Wednesday, March 17, 2010

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

As you may be aware, I’m in the process of writing my own DSM. In Part I of my Alternative Diagnosis to Depression, I scrapped the antiquated and arbitrary depression symptom checklist and replaced it with something I haven’t given it a name for yet, that nevertheless actually offers clues to our real mental state.

Clinicians or patients would tick off contrasting items on a six-part survey organized according to domains. Thus: Emotion (too much feeling or too little); Perception or Sense of Self (wholly negative or some positives); Thinking (overthinking or underthinking); Behavior (wholly passive or some active); Mental (speeded up or slowed down); Physical (high or low).

Symptom (characteristic) patterns or anomalies would resolve into three types of depressive states:
  1. Vegetative depression (Too little emotion, Negative perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low). 
  2. Agitated depression (Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening).
  3. Mixed depression (subject displays roughly equal vegetative and agitated qualities).
But that is merely the beginning. The DSM serves up various “specifiers” (such as “recurrent”) to add variety to its single plain vanilla depression flavor, and it’s useful to borrow the technique.

A heads up or two:

The Atypical Depression/Melancholic Depression dichotomy as specifiers to DSM depression has been scrapped. Those specifiers were based on the antiquated DSM depression symptom list, resulting in considerable confusion and suspect validity. It is submitted that the Vegetative/Agitated distinction as separate diagnoses is more closely aligned to reality.

Considerable emphasis here is placed on dimensional/spectrum considerations to depression. The current DSM acknowledges psychosis in depression and the DSM-5 would acknowledge “mixed anxiety depression,” but with little attempt to explain their dynamics or their interaction. In this presentation, elements of anxiety, psychosis, mania, and personality are presented as bearing a relationship to various depression characteristics.

In particular, close regard is paid to depressions that behave as bipolar depressions, including “Agitated (or Mixed) Depression with Mania” and “Agitated (or Mixed) Depression, Highly Recurrent or Cycling.” The combination of these two forms the basis of a separate diagnosis of “Bipolar Spectrum Depression.”

The diagnosis of "Dysthymia" (low grade chronic depression) has been eliminated. Instead, severity criteria are used to distinguish "moderate" from "severe" from "very severe" depression. Moderate depression may have similarities to dysthymia, but the threshold is higher, removing any ambiguity.

Let’s got on with it:


A. Variable Characteristics (at least one item must be checked)

Vegetative, Agitated, or Mixed Depression, Pleomorphic

There has been an observable change over time in domain characteristics (such as from agitated to mixed or mixed to vegetative) between episodes or during an episode.

Vegetative, Agitated, or Mixed Depression, Constant

There has been no observable change over time in domain characteristics between episodes or during an episode.

Vegetative, Agitated, or Mixed Depression, Pleomorphic/Constant Undetermined

The clinician has had no opportunity to observe change or lack of change over time, or cannot make a determination based on history or patient reports.

B. Dimensional Characteristics (at least one item must be checked):

Vegetative Depression With Anxiety

Various vegetative domain characteristics (such as exaggerated worthlessness) may manifest as fearful anxiety, an immobilizing state characterized by an irrational unwillingness to engage with others or in tasks (such as leaving the house or completing an important project).

Agitated (or Mixed) Depression with Anxiety

Various agitated domain characteristics (such as irrational worry) may manifest as anxious distress, a state of nervous tension characterized by over-reacting to events (such as obsessing over a perceived insult).

Vegetative (or Mixed) Depression with Psychosis

Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).

Agitated (or Mixed) Depression with Psychosis

Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).

Agitated (or Mixed) Depression with Mania

Various agitated domain characteristics (such as racing thoughts) may manifest as highly energized distress that may include an irrational (but nonpsychotic) sense of persecution, extreme impatience with one’s own situation or in dealing with others, irritability, and explosive outbursts.

Vegetative (or Mixed) Depression with Catatonia

Various vegetative domain characteristics (such as psychomotor slowing) may manifest as physical and mental stupor.

Vegetative (or Mixed) Depression with Personality Complications

Various baseline personality traits (such as introversion) may amplify certain vegetative depression characteristics (such as isolating) and impede recovery. Opposite personality traits (such as extraversion) may interact with vegetative depression characteristics in unexpected ways. 

Agitated (or Mixed) Depression with Personality Complications

Various baseline personality traits (such as novelty seeking) may amplify certain agitative depression characteristics (such as reckless behavior) and impede recovery. Opposite personality traits (such as harm avoidance) may interact with agitated depression characteristics in unexpected ways.

