This is OUR DSM (Forget About Clinicians)

As you know, I have begun work here on a People’s DSM, with my own version of what depression and bipolar should look like. I suffer from no delusions that clinicians will actually take this seriously. As the title says, this is the People’s DSM, not the Clinician’s DSM.

Let me back up a bit and explain:

The DSM-III of 1980 was intended as a means of clinicians communicating to other clinicians. A nurse on an Indian reservation and a celebrity psychiatrist in an Upper East Side practice talking on the phone, in theory, would each know what the other meant by “depression” or “bipolar” or “schizophrenia.”

In order to accomplish this, however, the DSM was forced to err on the side of simplicity. A lot of the vital nuances were lost, which tended to defeat the purpose. In any case, the DSM was supposed to be the Doctor’s Dictionary. Nothing more.

The totally unexpected overnight success of the DSM-III, however, changed all that. In no time, a mere dictionary morphed into the diagnostic bible, not to mention the clinician’s cheat sheet, with the quickie symptom checklist standing in for sophisticated evaluations and clinical wisdom.

With the DSM becoming the means by which clinicians got paid, total corruption set in, guaranteeing that diagnostic psychiatry would be stuck in a simplistic 1980 mindset forever. From our perspective as patients and loved ones, this meant our own learning would be very narrowly based. The Doctors’ Dictionary sadly turned into The Patients’ Primer. As I explained in an article on mcmanweb last year:

Go to nearly any mental health website (not this one), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria. Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time.

This is where I got involved. It’s not my place to tell clinicians how to do their jobs. But with our lives on the line, we cannot afford to be as misinformed as they are. That’s what Knowledge is Necessity is all about. On my website, I introduced my DSM Report Cards and The People’s DSM this way:

In February this year, the American Psychiatric Association's DSM-5 Task Force issued its Proposed Revisions to the next edition of the DSM, due out in 2013. The proposals, if enacted, will do very little to change the depression and bipolar diagnoses, but they do provide us with a golden opportunity to rethink issues that we tend to take for granted.

And further on:

Don't worry, no one listens to me. But both exercises are food for thought. Without awareness into our respective conditions, we are at the mercy of clinicians in a hurry. Now, more than ever, knowledge is necessity.

A few hours after I happened to write that, I attended a NAMI "In Our Own Voice" presentation. One of the presenters, let’s call him Adam, mentioned that at different times he had been diagnosed with depression, bipolar, and schizophrenia. Someone in the audience happened to ask why the schizophrenia diagnosis.

We pick up the account on a blog I write for HealthCentral’s BipolarConnect:

Adam explained that when he was depressed he was also experiencing psychotic delusions, which is why his doctor assumed he had schizophrenia. I turned to a friend in disbelief.

This is crazy, I whispered to my friend, a schizophrenia diagnosis on the basis of just one psychotic episode? The doctor has to be an idiot.

Often I get the impression psychiatrists are doctors not smart enough to be proctologists. I went on to say that the current DSM, flawed as it was, should have led Adam’s psychiatrist to a far less extreme diagnostic call. Which leads us to the $64,000 question:

So would an improved DSM have afforded Adam’s doctor greater guidance? No, sad to say. The current DSM was more than adequate, and therein lies the problem: The best diagnostic manual in the world is only as good as the doctor reading it.

As I said to my friend, there are too many idiot doctors out there. Way too many.

So, back to why we are here:

The smart doctors are already practicing psychiatry according to The People’s DSM. All I did was gather their insights, along with yours, and tie them in a bow. So smart clinicians hardly need to change their ways. And the dumb ones who badly need remedial education, well, they’re too dumb to know that.

In short, the People’s DSM is for our benefit only, to get us thinking about issues vital to our well-being. But I would add this qualifier: It is by no means anyone’s final word. This is supposed to be the start of the conversation, not the end of it. The official DSM had the opposite effect.

So, never mind what clinicians think. It’s what WE think that is important. They’re the ones who get paid, but it’s our lives on the line, not theirs. As I keep saying over and over and over, Knowledge is Necessity.

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

As opposed to depression, a highly-complex illness that clinicians dangerously over-simplify, one can make a strong case that bipolar is far more simple than it looks. Change the name to “cycling illness” characterized by “phases” rather than “episodes” or “states,” borrow what’s relevant from what we already have for depression, fill in the blanks with a little bit about what “up” looks like, and stop right there.

