Atypical Depression - Entirely Too Atypical?

I just finished uploading four new articles on depression on my mcmanweb site. The articles replace and greatly expand upon two earlier pieces that introduced depression. In addition, I also wrote a new article to replace my old one on atypical depression.

In the second of my introductory pieces, I propose a “vegetative-agitated” depression distinction that would better serve patients than the highly confusing “typical-atypical” distinction. The following extracts from my two articles make my case ...

Vegetative or Agitated?

In other words, are you feeling sort of like you have a bad cold but without the runny nose, fever, and diarrhea? No energy? Can't get started? No motivation? Can barely string two thoughts together? Just want to curl up into a ball and not wake up? Your clinical condition is dead but breathing. You get the picture.

Or does your depression feel more like you're in neutral, but with the motor running out of control? "If only, if only," a piece of your over-ruminating prefrontal cortex may be chanting. "I can't take it!" the primitive reacting limbic region of the brain may be screaming. You want to grab the world by the throat and shake it. Folded into all of this may be anxiety. You get the picture.

Two very different mental states, obviously. But way too many doctors (my guess is most) refer to both conditions as "depression" and send patients out the door with the exact same prescription.

Figuring out depression is very binary, really. Emotion, mental activity, physical activity, and tell-tale behavior - too much or too little, high or low, up or down, under or over. Gradually a picture begins to emerge, a very complex one full of anomalies, a testament to your uniqueness and to the fact that no two depressions are alike. Nevertheless, the picture is likely to resolve one of two ways.

Which side of the universe you find yourself on suggests different (though overlapping) treatment and recovery strategies: energizing agents and lifestyle practices for vegetative depressions, calming agents and lifestyle practices for agitated depressions.

Typical or Atypical?

According to the DSM-IV, as opposed to major depression, the patient with atypical features experiences mood reactivity, with improved mood when something good happens. This would broadly translate to an individual momentarily taking leave of his or her Stygian gloom to laugh at a friend slipping on a banana peel.

Likewise, there would be an element of enthusiasm to news of winning the Powerball lottery.

In addition, the DSM-IV mandates at least two of the following: Increase in appetite or weight gain (as opposed to the reduced appetite or weight loss of "typical" depression); excessive sleeping (as opposed to insomnia); leaden paralysis; and sensitivity to rejection.

Sensitivity to rejection could be interpreted as the flip side to mood reactivity. Here, there is a visible response to bad news rather than good. Either way - mood reactivity or sensitivity to rejection - beneath despair that borders on catatonic, we see signs of life, of a "dead but breathing" individual capable of animation.

But is this only confusing the picture?

A 2001 study by Posternak and Zimmerman cast doubt on the only feature of atypical depression that is mandatory under the DSM - that of mood reactivity. In their study, the authors evaluated the five symptoms of atypical depression across five different groups of patients (including women, different age groups, and according to severity and length of time of symptoms), and discovered mood reactivity only featured among the women patients, suggesting this particular criteria should be dropped.

In practice, psychiatry is retrofitting a set of diagnostic anomalies over the notorious DSM symptom check-list. Thus, before we can even determine if an individual has atypical depression, a clinician must first find evidence of "major depressive disorder." (Check-list depression, in other words.)

Then, in making a diagnosis of "major depressive disorder with atypical features" the clinician, in effect, is asked to contradict parts of that same check-list.

A 2010 abstract to a review article (the full article is in Japanese) tells us that we are probably looking at four views of atypical depression. To give you an indication of the complexity of the discussion, following is a representative segment of one sentence of the abstract:

...reflects the theory that mood nonreactivity is the essential symptom of "endogenomorphic depression", which was proposed by Klein as typical depression.

The original Japanese would have been no less confusing, a point which the author seems to happily acknowledge. Indeed, the abstract resolves into brutal clarity in its summary dismissal of the diagnosis:

Consequently, the concept of atypical depression has become overextended and gradually lost its construct validity.

In the current discussion over what constitutes atypical, psychiatry has lost sight of the fact of how the term came about in the first place - as a hypothesis for why certain patients with unipolar depression responded to MAOIs rather than tricyclics.

Let the conversation build on that important piece.

***

My new depression articles:

What Is It? 
Figuring Out Depression 
Placing Depression in Context
Depression Plus
Atypical Depression

I Talk to the Real Experts About Depression (That's You)

From my keynote to the Kansas State DBSA conference in late April ...

Okay. This is going to look like I’m going off on a tangent, but the Yellow Brick Road zig-zags, so bear with me. We’re here, in Kansas, at a DBSA conference. Which means just about all of us here have experienced depression. So - can anyone here give me a one-sentence description for depression?

It sucks.

[More answers ...]

A deep dark hole.

Like having two doberman pinschers waiting for you to get out of bed in the morning. You aren't going anywhere.

It's like you're worthless.

You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.

It's like trying to walk through mud up to your neck.

And I've got some insights on Kansas mud. Cuz I talk to my mud. I live in southern California where the soil is loose and sandy, and if you get it on your pants and shoes you just go - choot-choot-choot. So three days later, I see some mud from three days ago on my pants, and it's like, "C'mon, mud." And the mud talks back to me - just like skunks - and says, "oh yeh, you people on the left coast, you who eat panini, where do you think the flour from the wheat of that panini comes from? You treat me with respect, and next time you talk to me you address me as sir."

So, that's Kansas mud.

When I'm depressed, I get agitated and angry a lot. I used to joke - because I only got my driver's license two years ago after not driving for 30 years - I get road rage a lot and I don't even drive. Some of you feel like that with your depressions? Okay ...

