each has some value; each reveals something new. But this book doesn't really pursue any of them. It's hard to follow the chronology -- I honestly had no idea what happened when. (Even a brief one or two page timeline would have really helped. Better yet, make it a card or a bookmark that you could pull out and refer to throughout the book.) The only person we really get a good view of is Spitzer (plus a few of his predecessors); we meet some of his collaborators, but they come and go. We meet his opponents, sometimes repeatedly, but they aren't personalities, really; more like the moles in a whack-a-mole game: "Here's Dr. Burris objecting to X. Here's Dr. Spitzer striking back. Here's Dr. Offenkrantz wanting an appendix. Here's Dr. Spitzer striking back...." The photos and two or three sentence "pictorial essays" about these people aren't much help.

As for topics -- we learn, for instance, that there was a great controversy over Borderline Personality Disorder. But what is BPD? Well, I know the answer, because I've read the relevant section of the DSM-5, but you won't learn from this book. There is very little discussion of what the DSM-III actually contains. All we hear about is the arguments over psychoanalysis. All these are very neatly laid out in sections with big bold headlines grouped into chapters -- but they don't tell a story. It feels like an outline where each section swallowed anything related to it, without any connection between the sections.

And the final overview, that should put the whole thing in perspective, instead insists on muddying the waters, devoting much of its attention to insulting empiricism. This is simply muddle-headed. The fact that, in 1980, empirical studies could not identify all causes of diseases, and that fact that, in 2013 when the DSM-5 came out, it still could not do so, does not change the fact that without empirical thinking, you don't have data. It's like devoting a whole history to the titanic struggles of the Allies to winning World War II -- and then saying that the Allies shouldn't have won because they were cruel enough to firebomb Dresden. And the fact that drug companies have too much influence in psychiatry is not the fault of the DSM-III; it's the fault of our political system. The concluding section is not only wrong, it takes away badly from the DSM-III -- which was not the last word, but which represented a tremendous advance against the disaster that was American psychiatry in the 1960s and 1970s.

I had enough background about the DSM and its development that I had some idea of what was going on here. But, because the book is so big and its organization so hard to discern, I feel as if I probably missed at least 80% of the information that author Decker processed to write this book. A reader without my background is likely to find it even harder to read. Don't get me wrong: there is a tremendous amount of information here. I am glad to have the book, and would regard it as worth the rather exorbitant price. But I feel as if a book half the size could convey twice the useful information -- if it were set out in a more obvious way. On the other hand, that shorter book doesn't exist. And this one is certainly to be recommended over no history at all.… (más)