Indeed, my first installment did just that. When stripped to essentials, cycling illness is basically a pattern of down and up. And since we tend to be down way more than we are up, it’s fairly accurate to say that cycling illness is depression with speed bumps.

“Up” is anything that contrasts with down. You don’t have to be dancing on tables. “Normal” or “better than normal” will do, so long as it shows you have a depression that is not standing still.

Complex depression, simple illness. Simple, really.

Okay, “up” needs to be explained a lot better than what you find in the current and highly antiquated DSM mania/hypomania symptom list. You can have racing thoughts, grandiosity, pressured speech, and all the rest, but are you feeling great or feeling lousy?

The DSM doesn’t tell you. Can you believe it? Myth has it that we’re supposed to be feeling like Leonardo DiCaprio with Kate Winslet on the bow of the Titanic (or vice-versa), but too often we’re more like Kim Jong il on a bad hair day.

Depression with a power surge, in other words. “Dysphoric” mania/hypomania, as opposed to “euphoric,” which I laid out in full in Part I.

Another way of looking at it is our depressions and manias are mixed. Hence the need for this Part II exercise. Think of dysphoric mania/hypomania as the cycle gone crazy - out of phase, so to speak - with both up and down screaming for attention at once. One is crashing down the door while the other hasn’t yet left the building.

How much depression inside mania/hypomania do you need? Only enough to turn euphoric mania/hypomania dysphoric. No need to count symptoms. Simple. Do we even have to add the specifier, “mixed,” to dysphoric? No. It’s totally redundant. Then again, maybe we better, thus:

1. MANIC PHASE, DYSPHORIC (MIXED)
2. HYPOMANIC PHASE, DYSPHORIC (MIXED)

Meanwhile, over on the other side of the diagnostic divide, we already have “agitated (or mixed) depression with mania” (which we would include on this side of the divide, as well, without specifically having to spell it out). In some cases agitated depression may appear difficult to distinguish from dysphoric mania/hypomania, but, hey, this is life in the real world. Depression and mania co-exist on the same spectrum, and, contrary to what the current and future DSM would have you believe, the two overlap. One bleeds over into the other. They don’t separate for the convenience of clinicians in a hurry.

Finally, what about situations involving say just two symptoms of mania combined with just three symptoms of depression? Going by official DSM criteria, you are healthy. Except for the fact that you are feeling rotten. Fortunately, The People’s DSM is not anal about symptom counts. Problem solved.

Dare we get more complicated?

Coming soon: We get more complicated. In the meantime, your feedback is strongly encouraged. Comments below ...

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

In the “rip it up and start over” spirit of this series, let’s replace the term “bipolar” with “cycling illness” to reflect the true nature of what we are dealing with. I know the name won’t fly - that we’re stuck with bipolar - but, hey, this is a rough draft where I get to say what I really think.

The term, “bipolar,” implies a static and symmetrical illness where the subject flips back and forth between two sharply contrasting (and “polar” opposite) mood “episodes” or “states” that bear no seeming relation.

“Cycling” acknowledges the reality of a dynamic and not necessarily symmetrical condition where one mood “phase” gives rise to another and perhaps yet another.

In addition, cycling acknowledges the likelihood of other cycle disturbances, such as sleep.

On with the show ...

Mood Disorders
Cycling Illness (all of the below must be met):

1. Evidence of a mood cycling pattern (through clinical observation, case history, or patient or witness reports), with discernible contrasting phases.
2. At least one phase (or the combined effect of more than one phase) must be a significant departure from baseline condition
3. At least one phase (or the the combined effect of more than one phase) must significantly impair ability to work, relate to others, and enjoy life.

A. Types: 

Cycling I: Subject experiences one or more mood cycles from depressive low or a non-manic low to manic high.

Cycling II: Subject experiences one or more mood cycles from depressive low to hypomanic high.

Cycling III: Subject experiences one or more mood cycles from depressive low to non-depressive high. 

Cyclothymia: Subject experiences one or more cycles from elements of depression to elements of hypomania.

B. Phases:

DEPRESSIVE PHASE

Subject may experience recurrent or highly recurrent or cycling depression (see My Alternative Depression Diagnosis - Part II).

MANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous “larger than life” presence.

Dysphoric

Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, a sense of impatience, an inability to control impulses, lack of judgment, and a need to satisfy cravings and indulge in projects or engage in risky behavior.

Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others. 

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions. 

Qualifying Criteria:

Mania lasts most of the day for at least two days and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

HYPOMANIC PHASE (check one):

Euphoric

Subject may experience uncharacteristic feelings of joy, enhanced positive abilities, and a sense of ease with the world and those around him or her. Subject may project a sociable charismatic presence.

Dysphoric

Subject may experience uncharacteristic feelings of irritability, enhanced positive and negative abilities, and a sense of unease with the world, him or herself, and those around him or her. Subject may project an unpleasant mildly threatening presence. 

Domains (both must be checked):

Behavior:

Subject may display high energy, little need for sleep, pressured speech, feel a need to get things done or experience pleasurable activities, and not think through the consequence of his or her actions.

Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others.

Thinking:

Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.

Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.

Qualifying Criteria

Hypomania lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).

NON-DEPRESSIVE HIGH PHASE

Subject may simply feel “normal” or “better than normal” and not feeling depressed, but does not cycle higher into hypomania or mania. Nevertheless, “normal” or “better than normal” stands in sharp contrast to depression and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-depressive high phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than  antidepressant medications).

NON-MANIC LOW PHASE

Subject may feel “normal” or “worse than normal” and not feeling manic, but does not cycle lower into depression. Nevertheless, “normal” or “worse than normal” stands in sharp contrast to mania and points to evidence of a cycling phenomenon.

Qualifying Criteria

Non-mania low phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect.

***

Discussion Points

There is considerable overlap between “Cycling Depression” as part of my Alternative Depression Diagnosis and “Cycling III” as part of my Alternative Bipolar (Cycling) Diagnosis. I would submit the overlap far closer resembles reality than the artificial (and out of position) categorical gap imposed by the current (and future) DSM. Nevertheless, a differentiator or two would be helpful. Perhaps evidence of bipolar in a family member for a Cycling III diagnosis?

Your views?

Also, I can use some help on hypomania. Just because it is a deviation from a subject’s baseline condition doesn’t mean it has to be regarded as a pathology. Like any phase of a cycling illness, hypomania has to be looked at in terms of what is likely to come next in the cycle. A shift from euphoric to dysphoric hypomania? A swing up to mania? A steady slide down into something approaching normal? Or a precipitous crash into depression?

My view is that clinicians tend to treat hypomania as if it were mania and thus they err on the side of over-medicating us. Your views?

***

This is a lot more to come to my alternative bipolar (cycling) diagnosis, including mixed phases, rapid cycling, and dimensional and spectrum considerations. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

Further Reading from Knowledge is Necessity 

Grading Bipolar - Stating What's Obvious


From BipolarConnect 

The Depression-Mania Two-Step
The Depression-Mania Two-Step - Part II
What It's Really All About is Cycling

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 ...

MODIFIERS:

A. Depression Coincident with Stress and Trauma:

Reactive

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).

Traumatic

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.

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:

SPECIFIERS:

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.

BIPOLAR SPECTRUM DEPRESSION:

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.

Moderate:

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.

Severe:

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.

Rethinking Depression

Yesterday I came across a piece in the New Yorker by author Louis Menand, entitled Head Case: Can Psychiatry be a Science? The article offers an excellent review of the key debating points concerning the psychiatry’s reaction to the metaphysics of depression, namely:

Is depression really an illness? Or is it a normal reaction to a crazy world? If antidepressants can fix the problem in six weeks, then why spend six years on the couch soliloquizing about your bad potty training? Or, if they can’t, then what the hell is wrong with psychiatry?

On and on it goes. If you want to get up to speed fast on a subject vital to your life, then I highly recommend the article.

The piece zoomed in on the same set of studies that Newsweek made the basis for its outrageous cover story, Why Antidepressants Don’t Work (see my highly-critical post). Consider the New Yorker piece chess to the Newsweek’s checkers, with a much more nuanced look at the issue.