Vegetative, Agitated, or Mixed Depression, No Dimensional Characteristics

Are you sure? 

C. Chronicity (Check one):

Vegetative, Agitated, or Mixed Depression, Chronic

Lasting most of the day, most days, for at least two years.
Vegetative, Agitated, or Mixed Depression, Recurrent

History of at least one prior depression.

Vegetative, Agitated, or Mixed Depression, Highly Recurrent or Cycling

Depressions come and go, generally of short duration at short intervals, as if part of the same depression cycling up and down. “Up” merely needs to be higher than “down.” Subject in “up” may feel less depressed than usual, perhaps “normal” or “better than normal” for two days or more before cycling down into deep depression.

“Up” in the context of a depression diagnosis is not elevated enough to be mistaken for bipolar hypomania.

Vegetative, Agitated, or Mixed Depression, Chronicity Undetermined

The clinician has had no opportunity to observe a pattern over time, or cannot make a determination based on history or patient reports.

D. Suicidality (Check one):

Vegetative, Agitated, or Mixed Depression with Suicidal Ideation:

Subject obsesses on thoughts of dying or taking his or her own life, may feel an intense need to escape intense psychic pain or stop becoming a burden to others, or may see death as a release from life.

Subject has either formed a clear plan or is strongly considering his or her options, and appears prone to carry out his or her stated intentions.

Subject is not merely thinking randomly of suicidal thoughts, nor seeking attention nor engaging in self-harm such as cutting.

Vegetative, Agitated, or Mixed Depression, No Suicidal Ideation:

Suicidal thoughts and self-harm behavior may be present, but there is a clear lack of intention to act on these thoughts or escalate self-harm.


Various types of Agitated or Mixed Depression may present as the above diagnosis.

Existence of both of the following:
  1. Agitated (or Mixed) Depression with Mania Features
  2. Agitated (or Mixed) Depression, Highly Recurrent or Cycling
May also include:
  1. Agitated (or Mixed) Depression, Pleomorphic
SEVERITY (Check one):

Severity is about functionality, not counting symptoms. Thus, for a depression diagnosis, the episode must significantly impair the subject’s ability to work, relate to others, and enjoy life.


Subject is able to function at work and in relationships, and in general is able to meet obligations, but is in a state of constant struggle, finds little joy in life, and may be fearful of the future.


Subject is unable to function effectively at work and in relationships, is unable to meet many obligations, may have reached the conclusion that struggle is not worth the effort, finds no joy in life, and may lack the capacity to have regard for the future.

Very Severe:

Subject is unable to function at all at work and in relationships, is unable to meet any obligations or look after him or herself, may have reached the conclusion that life is not worth the effort, and may have lost all hope in the future.


Next - situational vs clinical depression, depression and stress/trauma, late onset, early onset, postpartum, PMDD, and more ...


Notice to readers - April 13:

I now have good evidence that "Dr Drake" is the result of a hoaxer. Unfortunately, I cannot do a mass erase of the comments. Erasing them one by one will take forever, and I much have better things to do - such as have a life. So, please disregard the comments below.


Anonymous said...

I can't tell you how much more insightful and useful your descriptions are compared to the DSM "rip it up and start over" edition.

John McManamy said...

Many thanks, Anonymous. Much appreciated.

Dawn said...

This is an ambitious project John. I especially like your three descriptions of depressed states. After reading the New Yorker article, I thought we need more specifying names, like the Inuit have for snow. The word depression is too broad, too dilute to mean anything.

One of the reasons it took so long for a correct diagnosis for me was, I wasn't depressed in the obvious, low mood, can't get out of bed type of depression I had observed in someone else. I just cried often. I wasn't depressed really, in the can't function at work and in relationships area, at least most of the time. I was functioning at work but had "reached the conclusion that struggle is not worth the effort, finds no joy in life, and may lack the capacity to have regard for the future."

Is that depression, really? Isn't that normal sometimes? I stayed squarely in the skeptical "Is depression an illness?" until my brain quite inexplicably moved into "clearly forming a plan with considerable intent to carry it out." One of your articles recommending that you "do the opposite of what your brain is telling you to do" helped me do just that and make some important phone calls.

So, we need more words, more clarity, maybe more names, though God knows, not more labels. Much less stigma. But if the list gets too long, will it get used?

John McManamy said...

Hey, Dawn. Many thanks for writing this. I definitely agree with you. I hate the word depression. I foresee the day with the help of brain science that we scrap depression entirely in favor of 10 or 100 diseases that tell us what is going wrong in specific brain areas and functions. Then we'll have many words for snow - and be able to separate it from sleet and hail and rain.