I just don't want to be here anymore.

I told my doctor a while back, I'm not suicidal; I'm homicidal.

That's me. That's why I'm proud to be crazy. Seriously, I hate these politically correct people who want to take crazy away from me, because that's how I choose to describe myself. Anyway ...

I think especially for a lot of guys, it's withdrawal and grouchiness.

Another one - lack of motivation, total apathy. Okay, we've got a pretty good list here. Now, how many have heard of the DSM, the DSM-IV? Unanimous consent there. Great. Now, as you know, the DSM is a piece of fiction put out by the American Psychiatric Association ... We got a consensus on that.

As you may recall, there is the world famous symptom list. You know, five of nine symptoms. But first, you have to have one of two, okay? So get this - I'm going to read this out - here’s number one, for depression:

“Depressed mood most of the day.”

I'm trying to figure the logic here. Describe depression to me. Depression is - depressed mood most of the day.

Have you ever tried to describe what carrots taste like to someone who hasn't had carrots? Oh, carrots, you know, carrots - they taste like carrots.

Right, that really tells me a lot. I’m depressed. And I’m depressed because - I’m depressed. But what is my state of mind? What are my feelings? What are my emotions? What are my moods?

Well, the DSM does give the example in "depressed most of the day" of feeling sad. But I’m going to put this to the best experts in the world, which is you guys. Does depression equal sad? I mean we've listened to all these other symptoms ... Right.

Well, maybe the other symptoms can help us out. The other one of that "one of two" is loss of pleasure. We're kind of getting there a little bit, but here's four of them in a row:

Weight loss or weight gain. Oh, great, so everyone who goes to Weight Watchers is depressed. 

Insomnia or hypersomnia. That’s not telling us much. Let’s try the next one: Psychomotor agitation. So we walk funny.

What the ...

We’re not through. Fatigue or loss of energy. You get tired at two o'clock. Big deal.

I’m no expert. I’m a patient just like you. But I do know how to count. So we've got nine symptoms on the list, and make that eight because that first one is just too ridiculous for words. So, we've got eight symptoms, and we only need five to cross the diagnostic threshold for a diagnosis.

And four symptoms are physical. We eat too much or too little. Same with sleep. We walk funny. We get tired. Fine fine fine. So does the entire rest of the human race. Tell us something different.

Tell us what friggin’ state our minds are in. Tell us our thoughts, feelings, and emotions.

No wonder no one can help us. No one has even bothered to open up the hood and look in.

So, get this. You people here - turning out on a Saturday, in Kansas - do you want to read out the list here?

It sucks. Deep dark hole. Like two doberman pinschers waiting for you to get out of bed in the morning. You're worthless. On a raft in the middle of the ocean, not going anywhere, totally becalmed. Like walking in mud up to your neck. Just don't want to be here any more. I'm not suicidal, I'm homicidal. Withdrawal and grouchiness.

Is that a better list than the DSM list? Congratulations - you guys have beat the best psychiatrists in the world. Give yourselves a round of applause, here.

Rerun: Piecing Together the Borderline Puzzle

More on borderline personality disorder, from last year ...

May is Borderline Personality Disorder Awareness Month. Our story so far:

In 1980, borderline personality disorder received formal recognition as a diagnosis with its inclusion into the DSM-III. The catch was that the illness was consigned to "Axis II," widely regarded as psychiatry's wrong side of the tracks. As an editorial by John Oldham MD of the Menniger Clinic in this month's American Journal of Psychiatry explains:

The decision derived from the belief that borderline and other personality disorders were "caused during early development by parental neglect, abuse, or inconstancy." The prototypical image of a patient was that of an angry volatile individual prone to reject help, blame others, and behave self-destructively. "Too often, this behavior was seen as willfully oppositional, and borderline personality disorder patients were spoken of as dreaded pariahs."

Our current clinical and scientific knowledge, Dr Oldham advises, is changing those perceptions. Core "heritable endophenotypes" of affective dysregulation and impulsive aggression have been identified. Brain scans reveal specific abnormalities, namely a hyperactive limbic system, in particular the amygdala (which mediates arousal and fear). Thus, certain individuals are primed to overanticipate and overreact when their personal dealings hit a snag.

This state of emotional overdrive is difficult to extinguish, owing to impairment in the cortical areas to inhibit this limbic-driven emotionality or impulsivity.

As if this isn't bad enough, this phenomenon of "brain gone wild" interferes with forming emotional attachments during child development, which may be magnified by lack of adequate parental support. As Dr Oldham describes it:

"These combined etiological factors produce arrested, distorted, or incomplete integration of aspects of self and others, resulting in early onset and persistence of profound interpersonal difficulties. Normal early development becomes derailed, and the crucial developmental milestone of basic trust is not achieved."

No wonder no one has come up with a med to treat borderline patients. As a second editorial - by Otto Kernberg MD and Robert Michels MD of Cornell - explains, only 30 percent of patients with borderline respond satisfactorily to meds over the long term.

(Editorial sidebar: Psychiatry has unofficially used response to meds as an indicator of whether the illness is biological or merely a construct of the mind. Thus, borderline gets nowhere near the same respect as schizophrenia, which - ironically - evidences similarly low and perhaps even worse response rates.)

Dialectical behavioral therapy and other talking therapies produce beneficial results in the short term, but Drs Kernberg and Michels caution that "basic underlying chronic personality dispositions may remain unchanged."

