Sunday, March 21, 2010

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

As you know from reading this blog, the people charged with coming up with the DSM-5 failed to turn in their homework. After handing out nine report cards with an average grade of F (I was way too generous), I decided to get crackin' on my own DSM, starting with depression.

My first installment recognizes the true complexity of depression by breaking the illness into six domains (such as “thinking” and “behavior”) which resolve into two types of depression: “Vegetative” and “Agitated,” plus an intermediate “Mixed” state.

My second installment adds a set of specifiers that would further break down depression according to variability, chronicity, dimensional, spectrum, severity, and suicidality considerations. Thus, “Agitated Depression, Highly Recurrent or Cycling,” “Mixed Depression with Anxiety,” and so on, plus a separate diagnosis of “Bipolar Spectrum Depression.”

Today, I drill deeper down to the “modifiers.” These involve environmental, lifetime, cultural, and gender issues that may either trigger or compound the course of an episode. Typically, we cannot prove cause and effect. Coincidence is our only clue.

On one hand, this kind of speculation may be a pointless exercise. On the other, careful attention to the modifying red flags may make all the difference in the world. To pick up where we left off ...


A. Depression Coincident with Stress and Trauma:


Depression that anticipates, coincides with, or follows soon after a major personal loss (such as of a loved one, a loving relationship, or employment), hardship (such as financial), interpersonal difficulties (such as a toxic family situation), or traumatic event (such as a danger to one’s physical safety or an extreme change in personal circumstances).

Reactive depression may also result from the culmination of negative personal events and circumstances over time.

The depression appears to bear a relationship to the coinciding event (such as evidence of a long period of high functionality followed by low functionality in the wake of a messy divorce).

The subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to negative or stressful events in general, or a particular negative or stressful event.

The depression shows no sign of abating after four weeks or after the resolution of the coinciding event (such as finding new employment after being downsized).


Subject may appear overwhelmed or functionally impaired by unresolved trauma issues, such as early abuse or neglect.

The depression appears to bear a relationship to recollections of the traumatic event or events (such as evidence of flashbacks, nightmares, emotional triggers, or obsessive ruminations). 

Subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to his or her traumatic recollections.

B. Depression Coinciding With Age (Check One):

Note: Age ranges are approximate and may overlap.

Child and Adolescent Onset

From early childhood to early teenhood (ages 5 to 15). Symptoms may be masked or exacerbated by developmental issues or hormonal changes, or life transitions particular to children and adolescents.

Youth Onset

From late teenhood to early adulthood (ages 15 to 25). Symptoms may be masked or exacerbated by developmental issues, hormonal changes, or life transitions particular to those entering adulthood.

Adult Onset

From young adulthood to middle age (ages 21 to 45). Symptoms may be masked or exacerbated by life transitions particular to those settling in to adulthood.

Mature Onset

From midlife to retirement age (ages 40 to 65). Symptoms may be masked or exacerbated by hormonal changes or life transitions particular to those in their middle years.

Late Onset

From retirement age upward (ages 60 and above). Symptoms may be masked or exacerbated by hormonal changes, life transitions, or medical and neurological conditions particular those in late life.

C. Depression Coincident with Female Hormonal Fluctuations

Postpartum Onset

The depression occurs within one year of childbirth.

The depression appears to bear some relationship to the childbirth (such as evidence of other emotional difficulties surrounding the birth).

The subject displays unexpected difficulty in adapting to the demands of the new child.

Premenstrual Onset

Depression coincides with the second half of a woman’s menstrual cycle, and ends when menstruation begins or soon after. Subject may also manifest difficulties in managing emotions, and may feel intense mental anguish and physical discomfort. The condition is far more severe than PMS.

D. Gender (Check one):

“Female” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Female subject (or male who identifies as a female) may over-ruminate, may express emotional pain by appearing sad (such as breaking into tears), may seek out others, may see her condition as a situation of her own making and blame herself, may seek comfort in indulgences (such as satisfying a sweet tooth or impulse buying), may reach out for help in indirect ways (such as expressing a wish to die), or may engage in suicidal gestures (such as taking a non-fatal dose of pain-killers).

“Female” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of female (or male identifying as female) behavior or out-of-character with baseline behavior (such as a male who cries).

“Male” Features, Gender Congruent

Depression manifests in a way consistent with “western” social expectations or baseline behavior.