I'm trying to be careful that we don't diagnose normal people who feel down with depression. There's too much of that going on. But we do have a walking wounded population. People who are barely hanging on who need to take some kind of corrective action.

People like you or me who kept trying to tough it out until one day we saw the folly of our ways - but often after we crashed.

You've given me a lot to think about. Please keep commenting.

Ian said...

Hi John,

I've been reflecting on the posts of the last few days and wondering if this level of detail is helpful?

I raise this question on two counts.

Firstly, for the person with depression do we run the risk of encouraging even more rumination and self analysis which in turn places more stress on the mind at a time when it is already struggling?

Secondly, even with the medications and treatments currently available, we use sledge hammers to crack nuts (no pun intended.

How likely is it that we'll get any better treatments based on a more detailed understanding of the depression. Probably more likely than if we don't, I'll admit. But at the end of the day almost everything I've read boils down to a combination of the individuals' desire to get well, exercise, good food, relationships - in short living - as an antidote.

Is there a danger that we overcomplicate the problem and end up spending more time focussing on that than looking at solutions?

What do you think?

John McManamy said...

Hey, Ian. I was looking forward to having to defend this, so many thanks for commenting, so here goes:

Complexity: It's important to acknowledge that depression is complicated. Otherwise, like one of me readers observed, depression becomes to mental illness what "infection" is to mental illness.

Having said that: I've simplifed depression to two basic types, plus an intermediate mixed type.

Treatment and therapy considerations. Here's what I'm operating on:

No more indiscriminate use of SSRIs. Vegetative depression suggests the use of dopamine enhancers, instead. Wellbutrin, Provigil, ADD meds, Parkinson's meds. Whatever works best to boost the dopamine system, get the frontal lobes back on line, boot up energy, reward and pleasure, alertness, and motivation.

Agitated depression suggests meds to slow down a runaway brain. Short term benzodiazepines, mood stabilizers. Perhaps an SSRI if the patient is obsessively ruminating.

We're still using a sledgehammer to crack nuts, but now we have an indication of which sledgehammer to use to crack which nut.

Also, dimensional and spectrum considerations mean we're identifying a population whose depressions behave like bipolar or may have anxious characteristics, etc. Again, different meds.

The different depressions also clue up talking therapists. An over-ruminating patient is going to require different talking therapy than an unmotivated patient.

Likewise, a patient has clues into lifestyle choices/illness management.

I'd be very interested in your response to this. Because you're right - there is no sense in making depression complicated if it doesn't lead to more discriminate and sophisticated treatments.

Let me know what you think.

Lori-wildflowersandweeds said...

Wow such great dialogue, and in my opinion your work and insight to the explanation of depression, it is to be applauded John.

Mental illness is complicated, our brains are complicated. Think of it this way, the first computer took up an entire room, now it is so small it can fit in our hand. Research, technology, and understanding go a long way, and we continue to down size as we better familiarize and understand it. However for progress to incur, sometimes we have to let go of old ideas and ways of thinking (DSM and those who write it) and give way to new approaches. NO matter how much a book has ever taught me, real life experience has always been the best those writing the DSM consult those with mental illnesses? Just wondering? In my experience, though "nuts" we can be a rather brilliant bunch! :D

Way to go John!

p.s. Are the people who author the DSM politicians?

John McManamy said...

Many thanks, Lori. You're spot on about real life experience. We're the ones who live this illness. I go to the same conferences psychiatrists go to. I read their journals. I ask them questions. I've learned a lot from them. They've given me amazing insights. And this includes most of the people on the DSM-5 mood disorders workgroup. I've talked to a lot of these people, ate at the same tables as them.

But in the final analysis, this kind of knowledge means nothing to me unless its been filtered through my own experience and the experience of fellow patients and family members. That's the major reason I attended DBSA groups for 6 years religiously and another 3 sporadically and why I'm now serving on the board of my local NAMI. Plus I'm in constant dialogue with patients and loved ones.

Yes, psychiatrists and therapists see patients everyday, too. But within the confines of a doctor-patient relationship, and often when we are at our worst. We rarely engage with them as equals. It's not in their mindset.

In a recent piece, The DSM-5: What Went Wrong, I gave some of my theories, including "paradigm freeze." The people on the workgroup are all brilliant, but they're insiders, not boat rockers, and innovations don't come from insiders. They are all clearly aware that brain science is on the verge of revolutionizing psychiatry, but this only seems to have made them fearful. They're merely minding the store, waiting for the next paradigm shift.