Thus, years and decades after completion of therapy, individuals with borderline may still face major challenges in personal satisfaction with how their lives are going. On one hand, borderline has been dubbed the "good prognosis diagnosis," based on research showing an 80 percent remission rate over ten years. But the authors caution that these findings are focused more on DSM symptoms, "and much less on the subtle and permanent features of their difficulties in work, love, social life, and creativity."

The bad news is that despite the significant gains in our body of knowledge, "the relationships between clinical symptoms, deeper psychological structures, and underlying neurobiological systems are, as yet, to be explored."

The good news is we are learning as we go. As the authors conclude:

"Borderline patients have long been to psychiatry what psychiatry has been to medicine - a subject of public health significance that is underrecognized, undertreated, underfunded and stigmatized by the larger discipline. As with psychiatry and medicine, this is changing. New knowledge, new attitudes, and new resources promise new hope for persons with borderline personality."

Further reading from mcmanweb:

Borderline Personality Disorder
Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, and the ground beneath her could collapse any second.

"It’s like demons possess me," she related. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

She emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"). Anne concluded with reference to her favorite bumper sticker, "Don’t believe everything you think."

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part IV

Okay, time for the boring stuff. In my alternative depression diagnosis, I sensibly restored complexity to an inexcusably oversimplified illness. Bipolar demands an opposite approach. Strip the illness to its essentials and we are talking about a cycle involving down and up, where up simply has to be higher than down.

Concentrate on the fact that we are dealing with a cycling phenomenon, and sensible treatment and illness-management is more likely to follow.

Nevertheless, it’s prudent to add shading and texture. Thus, Cycling I, II, and III, plus cyclothymia - plus (as specifiers) allowances for mixed phases (essentially out-of-phase cycles), plus (more specifiers) the reality of various psychosis complications. These were all dealt with in Part I, Part II, and Part III to my Alternative Bipolar Diagnosis.

In Part IV, I’m going with yet more specifiers (and modifiers), but in keeping with a rough draft (and to keep from boring you to tears) I’m just going with the bare bones, short and sweet.

Cycling Specifiers

Timing: Short phases or long? Undetermined? Short intervals of remission or long? Undetermined?

Rapid cycling, ultra-rapid cycling, and ultradian cycling would be included here. Important point: Here’s why “bipolar” is an erroneous name for what should more accurately be called cycling illness. Bipolar places priority on the episode over the cycle. So, technically, under the current DSM, someone who cycles up and down and back again in the course of a week is not in an episode (as the minimum is a week for mania) long enough to qualify for a bipolar diagnosis.

WTF? True, we don’t want to diagnose someone with a mental illness who is feeling out of sorts for just a day or two. But indisputable evidence of a cycle clearly trumps minor quibbles over length of episode (or, more accurately, cycle phase). Looking at it another way, if you’re cycling that fast you’re in a special kind of episode (phase) that is clearly playing havoc with your life.

Reducing mania and hypomania to a two-day minimum obviates a lot of these concerns. (Note to self: include an exception to the depression and mania and hypomania time minimums where there is clear evidence of ultra-rapid or ultradian cycling.)

Emphasis: Mostly depressed? Mostly manic? Mostly hypomanic? Mostly mixed? Undetermined?

People with “bipolar” tend to be depressed three times longer than they are manic or hypomanic, with residual symptoms persisting even longer. Individuals with bipolar II stay depressed for even longer. If that’s the case, this needs to be spelled out. Likewise if an individual is manic/hypomanic or in various mixed phases most of the time. It makes no sense to give individuals a vague diagnosis with no indication of what their particular version of crazy looks like.

Most recent phase: Depression? Up? Mixed?

This is straight out of the current DSM playbook.

Severity:

Particular phases of the cycle may be relatively benign, but the demands of adjusting to these phase changes may be too much to handle. Loving one day, hostile the next? Not a way to stay in a relationship or hold down a job.

Sleep Specifiers

Our next specifier would bring sleep into consideration, as disruptions to the sleep cycle and the mood cycle are strongly linked. Indeed, one can make a strong case that the mood disorder is the downstream effect of the sleep disorder. Another way of looking at it: Addressing the sleep issues resolves a lot of the mood issues.

We can make this as complicated as we like, but let’s opt for simplicity:

Sufficient consolidated and undisturbed night sleep: Yes? No?

Sufficient daytime wakefulness to meet work and personal obligations and self-enjoyment? Yes? No?

Sleep/wake phase delay/advancement: Yes? No?

Dimensional Specifiers

These cut across diagnostic categories and would be the same as for the Alternative Depression Diagnosis, only linked (if possible) to each phase. Otherwise, to the diagnosis as a whole. Thus:

... with anxiety.

... with personality complications.

(Note to self: the depression phase would also include suicidality and other specifiers from the Alternative Depression diagnosis.)

Severity Specifier

We mentioned severity in relation to the cycle. Normally, each phase would require its own severity specifiers, as well, but mission already accomplished for the up phases in the form of Cycling I, II, and III. For the depression phase, we copy and paste from the Alternative Depression diagnosis.)

Modifiers

I distinguish “modifier” from “specifier” by virtue of how gender, age, and cultural identity may affect the course and presentation of the illness. Depressed women, for instance, are more likely to act in accord with current DSM criteria (such as “appears tearful”) while men who express their psychic pain as anger are likely not to get diagnosed. I’m not sure how this plays out for mania, but let’s make room for discussion. 

