A Footnote to the Revolution in Psychiatric Diagnosis

The critique of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, rather than the more recent DSM-IV) presents the historical judgment that “Descriptive psychiatry was reborn in the United States at Washington University under the leadership of Eli Robbins [sic]” (Galatzer-Levy and Galatzer-Levy 2007, p. 163). But what follows is an indictment of Robins’s scientific integrity:

Perhaps the most fateful mistake of this type for the history of psychiatry was the misdiagnosis of the psychiatrist, Eli Robbins, whose symptoms of what turned out to be a demyelinating disorder were mismanaged as a hysterical condition. . . . Not surprisingly, Robbins detested psychoanalysis throughout his life. As chairman of psychiatry at Washington University, Robbins spearheaded the development of the “Research Diagnostic Criteria” that led to the DMS-III. The criteria were designed to clearly categorize psychiatric illness in order to narrow the focus of study so that one could have confidence that research investigations were limited to patients suffering from a single diagnostic entity. Notably, these criteria shifted the definition of hysteria. The new definition required the presence of many medically unexplained symptoms in multiple systems, rather than isolated “conversion” symptoms in a single system. These more rigorous criteria greatly decreased the number of patients diagnosed with hysteria. It was as if the criteria were designed to ensure that no one would again be misdiagnosed as Robbins had been.

(pp. 169–70)

This Resentment Fable is not new. Dr. Richard Hudgens recalls first having heard the story in 1963 from a now deceased psychoanalyst in North Carolina; he dismissed it as a regional shaggy-dog story (personal communication, 2007).

Mrs. Lee Robins’s recollection of her then new husband’s 1946 illness is vivid (personal communication, 2007). Having completed his psychiatry residency training in Boston and brief summer Army assignment in Texas, Robins was pleased to have a brief vacation in Boston en route to newly directed overseas duty in Germany. In September he developed an acute febrile illness with severe anorexia, malaise, and pain, especially localized in his proximal left upper extremity. He endeavored to provide self-treatment until the hotel management evicted the couple because of reservations for the World Series, which began on October 6. Severe shoulder pain was still his major symptom when he was admitted to the Waltham Army Hospital, where his Army non-specialist physician offered the diagnosis of hysteria. But as the pain resolved, severe weakness of the left shoulder muscles became evident, along with some weakness in the right shoulder and leg. Robins’s colleague and friend Mandel E. Cohen recalled: “I was the consultant for this area, and I was asked to see this patient who they diagnosed HYSTERIA. There was an epidemic of polio in Texas, where Eli was working. He had some weakness of the shoulder. We arranged for a weekend pass, out of the Army Hospital. A lumbar puncture showed an increase in lymphocytes, and the diagnosis was clear, not hysteria, but polio” (Rich 1995). Robins was then also examined by Dr. Raymond Adams, who confirmed the diagnosis (personal communication, 2007). Residual atrophy of left upper extremity muscles was still evident when I first examined Robins in 1961, at the onset of the unusual seizure symptoms that were the first manifestation of the debilitating course of multiple sclerosis.

No data justify the view that Robins maintained any resentment for the inaccurate diagnosis; he was an M.D. who missed it himself! Mrs. Robins recalls that her husband was doubly amused by the irony of the hysteria proposition. His own then unpublished research described the compensation factor as an essential feature of the diagnosis of “hysteria in men” (Robins, Purtell, and Cohen 1952). But the Army doctor’s presumption of motivation to escape foreign duty was inverted: he was disappointed, not pleased. After brief convalescent sick leave, Robins was assigned to be Chief of Neurologic and Psychiatric Services at the Waltham Army Hospital (March 1947–February 1948).

Research chronology is pertinent. Late in 1942, Cohen, then Instructor in Medicine and Neurologist at Massachusetts General Hospital, recruited James J. Purtell, psychiatry resident at the...