What they don't seem to realize is misdiagnosis is going on right now and we're the ones who suffer. We can't afford to wait 20 for the next psychiatric revolution.

Ian said...

Thanks John. A great response.

I guess that I'm becoming increasingly less hopeful about psychiatry being able to help me.

I shouldn't project this lack of faith in psychiatrists generally onto your excellent work. I should just be more hopeful that one day I will find a psychiatrist who is as interested in taking an evidence based approach to my illness as I am.

When I try to engage my psychiatrist in a meaningful discussion about my symptoms and possible alternative approaches, I'm met with a condescending 'but you're the fruit loop, not me' response, and told in no uncertain terms to keep taking the tablets.

Welcome to the UK's National Health Service.


Elizabeth said...

Your checklist system is quite superior to the proposed new DSM, which doesn’t surprise me, as you have quite a handle on the nuances of depression. We might indeed get more targeted med cocktails out of the system.
But I would like to see the psychiatrists make some real attempt to treat our symptoms with more than just pills. I fear that a checklist that is more complex and exacting would prompt the psychiatrists to give us a pill or two for each. And I worry that no one seems concerned with the possibility that those four or five pill cocktails are doing harm to our bodies, including our brains—certainly few seem to be concerned with the possibility.
There are tools out there, many as effective or more effective than the meds, and with only positive side-effects, and it might be helpful if psychiatrists stopped treating them as outside their realm. Say a patient is being treated for bipolar depression with anxiety, and the patient enters the office complaining of heightened anxiety. Given the patient’s ability, I’d like to hear something like this from the psychiatrist: “I want you to report to me next session that you have taken at least five half-hour walks a week, and I strongly suggest you try to work up to an hour walk every day. Then we’ll see if we still need to consider increasing your anxiety medication. Maybe we can decrease it. Here’s a one month calendar for you to track your progress. On the back are some helpful tips, along with walking clubs around town and ways to increase your walking regime. Bring it next session. And I’ve organized one for my patients, by the way, if you’d like to join—you’ll find contact information for that on the back of the calendar too.”
Really, would that be so hard? Yet, I know, it reads utopian.
My last psychiatrist once sent her patients a letter telling us that all sessions would be at least 20 minutes long. I don’t have the letter anymore, but as I recall her intention was to increase communications with her patients, although she was vague as to the reasons—whether they were to offer her the potential to pick up more symptoms or for some sort of talk therapy. I’m sure she had the best of intentions, but at least in my case, we rarely made it past ten. From what I could tell, aside from asking me some pretty obvious questions and writing scripts, usually adding in the next newest med, she didn’t have any other tools to help me.
Psychiatrists have discounted environmental factors to a fault and relegated concerns over the patient’s social environment to the therapists. OK, I guess. But if mental illness is an illness rooted primarily in biology, as most now assume, there’s much the patient can do himself to alter that biology, such as diet and exercise. We exhort our other doctors to increase their awareness of these and to counsel patients to alter their lifestyles. It’s time we asked the same of the psychiatrists.

John McManamy said...

Hey, Ian. Unfortunately, my People's DSM is totally useless in the hands of condescending pdocs who don't listen. Pdocs who don't listen - it's by far the biggest complaint I get from readers and it hasn't changed in the 11 years I've been writing about mental illness.

I once pointed this out in a talk I gave to psychiatrists and other clinicians - and of course they didn't listen.

In an ideal world, I would require every would-be psychiatrist to take a battery of psychological tests to weed out the misfits. They do this for a whole host of various vocations. My guess is that 2/3 would fail and out of that maybe 1/3 of them would respond to some kind of remedial training or therapy.

I would also require as part of their continuing education that they keep taking courses in listening to patients.

Hey, but who listens to me? :)

John McManamy said...

Hey, Elizabeth. You pointed out a real problem and maybe I can restate it: I've pointed out a lot of nuances to depression, which could open the door to a lot of abuse if this prompts psychiatrists to prescribe a different med for every nuance.

Psychiatrists suffer the same mindset as physical doctors - namely they prescribe pills for everything. Patients are also at fault as they expect to be prescribed pills. I think a lot of docs have simply given up.

Physical doctors have been saying for years - good diet and exercise. But people would rather lie on the couch and eat bad food and live miserable lives - oh yes, and take statins and have bypass surgery.

But that is no excuse for pdocs shrinking from their medical duties. Anything that works is good medicine. I strongly endorse what you say. I actually told a gathering of psychiatrists and clinicians that simply sending a patient out the door with a prescription is not treatment. They hated hearing this.