Child and Adolescent onset deserves special consideration. The current DSM lacks an early-onset specifier for bipolar, which can be interpreted to mean that the illness manifests similarly in kids and adults. Except for the fact that this is not the case. Kids tend to cycle far more rapidly, often in the course of a day with a clear relation to sleep/wake cycle disturbances. Moreover, kids tend to experience mixed phases that are expressed as severe rages.

Thus, if we keep the criteria for cycling and mixed states (not to mention sleep) unrealistically narrow (as under the current DSM), both adults and kids are left out in the cold. The simple solution is to widen these criteria (as we have already done), and include the early onset modifier. This would keep the diagnosis consistent across the life-span, while allowing scope for differences in presentation.

Note the diagnosis remains sufficiently narrow to distinguish cycling from other forms of kid behavior. Nevertheless, there is considerable room for discussion in dealing with kids’ issues, so feel free to fire away.

Conclusion

This wraps up my Alternative Bipolar (Cycling) Diagnosis for now, but we’re by no means finished. Please feel free to join the conversation. Comments below ...  

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part III

Thus far (in Part I and Part II), I have kept what I refer to as “cycling illness” simple. As long as we appreciate that down and up are connected as different phases in the same cycle, there is little room for confusion. But there is a major complication called psychosis. If the psychosis is severe enough and prevalent enough, suddenly clinicians are faced with some very tricky diagnostic calls.

The current DSM recognizes psychosis as an illness in its own right and acknowledges its occurrence in other illnesses, including depression, bipolar, and schizophrenia, not to mention the hybrid diagnosis of schizoaffective. In theory, clinicians have a rough guide to work with. In practice, uncertainty prevails, namely:

How, precisely, does psychosis tie in to mood? And, while we’re at it, is there actually one person in the whole wide world who can explain schizoaffective, much less the reason for its existence?

Brain science and genetics promise to yield far more definitive answers than we presently have, which may explain why the draft DSM-5 changed virtually nothing. My view is we need to do our best based on the knowledge we have now, even if future scientific discovery proves us wrong. Let’s get to work:

The current DSM treats “with psychotic features” as a specifier to bipolar rather than to depression or mania. Let’s keep the specifier approach, but find more precise applications, thus:

Euphoric Mania with Psychosis

Various euphoric mania characteristics (such as enhanced positive abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as a superman on a special humanitarian mission).

Dysphoric Mania (Mixed) with Psychosis

Various dysphoric mania characteristics (such as enhanced negative abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as the only one in the world aware of a vast conspiracy).

And a copy and paste from the Alternative Depression Diagnosis Part II:

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).

***

Thus, in these situations, psychosis is strongly linked to different phases of the cycle in terms of both timing and congruency. When the mania recedes, for instance, so does the psychosis. This suggests mood stabilizers as a first option rather than an antipsychotic.

If, on the other hand, the psychosis appears have a life independent of the cycle, then the clinician needs to spell it out, such as: “Cycling l, with Co-Occurring Psychotic Disorder.” (The current DSM lists “Delusional Disorder” and “Brief Psychotic Disorder”.)

This suggests different treatment options, such as an antipsychotic for the psychosis plus a mood stabilizer for the cycle (with perhaps the antipsychotic serving double duty in lieu of a mood stabilizer).

It is important to emphasize that psychosis with a life of its own is not synonymous with schizophrenia. Generally, more is going on with schizophrenia than just psychosis. Nevertheless, a very compelling case can be made for an overlap between bipolar and schizophrenia. Unfortunately, the DSM’s ‘tweener diagnosis of schizoaffective is more of a problem than a solution. Thus:

Kill the Schizoaffective Diagnosis

The operative phrase to the schizoaffective diagnosis is: “There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.”

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for “continuous signs of the disturbance,” but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can’t appear without schizophrenia symptoms.

Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let’s kill the schizoaffective diagnosis, then. And while we’re at it, let’s rethink schizophrenia, complete with a name that accurately describes the illness. But that’s for later, along with a full review of psychosis. In the meantime, to sum up:

1. When the psychosis can be linked to a phase of the cycle: Specify the phase within the cycling diagnosis.
2. When the psychosis appears independent of the cycle but does not meet criteria for schizophrenia: Stick to cycling diagnosis, with a co-occurring psychotic disorder.
3. When the psychosis appears related to schizophrenia: Go with a schizophrenia diagnosis, with a mood symptoms specifier.

Please note that I do not regard this draft as anything approaching the final word. If you have your own approach to breaking down psychosis, or can think of a hybrid bipolar-schizophrenia diagnosis that makes sense - or for that matter can make a good case for not fixing what ain’t broken - then, please, let’s hear from you.

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV

Spitzer and the DSM - Part IV

In Part I, I introduced Robert Spitzer, architect of the ground-breaking DSM-III of 1980 and what psychiatry was like when Freud ruled the roost. Part II described the Spitzer's triumph in unseating Freud, and Part III recounted Dr Spitzer's boorish behavior at the dinner table at the 2003 APA in San Francisco. To pick up where I left off ...

Yet when I surveyed all that my hands had done
and what I had toiled to achieve,
everything was meaningless, a chasing after the wind;
nothing was gained under the sun.

- Ecclesiastes 2:11

Nearly two years later, the Spiegel profile in The New Yorker gave me an insight into Dr Spitzer’s table manners. According to the piece:

Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’ ”

Then, following the runaway success of the DSM, things apparently went to his head. According to the New Yorker, “emboldened by his success, he became still more adamant about his opinions, and made enemies of a variety of groups.”

And again:

“A lot of what’s in the DSM represents what Bob thinks is right,” Michael First, a psychiatrist at Columbia who worked on both the DSM-III-R and DSM-IV, says. “He really saw this as his book, and if he thought it was right he would push very hard to get it in that way.”