Male subject (or female who identifies as a male) may lack the capacity for ruminative introspection, may express emotional pain by appearing angry and aggressive or sullen, may not seek out others, may deny anything is wrong and blame others, may seek comfort in alcohol or drugs or risk-taking activities (such as venturing into dangerous neighborhoods), may alienate those in a position to help, and may be planning a suicide attempt.

“Male” Features, Gender Incongruent

Depression manifests with a significant number of features that may run counter to “western” social expectations of male (or female acting as male) behavior or out-of-character with baseline behavior (such as a female who acts aggressively).

E. Cultural Identity

Within any given social or ethnic group regarded as a “minority,” depression features may be masked or exacerbated by cultural norms particular to that group (such as distrust in confiding to outsiders or an emphasis on keeping emotions in check), by language barriers, or by different ways of interpreting similar phenomena (such as seeing depression as a disease of the soul).

On the other side of the coin, behavior that perfectly accords with the cultural norms of a  particular social or ethnic “minority” group (such as demonstrable displays of grief or apparently submissive gestures) may be mistaken by western observers as signs of depression.


Elizabeth said...

Well, John, now you’ve really gone and done it. Environmental factors in the DSM?

Of course I’m kidding. It would be wonderful if psychiatrists came back to a balanced view, admitting that environment plays a significant role in depression and recovery. So I’d add a bit more to your section “Depression Coincident with Stress and Trauma,” having to do with the effects of what we could loosely call stigma, for one; and the effects of mental illness on a person’s social and economic life, for two.

As I see it in my own life, much of my ruminative depression is fed by a sense that the disorder itself has imposed itself as a looming figure in my environment. This figure puts me in terror as much as any other abuse or trauma ever has. I fear my employers will find out. I fear letting friends know, and so I pick my friends more carefully than I would otherwise. I fear the next episode. On and on. So the biological alters the environmental, and perhaps vice versa.

Willa Goodfellow said...

Nope. Every depression is individual, but in this stage I think you have crossed the line between distinctions that are helpful and distinctions that divert attention from listening to classifying.

The gender congruent/incongruent modifiers undo the progress you made at the beginning that directs people away from cultural biases and toward the variety of manifestations of the illness. That you have to create the incongruent category indicates that the gender category doesn't add helpful information.

It is obvious that, culturally, I am a fem. (We fems can do anything you can do -- we just want to do it with lipstick!) But I want my psychiatrist to ignore gender stereotyping, and recognize my irritability not as personally directed at her, but rather as one way that depression might manifest. Who says it's not congruent?

Meanwhile, the category creates a barrier to treatment. Would you seek help when your particular pain might be labeled as "gender incongruent?"

This is particularly problematic when addressing suicidality. We need some better general principles about suicidality, not more conditioned by culture and gender bias. (The current ones aren't particularly helpful either, and are ignored in successful suicide prevention -- but that's another blog post.) Your description of female gender congruent suicidality reinforces the stereotype that women do self-harm as an attention-seeking device; if they survive, "they aren't really serious." For male gender congruent suicidality, you reinforce "they can't be stopped when they have made up their minds." That more men choose guns (more lethal/less survivable) and more women choose pills (less lethal/more survivable) may well be a sociological phenomenon, not a difference in type. In some cultures, the most common method is drowning. Is that male or female congruent? What about hanging? Is cutting different from stabbing? from slashing one's wrists? And when a woman uses a gun, what purpose is served by calling it gender incongruent after the fact?

Get yourself out of this cul de sac and keep going!

One therapist I know says the only purpose for diagnosis is as a guide to treatment. So on the other hand, attention to women's hormonal lives could use more attention. It does have implications for treatment. Where does it appear in the other DSM?

John McManamy said...

Many thanks, Elizabeth. Yes, looks like room for amplification here. I'm glad you see the need to recognize environmental considerations.

John McManamy said...

Hey, Willa. I was afraid someone would bring this up. With the "modifiers," I begin sacrificing clarity.

Here's the situation: Depression gets filtered through our gender and cultural experiences. Some of this may be biological, some of it may be learned. Whatever the cause, bottom line is my depression is going to look a lot different than someone else's.

This may explain why twice as many females get diagnosed with depression than men. A woman may cry, I may get angry and tell you to f- off. But my depression goes unrecognized till I'm ready to jump in front of a truck.

There is strong expert opinion that something needs to be done.

So, here I am in a cul-de-sac. I see your point. I knock out the "gender incongruent" stuff. I did include anger and other "male" behaviors in Part I. Do you think this is sufficient?

Readers, please jump in here. Willa has raised a very valid criticism that clearly needs addressing.

Thanks, Willa.