This is why we now have a recovery movement. But recovery techniques are only as good as the work ethic of the patient. I'm not saying patients who don't get well are lazy. What I'm saying is change is very difficult, even for "normal" people.

No one sticks to their diet and exercise regimes or their resolutions. Change is notoriously hard. But this also speaks to your point. We would be more strongly motivated to do positive things to manage our anxiety etc if our doctors and clinicians kept reading us the Riot Act and holding us accountable and educating us instead of automatically reaching for their prescription pads.

I suppose if you changed the name of psychiatrists to psychiatric pill specialists then there would be truth-in-labeling. The way I see it, they're very important in stabilizing our condition with pills when we flip out or crash. They're way less important - indeed only peripheral - to our recovery.

Dr. Drake said...

It's a nice academic (and pretentious) exercise, but there is far too much detail for it every to be used by practicing psychiatrists. And since you're not practicing anything, let alone medically licensed in any way, your conceit is pretty amusing.

John McManamy said...

Hey, Dr Drake. Ordinarily I would have hit the "reject" button to this. But here's the deal - you're saying because someone is not medically licensed, then they're too stupid to comment on psychiatry. Especially those who live with mental illness.

Heaven help that I - and my fellow patients - may actually know something about my illness.

Here's the deal, Dr Drake. If this is your attitude, then you're not fit to practice medicine, and I would be would be more than happy to expedite your departure.

Bloodthirsty Warmonger said...

What a refreshing breath of fresh air your analysis of depression is! I may not be a physician or psychologist, but after working with support groups for the past decade, I have seen how the classifications of depression and bipolar disorder are way too oversimplified. There must be at least a dozen different flavors each of depression & bipolar disorder.

John McManamy said...

Hey, Bloodthirsty Warmonger. Me, too. Also, like you, as well as support groups, people with bipolar and depression are my good friends. Plus many many more online friends. Plus family, which means I've shared a house and have had ample opportunity to see the illness up close and personal. Still do.

I'm glad you made note the diagnosis for both depression and bipolar is way oversimplified. I take it you were making a reference to "Dr Drake" above, who thought my Alternative Depression Diagnosis was too detailed to be of any use to practicing psychiatrists.

The obvious answer to that is if Dr Drake is too lazy to do a proper psychiatric evaluation and actually listen to his patients, he definitely should not be practicing medicine. You and I know there is way too much misdiagnosis going on in psychiatry with indiscriminate use of SSRIs.

My guess is Dr Drake is part of the problem.

But back to the positives. We're rethinking mood disorders. We're educating ourselves. I'm greatly encouraged by the comments here.

Readers: Please feel free to be rip apart my proposals. That's what I did with the draft DSM-5. But I did it without personal attacks on the people who worked on the DSM-5 or questioning their right to make their proposals.

Elizabeth said...

“It's a nice academic (and pretentious) exercise, but there is far too much detail for it every to be used by practicing psychiatrists.”

Is Dr. Drake for real? If he isn’t, he sure has pulled our cord. If he is, though, he’s offered the most damning indictment I’ve seen of the medical profession yet. I’ve seen lots of lazy doctors, and lots of doctors who are too busy seeing too many patients so they can make more money to bother to stop to think for five minutes about their patient’s condition. Their arrogance is usually justified by their training, by how brilliant and hard-working they have to be to become doctors. From what I can tell, too many stop thinking once they get that license, and Dr. Drake, in attempting to rebuke you, just admitted the sad fact about too many doctors. They don’t want to bother with any detail.

The nature of mental illness cannot be determined by a blood test or MRI. The only way to determine it is through symptoms. And this guy thinks doctors shouldn't be bothered with the only information they have? Dr. Drake, I can only hope you’re pulling our chord.

Elizabeth said...

“It's a nice academic (and pretentious) exercise, but there is far too much detail for it every to be used by practicing psychiatrists.”

Is Dr. Drake for real? If he isn’t, he surely has pulled our chain. If he is, though, he’s offered the most damning indictment I’ve seen of the medical profession yet. I’ve seen lots of lazy doctors, and lots of doctors who are too busy seeing too many patients so they can make more money to bother to stop to think for five minutes about their patient’s condition before writing that script. But their arrogance is usually justified by their training, by how brilliant and hard-working they have to be to become doctors. From what I can tell, too many stop thinking once they get that license, and Dr. Drake, in attempting to rebuke you, just admitted the sad fact about too many doctors. They don’t want to bother with any detail.

