The People’s DSM: My Alternative Depression Diagnosis - Part I

If you want anything done right, you have to do it yourself. With the DSM-5 task force and its various work groups and study groups a virtual walking and talking “How many psychiatrists does it take to change a light bulb?” joke, it is time for me to take matters into my own hands.

Following is a very rough draft to the first installment of “The People’s DSM,” which I am dedicating to the pioneering spirit of Robert Spitzer and those who worked with him on the ground-breaking DSM-III of 1980. Spitzer and company essentially ripped up the DSM-II and started over. Something the DSM-5 people should have done to the DSM-IV.

Something I’m doing right now. But I need your help. Please give me your feedback and suggestions and we’ll keep reworking it together till we get it right. On with the show ...

Mood Disorders
Depression

Introduction

The current depression diagnosis, with its antiquated symptom checklist, does not adequately account for extreme variations in emotions, thoughts, and behavior. Below are six domains to depression (such as emotion and thinking), each domain arranged in two complementary pairs, each pair with contrasting characteristics (symptoms or sets of symptoms).

These six domains would replace the symptom checklist.

For the Alternative Depression Diagnosis, clinicians need to check at least one characteristic from each domain. All four characteristics from a particular domain may be checked, even if they are opposite. As opposed to the previous DSM, this is not an exercise in symptom counting. More symptoms do not equate to a more severe depression.

Rather, this is an exercise in spotting symptom (characteristic) patterns and anomalies. Clustering of certain characteristics tends to resolve into one of two types of contrasting depressions: “Vegetative” and “Agitated”. There is also an intermediate “Mixed” depression.

All three may be called depression, but they are likely to demand entirely different and extremely subtle treatment and therapeutic approaches, as if they were different diseases. Current diagnostic practice does not encourage this.

A final note: Suicidal ideation is not included as a characteristic (symptom) here. This will be dealt with in a future installment.

Depressive states (all of the below must be met):

1. Must last most of the day for two weeks or more, with no apparent sign of improvement.
2. Must be a significant departure from baseline condition.
3. Must significantly impair ability to work, relate to others, and enjoy life.

Domains (at least one from each of six):

A. Emotion (Too Much Feeling or Too Little):

1. Subject may feel overwhelmed, and express intense sadness or anger.
2. Subject may experience emotional numbness, such as loss of pleasure, inability to grieve, or feel motivated.
3. Subject may experience excessive guilt or irrationally worry about one’s self or others.
4. Subject may lack the capacity to feel guilt or display concern for one’s self or others.

B. Perception and Sense of Self (Wholly Negative or Some Positives):

1. Subject may experience exaggerated worthlessness, feel deserving of his or her fate, and undeserving of a better personal situation.
2. Subject may experience a sense of exaggerated bad luck, feel undeserving of his or her fate, and deserving of a better personal situation.
3. Subject may view events in a negative light, discount good news, and see one’s personal situation as hopeless.
4. Subject may view events in a temporarily positive light, react to good news, and may see ahead to the possibility of one’s personal situation improving.

C. Thinking (Overthinking or Underthinking):

1. Subject may obsessively ruminate on destructive or self-defeating thoughts.
2. Subject may report difficulty concentrating or trying to plan ahead.
3. Subject may exhibit difficultly in processing routine mental tasks, such as remembering a phone number.
4. Subject may experience anxious or racing thoughts.

D. Behavior (Wholly Passive or Some Active):

1. Subject may experience difficulty engaging in routine tasks (such as keeping appointments or personal hygiene), pleasurable activities (such as hobbies), and relating to others (as if a fish out of water).
2. Subject may engage inappropriately in routine tasks (such as messing up an easy  assignment), pleasurable activities (such as drug or alcohol use or reckless behavior), and relating to others (such as being argumentative and confrontational). 
3. Subject may passively withdraw from social contact and isolate.
4. Subject may aggressively withdraw from social contact and withhold his or her companionship.

E. Mental (Speeded Up or Slowed Down):

1. Subject may experience a deadening of the senses (such as loss of sex drive or inability to taste food).
2. Subject may experience a heightened sensitivity to unpleasant sensations (such as the sound of a person’s voice).
3. Subject may experience a subjective slowing of the brain (such as a feeling of being dead).
4. Subject may experience persistent psychic pain (such as a feeling of wanting to crawl out of one’s skin). 

F. Physical (High or Low):

1. Subject may display nervous energy (such as pacing and inability to sleep or not eating).
2. Subject may display loss of energy (such as psychomotor slowing, fatigue, need to sleep, or overeating).
3. Subject may experience unexplained pain.
4. Subject may feel beyond the ability to feel physical pain.

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Depressive types

Vegetative depression (subject leans toward most of the following):

Too little emotion, Negative Perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low. 

Agitated depression (subject leans toward most of the following):

Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening.

Mixed depression (subject displays roughly equal vegetative and agitated qualities)

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Vegetative, agitated, and mixed depressions may bear a relationship. A subject may present first with agitation, as if struggling against his condition, then give in to a vegetative depression. Conversely, an agitated depression may signal progress from a vegetative state toward remission or a worsening of one’s condition.

Final Word (for now)

Replacing the classic symptom checklist helps address some major concerns, namely:

• “Male” traits are mentioned for the first time, such as anger, drug use, confrontation, and aggression (along with “female” traits such as rumination), which should help redress the gender imbalance in the depression diagnosis.
• It helps identify the subject’s predominant state of mind (other than just “depression”), as well as other states, which gives clinicians and patients something to work with.
• It acknowledges the complexity of depression and its infinite variations.

In addition, the vegetated/agitated distinction eliminates the current and confusing melancholic/atypical depression distinction. It also accounts for the “pleomorphic” nature of depression, where symptoms (characteristics) may present differently from depression to depression or even within the same depression.

Two important first principles: No two depressions are alike. Depressions cannot be treated as if they are all the same. The current DSM discourages both clinicians and patients from thinking this way. The People’s DSM is offered as an antidote to this practice.

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This is a lot more to come to my alternative depression diagnosis, including chronicity, cycling, severity, dimensional concerns (such as anxiety, mania and temperament), suicidality, and relationship to stress. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...