This sense of ownership cost Spitzer his chance to head up the DSM-IV. The new chair, Allen Frances MD of Duke University, put his committees on notice to cut back on “the wild growth and casual addition” of new mental disorders. In a piece published in the June 29, 2009 Psychiatric Times, Dr Frances appeared to be bragging about how little the DSM-IV task force actually accomplished:

“In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III ...”

This is one hell of an admission. Basically, Dr Frances is telling us that the diagnostic psychiatry of 2009 is based on a book that was published in 1980, back when psychiatric science virtually didn’t exist.

It is speculative to ponder on the “what-if’s,” but that’s my job. So, suppose Dr Spitzer hadn’t fallen in love with his 1980 opus. Suppose he possessed some rudimentary people skills. Suppose he had been able to combine his innovative brilliance with a sufficiently level head to guide the DSM into its next critical phases - to fill in the blanks from the earlier editions, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight.

Imagine, in effect, if you could pick up a current DSM right now and open the pages to an accurate description of your clinical reality. That book doesn’t exist. The DSM-IV is a dinosaur, and any clinician who relies on it as an authority is endangering his patients.

Things could have been a lot different. But the man who - through his superhuman efforts - unseated that twentieth-century icon Freud, through his own mortal foibles, wound up unseating himself. His personal disappointment turned out to be our huge loss.

To be continued ...

Robert Spitzer and the DSM - Part II

In Part I, I mentioned how I found myself seated next to Robert Spitzer, the architect of the ground-breaking DSM-III, and the inadequacies of the earlier versions. To pick up where I left off:

In an article published in Science in 1973, Stanford University psychologist David Rosenhan described dispatching eight healthy associates to various mental hospitals, each claiming to have heard voices. All eight were admitted, seven with the diagnosis of schizophrenia, one with manic-depression.

Following admission, all eight behaved normally. Although many of the real patients suspected a ruse, hospital staff interpreted even routine behavior on the part of the impostors as pathological, such as “writing behavior.” To obtain release, the “patients” had to acknowledge their diagnosis and agree to take meds. The “patients” were held on average for 19 days.

In the second part of his experiment, Dr Rosenhan let it be known at a particular hospital that more fake patients were on the way. The hospital was aware of the results of the first experiment, and were confident they could weed out the impostors. Out of 193 patients, 41 were singled out as phonies and another 42 were considered suspect. In reality, no bogus patients had been dispatched. All the patients were genuine.

According to Dr Rosenhan: “Any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.”

A year later, Robert Spitzer MD of Columbia University drew the assignment of leading a new revision of the DSM, the so-called diagnostic Bible that no one paid any attention to at the time.

Dr Spitzer drew his inspiration from the pioneering German diagnostician, Emil Kraepelin (pictured here), who was born the same year as Freud. It was Kraepelin who coined the term, manic-depression and separated out the illness from schizophrenia, thus giving psychiatry a basic navigating system. Kraepelin believed that mental disorders were best understood as analogues of medical disorders.

In other words, you don’t treat a heart attack as if it were cancer, or as if the two were somehow related. For one, an individual in the throes of cardiac arrest and someone with a specific organ system under siege have entirely different symptoms.

But psychiatry, which back in the seventies was still in thrall to Freud, viewed things totally differently. To Freud’s followers, symptoms (such as depression) were merely maladaptive reactions to inner turmoil. You didn’t treat the depression; you dug deeper to root out the underlying neurosis. To a Freudian, diagnostics didn’t matter.

The old-timers have no end of horror stories. At the 2004 APA in New York, I heard Jack Barchas MD of Cornell University - the man who pioneered research into serotonin’s connection to behavior - relate how an early mentor actually challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Dr Spitzer lined up support from the one university of the day not under the spell of the Wizard of Id, Washington University (St Louis), an outpost of intellectual sanity fairly crawling with Kraepelinians. In 1972, John Feigner, then a resident there, came up with a classification scheme that Spitzer adopted as the template to block out a first draft, which was completed in a year. In addition, Spitzer used his unlimited administrative control to establish 25 committees peopled with psychiatrists who despised Freudian dogma and who viewed themselves as scientists.

The catch was that there was precious little that could pass for psychiatric science at the time. Meetings often degenerated into free-for-alls where the loudest voices tended to prevail. Nevertheless, a working draft was thrashed out, which was tested by the NIMH for reliability. In other words, if presented with a basic set of symptoms, could different psychiatrists agree on the diagnosis? Or, at least, kinda come close?

One problem in the past was that one psychiatrist’s view of depression could be very different from that of another psychiatrist. Dr Spitzer’s solution was the “checklist,” something we all take for granted these days. (For instance, a diagnosis of major depression requires checking off at least five of nine listed symptoms.)

Something else we take for granted: ADD, autism, anorexia nervosa, bulimia, panic disorder, and PTSD - these illnesses and others debuted during Spitzer’s watch, and no one these days seriously challenges their legitimacy.

Finally, a “multi-axial” system separated out major mental illnesses (such a depression, bipolar, anxiety, and schizophrenia) from personality disorders such as borderline personality disorder (which made its debut in the DSM-III).

The draft copy that got circulated amongst the profession totally eliminated that Freudian article of faith, “neurosis.” To Spitzer and his task force, neurosis was an emperor with no clothes. Basically, if depression were a reaction to neurosis, then show me the neurosis. The depression was visible, tangible, treatable. But what was this underlying neurosis crap? Where was the scientific evidence?