As you will recall, Newsweek cited two extremely convincing meta-analyses by Irving Kirsch in support of the proposition that antidepressants are basically placebos with side effects. Over eight or so years, no one has been able to shoot holes in these studies. Trust me, the second Kirsch meta-analysis is bullet-proof, but the results are open to interpretation.

Namely: In the real world, patients are likely to try a second antidepressant if the first one fails. Various small studies at the time indicated that the odds of success go way up when patients adopt this approach. A later large-scale series of trials underwritten by the NIMH, STAR*D, confirmed this.

That was how I reported the issue eight years ago and in various follow-ups and this was the approach taken by the New Yorker. (Both the New Yorker and I also shot to pieces a bogus meta-analysis recently published in JAMA that Newsweek took at face value).

Not so fast, says Robert Whitaker, author of "Mad in America." In his blog on Psychology Today, Whitaker accurately points out that STAR*D used statistical hocus-pocus to come up with an otherwise unsupportable claim that two-thirds of the patients in the study recovered on antidepressants.

I too, found this conclusion difficult to believe, and didn’t feature it in my STAR*D reporting. What I did feature were two key results: 1) It is worth trying a second antidepressant after the first one fails. 2) Trying a third after the second one fails is problematic.

The second result is the real STAR*D story, one that features in many of the pieces I write here (and one the New Yorker hinted at) but that Newsweek and Whitaker and just about everyone else missed. Here’s the deal:

The DSM depression diagnosis is an emperor with no clothes. It doesn’t tell us anything we don’t already know. One of it’s nine symptoms is “depressed mood.” Huh? So, if you have “depressed mood” and aren’t sleeping right or eating right and have low energy and seem to be moving in slow motion, what state of mind are you in?

DSM depression is a plain vanilla diagnosis that disguises the fact that depression comes in many flavors with many different ingredients. The plain vanilla approach encourages clinicians and researchers to treat all depressions as if they were the same.

This is the major reason clinical drug trials - and for that matter talking therapy trials -  tell us so little. In any given trial, we can predict in advance that 50 percent of patients are going to get 50 percent better. The catch is which 50 percent? No wonder the results for the treatment group and the placebo group are about the same.

This is plain vanilla diagnostics at work. In all likelihood, there is a subgroup that is getting 80 percent better 80 percent of the time, as well as a large group of those who should never be taking antidepressants. But who are these people?

Of all things, STAR*D serves up a hint. As Frederick Goodwin, former head of the NIMH, pointed out to me, about two-thirds of the STAR*D study subjects had recurrent depression.

It seems likely that those in the STAR*D study with recurrent depression would not have fared so well on antidepressants, as recurrent depression is a close cousin of bipolar, but we’ll never know. STAR*D made no attempt to separate out this population. To the investigators, depression was depression.

The other lesson to be gleaned from STAR*D is this: After your second antidepressant fails, you need revisit your diagnosis. Maybe you don’t have depression. Maybe you have bipolar or a depression that behaves like bipolar. Maybe you have borderline personality disorder. Maybe depression is part of your baseline temperament.

But plain vanilla DSM depression offers no guidance. Chances are a large population of individuals in the STAR*D study did not even have depression. Same with clinical drug trials. Treatment works only if the diagnosis is correct.

Now we’re getting to the moral of this story:

Yesterday, I premiered “The People’s DSM.” My first installment featured Part I to My Alternative Depression Diagnosis. In the intro to the piece, I joked that, “if you want anything done right, you have to do it yourself.” But I’m not fooling around.

The DSM-IV depression diagnosis is based on an antiquated and totally arbitrary symptom list from 1980. The people working on the DSM-5, if they are serious, need to rip up that list and start over. Maybe then, psychiatry will get serious about what is really going on in our brains and come up with answers. Instead, they plan to leave the list intact.

As I said, sometimes you have to do it yourself. I’m not joking.

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

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

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

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

Mood Disorders
Depression

Introduction

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

These six domains would replace the symptom checklist.

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

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

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

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

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

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

Domains (at least one from each of six):

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

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

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

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

C. Thinking (Overthinking or Underthinking):

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

D. Behavior (Wholly Passive or Some Active):

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

E. Mental (Speeded Up or Slowed Down):

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

F. Physical (High or Low):

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

***

Depressive types

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

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

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

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

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

***

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

Final Word (for now)

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

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

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

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

***

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