The nature of mental illness cannot be determined by a blood test or MRI. The only way to determine it is through symptoms, and this ass says that doctors don't have the time (or ability?, or inclination?) to examine what information they have. Dr. Drake, I can only hope you’re pulling our chain.

Dr. Drake said...

Without gross clinical experience (and I don't mean your own narrow personal experiences) and interaction with medical peers and colleagues, an exercise like this is academic at best and basic personal conceit in general.

There really are reasons it takes roughly ten years to learn to practice psychiatry. Just reading books and like minded blogs does not equate in the least. Really, it's more about resentment of (perceived) power. Comments here make that clear. But it does raise the level of blog sycophancy for Dr. McMann. Nothing wrong with that.

John McManamy said...

Hey, Dr Drake. Why don't you tell us who you are so we can check out your credentials? It' pretty clear my readers think you're a jerk and you just proved it by calling them sycophants. I'm quite happy to have to keep indicting yourself by your own words here. Go ahead - tell us how better you are than everyone else here.

John McManamy said...

Hey, Elizabeth. Dr Drake just referred to you as a sycophant. I suspect his Dr degree is in history of polkadots. He certainly has no business practicing medicine. Trust me, he proves our point. Let's see him shoot his foot already in his mouth. :)

Elizabeth said...

How incredibly absurd! Is there really a Dr. Drake, and is he really a practicing psychiatrist?

Dr. Drake, our experiences are not narrow. We know our diseases in ways you cannot, ways that you might learn something from if you were truly interested in understanding our illnesses—although you’ve already told us you can’t be bothered. We also listen to the trials of others with mental illness. As my first psychiatrist said when I told him I’ve known many people with bipolar disorder, “birds of a feather flock together.” That psychiatrist blew his brain out in a motel room a couple of years later, and the local psychiatric community was a bit embarrassed that they’d lost their “regional expert” on depression in such a fashion. Poor man. Before he left us, he’d expressed disgust for his profession.

We see how our friends’ disorders affect their lives out here in the real world, not those artificial ones of the doctor’s office and mental ward, where you’ve presumably gotten your “gross” experience. We try to ease their suffering as they break down, while you just hand them the newest pills your pharmaceutical rep is pushing. We see them as people, not patients we can objectify. We watch their lives dwindle down to disability-check poverty. They’ve been misdiagnosed, given the wrong pills and too many of them. They’ve been under the care of a psychiatrist for bipolar, yet have flown into high manics on five meds a day. Some have suffered ECT-induced wiping of vast swaths of memory. All too often, we get the call: suicide. All under psychiatric care.

We seek out knowledge of our disorders and ways of coping and even healing, and unfortunately our psychiatrists are rarely much help in this regard. So people like John step in and do your work for you, and you take it upon yourself to belittle him while admitting that you can’t be bothered with anything a little complex. I put my two cents in, and you call me a sycophant. Do you call your patients names when they disagree with you also?

Fred said...

Apparently Dr Drake is the resident troll. Any list would be incomplete without one. He sounds like a quack. He sure quacks like one. Talk about pompous asses! I'm guessing he is not an MD, but an osteopath. Just an opinion.

John McManamy said...

Hey, Elizabeth and Fred. Totally agree. If "Dr Drake" is actually a psychiatrist or an MD or a clinician, his conduct is totally unprofessional and reprehensible. Clearly, he has unresolved personal issues.

A higher education takes years, but true wisdom and insight is a lifetime quest. Dr Drake gave up learning a long time ago.

Lori~ wildflowersandweeds said...