By the end of the seventies, Freudians were in retreat, but they still had the clout to sabotage Spitzer’s efforts. The term, neurosis, was restored, but relegated to parenthesis. In 1979, following some more strategic compromises, the DSM-III came up for approval before the APA. According to an eyewitness account from an article by Alix Spiegel in the Jan 3, 2005, New Yorker:

“People stood up and applauded. Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts, and instead he gets a standing ovation.”

The DSM-III became an instant runaway success worldwide. Finally, no more Freudian muck. Clinicians, researchers, and other stakeholders had a common language, could actually talk to one another. Patients for the first time could enter a clinician’s office with the reasonable expectation of an accurate diagnosis and the appropriate treatment. Imagine that.

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. What do I say?

To be continued ...

Robert Spitzer and the DSM - Part I

Psychiatrists appreciate a free meal as much as I do, which may explain why dinner symposia sponsored by various pharmaceutical companies used to the most popular events at APA annual meetings. I cannot recall what the topic was at this particular symposium at the 2003 APA in San Francisco, nor who the speakers were, but I can never forget who grabbed the empty seat next to me. “Robert Spitzer,” read his name tag.

Robert Spitzer (pictured here) is by far the most influential psychiatrist you never heard of, the man responsible for the ground-breaking DSM-III (diagnostic Bible) of 1980. It was Robert Spitzer who banged the final nail into Freud’s coffin and led psychiatry into the modern era. Until then, believe it or not, psychiatry had no practical system for distinguishing anxiety from depression, from bipolar disorder, from schizophrenia, from people who are assholes.

The first DSM, from 1952, naively attempted to separate out conditions with an obvious biological basis (such as “acute brain syndrome associated with intracranial infection”) from those for which it assumed came from a maladaptation of the individual to his or her environment. This later category included schizophrenia, which it labeled as “schizophrenic reaction.”

According to the DSM-I, these reactions (psychotic, neurotic, behavioral) “are as much determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations as by the precipitating organic impairment.”

Under this way of looking at behavior, symptoms were less important than whatever psychosis, neurosis, or behavioral quirk was supposed to be lurking beneath the surface. Indeed, only a token effort was made to differentiate the likes of “schizophrenic reaction” from “manic-depressive reaction,” both which were seen as “psychotic disorders.”

Psychosis was Freud’s prognosis for hopeless. Psychiatry virtually turned its back on these individuals, but not before blaming them and their parents for failing to adjust.

Depression, in the meantime, was viewed as part of “manic-depressive reaction, depressive type” or a “depressive reaction” under the heading of “psychoneurotic disorders.” Neurosis was the Freudian grand organizing principle to explain the walking wounded, viewed as psychiatry’s meal ticket. According to the DSM-I, “anxiety” was the driving force of neurosis, which may “be directly felt or expressed” or be “unconsciously and automatically controlled” by various defense mechanisms, such as depression.

That’s right. Depression was a “reaction” to anxiety, er, neurosis.

We’re not done. Depression could also be viewed as an expression of personality, as in “cyclothymic personality disorder.” The DSM-I saw personality disorders as a “lifelong pattern of action or behavior” rather than “mental or emotional symptoms.” These individuals were not exactly hopeless write-offs, but any psychiatrist who took them on as patients was regarded as a “hero.”

In the final analysis, none of this mattered. Whether written off as hopeless or viewed as a meal ticket, for all practical purposes the only effective treatment of the day was time. The only catch was that the time cure typically took years to accomplish.

The DSM-II of 1968 was largely a rerun of the DSM-I. Its biggest change was upgrading schizophrenia and manic-depression from adjectives modifying “reaction” to full-blown nouns. At this rate, psychiatry was ready to be dragged kicking and screaming into the twentieth century by the year 3014.

But even then, reform was in the air. By now, the first generation of psychiatric meds was on the market, along with new forms of talking therapy. Clinicians needed a rough guide to work with, along with a practical means of communicating with other clinicians and interested parties.

In the meantime, psychiatry was being subjected to attack from a variety of fronts, including a strong antipsychiatry/civil liberties movement rebelling against forced institutionalization and other abuses, an insurance industry questioning spending good money on unproven long-term talking therapies, and reform-minded psychiatrists fed up with the anti-science mindset of Freud’s followers.

On top of that, institutions were being emptied out. People with serious mental illness were suddenly on the streets. Psychiatry could either get involved or choose to keep milking its rich neurotic clientele, a business it was rapidly losing to budget-conscious psychologists and social workers.

In 1974, Robert Spitzer of Columbia University drew the assignment of overseeing the DSM-III, with the ostensibly narrow brief of harmonizing the DSM with international standards, but little did they know ...

Now, here he was seated next to me, and here I was looking up from my salad trying to think of something to say.

To be continued ...

Piecing Together the Borderline Puzzle

May is Borderline Personality Disorder Awareness Month. Our story so far:

In 1980, borderline personality disorder received formal recognition as a diagnosis with its inclusion into the DSM-III. The catch was that the illness was consigned to "Axis II," widely regarded as psychiatry's wrong side of the tracks. As an editorial by John Oldham MD of the Menniger Clinic in this month's American Journal of Psychiatry explains:

The decision derived from the belief that borderline and other personality disorders were "caused during early development by parental neglect, abuse, or inconstancy." The prototypical image of a patient was that of an angry volatile individual prone to reject help, blame others, and behave self-destructively. "Too often, this behavior was seen as willfully oppositional, and borderline personality disorder patients were spoken of as dreaded pariahs."