To all readers and those truly concerned with the grave concern of mental illness. I learned from my very educated, highly intelligent, and most of all intuitive and compassionate psychologist, that those who are rigid or highly defensive are fearful. Fear from what? Lack of conviction. Those who have to defend their positions by name calling or by means of anger or superiority are fearful of threat. We see all too often in this country, in way too many instances, too much ego…ego gets in the way of progress! We MUST ask ourselves what is this really about?! It’s not about who’s wrong or right, for what does that really matter in the end? People are suffering. No finger pointing necessary. Systems are broken. No blame, we just work on it. If we are a team, we are stronger. Period. There are those who will jump on the band wagon and those who won’t. Those who puff up their tail feathers in the name of their egos, so be it. I’m not going to sit around and lick my wounds. I have far too many wounds, and way too much work to do. My posterity’s health depends on me, being that mental illness is hereditary for hell sakes!
John, those of us who live this crap know you are on to something big, we love this new language and your idea of starting over is great, and it makes sense to us. My case in point: how many books, doctors, researchers, etc. have been able to bridge the gap and talk the same language better? We as the suffers, the patients, we get what you are saying. How many of us actually come out of the doc’s office and say, “Wow, I better understand myself and my illness, Great!” Knowledge is the one thing that helps me to not be fearful of my illness. Fear is a horrible way to live. In the end we are always responsible for ourselves. The team we have, that of our doctors, family, friends, support groups, blog groups, can help us to stay healthy, take our med’s, eat, exercise, and study and learn all we can about our illness to empower ourselves, but in the end it is on us. We must be the ones to be responsible.
Let’s start bridging the gap. Let’s find the people that WANT to listen and put them together to better serve this community that is suffering. Let’s build the bridge and make something happen.
If depression is the leading cause of why people miss work in this country. If depression is projected to be in epidemic proportions by 2020, I suggest we get on this, and do it now. Ego’s aside, we haven’t the time, the money or the energy to let naysayers ruffle our twisted feathers or minds. Where would the world be without Ludwig Boltzman, Beethoven, and Einstein? They certainly were not the usual go with the flow kind of guys for their time, but our world is a better place because of them...and they were AH, bi-polar?! They would have been the patients?! I’ll bet we would all sit down and listen to those crazy men now if we had the chance, eh?

Dr. Drake said...

Resorting to ad hominums just shows how little substance there really is here.

Every psychiatrist knows the DSM is just a starting point and will have their own personal classifications and noted comorbidities based on years of training and experience. Something none of you have. And yes, Elizabeth, your experiences are exquisitely narrow. This is all good for general discussion purposes but has no basis in the real world. Take it to any practicing physician and ask their honest opinion. It would be the same as mine and as two colleagues I've showed this to.

Blogging about psychiatry isn't psychiatry.

John McManamy said...

"Resorting to ad hominums."

Ahem. Need I remind you:

"And since you're not practicing anything, let alone medically licensed in any way, your conceit is pretty amusing."

"level of blog sycophancy for Dr. McMann."

I put no stock in those who claim to be psychiatrists hiding behind screen names. So far, all your comments prove is someone who has no insight into their own behavior.

Next time: Full name and credentials. Otherwise, take a hike.

Elizabeth said...

Let’s bring the conversation back to where this ridiculous wrangling started. John is trying to submit a more nuanced definition of depression so that people don’t get drugs that will hurt them, and perhaps even get drugs that will help them. We ask for more precise diagnoses in the hopes that there will be fewer harmful prescriptions and more helpful ones. I have been given the wrong drugs by the five-minute-diagnosis psychiatrists out there, and those drugs have wreaked havoc in my brain and life. Many psych patients have similar stories. If our reality has no basis in the real world, then I’d like you to define the real world.

I don’t know whether to doubt that you’re a real psychiatrist because you’re so dense and arrogant, or believe that you are a psychiatrist because you are so dense and arrogant.

I do know why I’m continuing on with this absurd conversation. I have a real problem with stupid psychiatrists, having dealt with a few to my detriment, and you epitomize their mindset. But really, why are you continuing on? I know I have real anger and frustration, which is the engine of this continuation. What’s your reason? Why are you so angry at us? We don’t invade your space—actually, we couldn’t if we wanted to. We’re your bread and butter, no? Society doesn’t hold you accountable for your mistakes—after all, we’re just crazy, and you did your best, right? So if you don’t care what patients think, if you feel their insights and experiences are worthless, what are you doing here?

John McManamy said...

Hey, Elizabeth. Touche! Our putative "Dr" thinks our experience is too narrow? Okay, let's turn the tables:

4 years pre-med - no mandatory psych, no patients.

3 years med school - some psych, no patients in depth.

4-5 years residency - patients only in clinical in-patient and out-patient settings, no real-world contact, all in confines of power relationship with clinician wielding all the power. Very NARROW medical focus.

CME - Industry-sponsored infomercials. Extremely narrow and misleading.

Prof consultations - one narrow conferring with another.

Don't get me wrong. Mental illness is far too huge to get a full grasp of it. All of us alike are the proverbial blind men trying to grasp the concept of "elephant."

But there is a huge difference between being narrow and narrow-minded. :)

Dr. Drake said...

I've looked back on this topic's replies to see where it went off kilter. I only intended constructive criticism on some of the presumptions that were presented.

Given the replies, I thank God I'm the one licensed to practice here. I honestly think you would get people killed.

John McManamy said...

Hey, Dr Drake. You were explicitly requested to provide your identity and credentials. Obviously any type of DSM - the official one or mine - would be of no use to you as you have proved yourself constitutionally incapable of following simple instructions.

And the personal insults, right to the very end.
You are banned from further comments here.

Lori~wildflowersandweeds said...

If there is one thing I have learned in my 20 years of counseling and now as I am in school to be a counselor LCSW (not nearly as pretigious as a PhD, but I,ve never cared much about LABELS), boundaries are important.

Dr. Drake was not aiding the in our goals here. Good call John! What really was his point other than to do a bunch of senseless name calling and put downs? The doctors I know, respect and love will be seeing "the people's DSM" and I will let you know their reaction.

John McManamy said...

Many thanks, Lori. A personal note. About five years ago, a similarly arrogant and clueless individual who claimed to be a clinician succeeded in getting under my skin.

Back then, I was just a guy with a website and newsletter trying to keep my head above water. I had received very encouraging reactions from patients and clinicians authors and advocates, but the kind of validation I would later receive wasn't there yet.

This so-called clinician tried to get me kicked off Wikipedia. He actually presumed to order me not to contribute, stating I was not a clinician.

I managed to fight back, but the struggle took a lot out of me. A few months later, Frederick Goodwin, former head of the NIMH and co-author of the definitive book on bipolar, wrote a glowing testimonial for my book.

More endorsements rolled in, from leading authorities, leading patient advocates, leading authors.

I felt a sense of validation. Here I was a patient, writing about complex scientific and clinical issues, being accepted, not as a patient, but as someone who knew what he was writing about.

A year and a bit later, I was informed I would be receiving a major international award.

I still have my issues about being accepted, but I have good reason to feel a lot more secure about myself than I did back then.

Anyway, here was this Dr Drake, five years later, trying to pull the same shit on me this other idiot had. Only this time, the situation was much different. I am not the same self-doubting person I was back then. I wasn't alone in the wilderness casting about for approval.

Unlike my earlier encounter, dealing with Dr Drake was as easy as flicking off a flea. But I do admit to copping an attitude. Somewhere out there is another me from five years ago, unsure and vulnerable. Maybe I can't help that person directly, but if I can make Dr Drake and his ilk think twice before they pull their stupid shit, well you get the point ...

Anyway, on to the positives: I hope the doctors you know like my People's DSM (and I'm looking forward to the feedback, bad as well as good). As for the doctors I know, some of them actually worked on the draft DSM-5 (that I graded with an F). I'm sure one day they'll thank me. :)

Final note: I'm VP on the board of our local NAMI in San Diego. The president is a psychiatrist. We're both settling into our new roles, but we enjoy an excellent working relationship. She sees me as an individual with a unique skillset who can help her out and who is an asset to NAMI SD. I see her as a very intelligent and tactful leader who can move our organization forward.

She values my opinion, she asks for my advice. She laughs at my jokes (and I at hers). Mutual respect, no barriers. How hard is that?

Lori~ said...

I get your point perfectly. I feel your passion and would expect nothing less than you to carry on with your endeavors...they ARE making a difference in many lives!

Anonymous said...

I'm an outsider who stumbled onto this discussion. I have no axes to grind and no dog in this fight, although I did have the good fortune of going to a very good psychiatrist for a couple of years when I was young.

Constructive criticism, Dr. Duck? Baloney. You entered the discussion as an invested priest and you left it defensively and every bit as nasty as you came in. I would guess the chances are very good you are a doctor. And I'm sure you talk to nurses and office assistants with the same condescension and occasional gratifying flares of temper. At the level of transactions, Dr. Duck, the folks on this blog possess a level of power you find yourself very uncomfortable with in your professional life -- they are customers. In that regard, quite a lot of people just like them hold a power over you you should respect -- and even fear, given your temperament. And there's the key: all of the doctors I know resent their patients because their patients know whether a doctor can handle intimacy or not. My guess? You rely on the investiture of the medical priesthood to shield yourself from having to meet your patients at an honest level. Sure beats listening, doesn't it?

I would guess you are twenty years removed from your training, and as you have likely stopped reading the academic literature any more than resentfully, you rely on advertising from big pharma to do your catching up for you. Wouldn't you rather retire? Then you won't kill anybody either. And you can spend all your time harassing the folks you've grown to hate: your patients who come to blogs like this one because their care is insufficient to a complex human need.

John McManamy said...

Hey, Anonymous. Brilliant post. You took the words right out of my mouth - and everyone else's I'm sure.