Our current clinical and scientific knowledge, Dr Oldham advises, is changing those perceptions. Core "heritable endophenotypes" of affective dysregulation and impulsive aggression have been identified. Brain scans reveal specific abnormalities, namely a hyperactive limbic system, in particular the amygdala (which mediates arousal and fear). Thus, certain individuals are primed to overanticipate and overreact when their personal dealings hit a snag.

This state of emotional overdrive is difficult to extinguish, owing to impairment in the cortical areas to inhibit this limbic-driven emotionality or impulsivity.

As if this isn't bad enough, this phenomenon of "brain gone wild" interferes with forming emotional attachments during child development, which may be magnified by lack of adequate parental support. As Dr Oldham describes it:

"These combined etiological factors produce arrested, distorted, or incomplete integration of aspects of self and others, resulting in early onset and persistence of profound interpersonal difficulties. Normal early development becomes derailed, and the crucial developmental milestone of basic trust is not achieved."

No wonder no one has come up with a med to treat borderline patients. As a second editorial - by Otto Kernberg MD and Robert Michels MD of Cornell - explains, only 30 percent of patients with borderline respond satisfactorily to meds over the long term.

(Editorial sidebar: Psychiatry has unofficially used response to meds as an indicator of whether the illness is biological or merely a construct of the mind. Thus, borderline gets nowhere near the same respect as schizophrenia, which - ironically - evidences similarly low and perhaps even worse response rates.)

Dialectical behavioral therapy and other talking therapies produce beneficial results in the short term, but Drs Kernberg and Michels caution that "basic underlying chronic personality dispositions may remain unchanged."

Thus, years and decades after completion of therapy, individuals with borderline may still face major challenges in personal satisfaction with how their lives are going. On one hand, borderline has been dubbed the "good prognosis diagnosis," based on research showing an 80 percent remission rate over ten years. But the authors caution that these findings are focused more on DSM symptoms, "and much less on the subtle and permanent features of their difficulties in work, love, social life, and creativity."

The bad news is that despite the significant gains in our body of knowledge, "the relationships between clinical symptoms, deeper psychological structures, and underlying neurobiological systems are, as yet, to be explored."

The good news is we are learning as we go. As the authors conclude:

"Borderline patients have long been to psychiatry what psychiatry has been to medicine - a subject of public health significance that is underrecognized, undertreated, underfunded and stigmatized by the larger discipline. As with psychiatry and medicine, this is changing. New knowledge, new attitudes, and new resources promise new hope for persons with borderline personality."

Further reading from mcmanweb:

Borderline Personality Disorder

Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, and the ground beneath her could collapse any second.

"It’s like demons possess me," she related. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

She emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"). Anne concluded with reference to her favorite bumper sticker, "Don’t believe everything you think."

Borderline Personality Disorder - Searching for Respect

In recognition of Borderline Personality Disorder Awareness Month, the second in a series:

Psychiatry has had one hell of a time trying to figure out borderline personality disorder, but we all know it when we see it. Case in point (from an article in this month's American Journal of Psychiatry):

"Ms A" told her therapist of an embarrassing episode in which she had shouted at a store clerk she perceived as rude. What set off the incident was the clerk would not accept her credit card.

Her therapist asked whether it was store policy not to accept credit cards or whether the clerk had singled out her credit card in particular.

"What difference does it make?" the patient responded in a fury. "Even if it was the policy of the store and not directed at me, he still should have been courteous!"

The patient then exploded into a screaming rage: "You’re not interested in empathizing with my feeling of being humiliated - only in figuring out how I caused the whole incident! It’s clear that you don’t care about me ... "

Yep, know it when we see it. Um - but what the hell is it?

As another article in the AJP (by leading expert John Gunderson MD of Harvard) makes clear, the very name borderline indicates various attempts at figuring out what the illness is NOT. In the words of outspoken critic Hagop Akiskal MD of UCSD, borderline over the decades has resembled "an adjective in search of a noun."

Back in the 1930s and into the 50s, it was thought that the noun had to be schizophrenia. According to the theory, it was believed that, in certain situations, some patients regressed into "borderline schizophrenia."

In the late 60s, those nouns became neurosis and psychosis. In a psychoanalytic framework, "borderline personality organization" occupied that nebulous middle ground between neurotic patients (who were considered treatable) and those who were written off as psychotics. "Neurotics who drive their shrinks crazy" would be another way to describe what clinicians observed in their offices.

Give psychoanalysis credit for bringing coherence to the phenomenon, including recognition of: emotional instability, need to attach to others, distorted sense of self and others, reliance on "splitting," and fears of abandonment.

From there, borderline progressed to a "syndrome," still within the purview of psychoanalysis. In 1980 - with the publication of the first modern DSM (DSM III), psychiatry formally recognized the diagnosis as "borderline personality disorder," but in the context of an endangered species consigned to a doomed habitat (Axis II).

Soon after, with the near-total collapse of psychoanalysis, borderline lost its chief group of champions, thereby leaving the diagnosis open to attack. Psychiatry's new generation of whizz kids reached for their chainsaws, along with the mandatory new noun. This time, the noun was depression, as in borderline being some kind of atypical depression.

But the diagnosis found support in new research that convincingly validated the illness, with a course that differed from schizophrenia and depression. Those with borderline showed clear signs of vulnerability to stress, but this - ironically - suggested yet another noun, PTSD (where there exists a substantial overlap).

The diagnosis entered the DSM-IV of 1994 virtually unchanged, though the question was raised about whether a patient could be considered borderline if he or she responded to meds. Against this backdrop emerged the hypothesis that borderline had to do with breakdowns in two key neurotransmitter systems, which translated to either: 1) difficulty in controlling impulses, or 2) emotional (affective) dysregulation.

Meanwhile (and predictably) bipolar became borderline's new candidate noun. Bipolar (with the new "bipolar II" diagnosis) was taking over territory formerly occupied by depression, and borderline was the next logical direction for expansion. But new studies pointed to critical distinctions between the two illnesses, including a failure in borderline patients to "mentalize," that is the capacity to relate to one's own mental states and the states of others.

Coincident with these findings was the success of the first therapy designed specifically for borderline patients, dialectical behavioral therapy. This brought on board a new generation of champions, which may have turned the tide in borderline's favor once and for all.

Still, as Dr Gunderson points out, for a highly prevalent, disabling, and deadly illness that virtually everyone these days acknowledges, borderline still has a long way to go before achieving respect. Psychiatrists receive virtually no training in the illness, few new investigators are entering the field, and proven treatments are often unavailable.

An upgrade to Axis I (in the company of bipolar, schizophrenia, etc) would be a step in the right direction. Says Dr Gunderson:

"It belongs on Axis I to signify its severity, its morbidity, and its unstable course. But it belongs there too to prioritize its usage and to underscore the need for its treatment to be reimbursed."

How about changing the name? Dr Gunderson kinda likes borderline, arguing that the term signifies the illness' "unclear boundaries while reminding us of an unwanted truth, namely, that psychiatric disorders, like other medical conditions, are heterogeneous and have flexible boundaries."

Me? I would go with "No-Noun Disease."

Further reading from mcmanweb:

Borderline Personality Disorder
Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.
Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function.
During the same round of questions, S Nassir Ghaemi MD of Emory University said that he thought borderline personality disorder was a "clinical condition" rather than a disease. As such, the condition is more appropriate for psychotherapy rather than medications treatment. Hagop Akiskal MD of the University of California, San Diego, was decidedly less accommodating: "I don’t have any use for the borderline diagnosis," he asserted.
Dr Akiskal, the leading proponent of the mood spectrum, has been badmouthing borderline for decades. A 1985 article he co-authored had this title: "Borderline: An Adjective in Search of a Noun." Dr Akiskal has made a study of personality, but in the context of temperaments distributed along a continuum ranging from benign to affective illness. ...

Breaking News: Psychiatry Comes Up With New Diagnosis of Asshole

A Knowledge is Necessity exclusive.

In a surprise move expected to be announced shortly, the American Psychiatric Association's Task Force responsible for overseeing the revision of the DSM - psychiatry's diagnostic bible - has come up with the new diagnosis of "Asshole."

Unlike other disorders, episodes, types, and specifiers listed in the DSM, the diagnosis of Asshole fails to mention any symptoms. Nor does it offer a description of the illness.

"Let's put it this way," said E Pontius Paella MD, director of the Darwin Awards Treatment Center at Johns Hopkins and member of the working group that came up with the new diagnosis, "you know one when you see one."

The new diagnosis is the result of heated discussion throughout the Task Force's many working groups, in particular the one responsible for updating the bipolar diagnosis. According to bipolar group member S Belinda Humphries MD of the University of Northern South Dakota, speaking strictly off the record: "We were sick of hearing from our bipolar patients about the bad rap they were getting as a result of Assholes who had mistakenly been diagnosed as bipolar."

Leading bipolar patient advocate Phil Toogood was ecstatic over the news. "It's about time," he commented. "Since the dawn of history we've been putting up with their shit. Every time someone does some asshole thing, people automatically assume the jerk must be bipolar. Maybe now the public won't confuse us."

It isn't just bipolars. Reports Charles Manson from his prison cell: "For years, assholes have been giving us sociopaths a bad name."

The illness is considered chronic and untreatable. When asked to give an example, Dr Paella commented, "That's easy. Rush Limbaugh. Say no more." Dr Paella did add that Assholes can go on to lead productive lives. "Look at all those idiot commentators on Fox News," he observed. "See, there is hope."

When advised that not every Asshole can aspire to a position on Fox News, Dr Paella replied: "No problem. They can always become antipsychiatry bloggers."

The new diagnosis of Asshole is expected to become official in 2012, when the American Psychiatric Association is scheduled to publish the fifth edition of the DSM.

Another Trick Question

You are depressed. The DSM checklist reveals you have nine depression symptoms out of nine. Question: Is your condition diagnosable as a depressive episode?

Not necessarily. "Checklist psychiatry" tends to influence how we view ourselves, but beneath the symptom menu to every Axis I DSM entry we find other qualifying criteria, such as a time period (two weeks for a major depressive episode). Also, before a diagnosis can be made, other possible causes (such as bereavement or a general medical condition) need to be ruled out.

The most intriguing qualifier, though, concerns functionality. With regard to depression, the episode must be severe enough to cause "significant distress or impairment in social, occupational, or other important areas of functioning."

Virtually identical wording appears across the Axis I panoply of episodes and disorders, including mania, anxiety, and schizophrenia. The prominent exception is hypomania.

So, in theory, it is possible to walk into a psychiatrist's office looking like a DSM basket case and yet obtain a clean bill of health. In practice, this is unlikely to happen. But suppose, just suppose, that we could have depression and not be depressed, that we could have a panic attack and not panic. And so on and so on.

Wait! I know what you are about to say. But before you call me crazy, I ask you to indulge me for a moment or two. Just suppose ...

Imagine.