1 Boring Old Man

Why linger so long on the DSM-III? For starters, it deserves it, given the magnitude of the consequences. Another more concrete reason is that I don’t have a DSM-IIIR and I can’t find it on the Internet, so I’m waiting for my $4.71 + shipping Amazon version to arrive. But there’s a further reason that I am finding hard to articulate. I guess I think if I keep writing, the words will find me [since I can’t seem to find them].

It has to do with the whole thing, not just one piece or another. In my nearly 70 years, I’ve done some career wandering. It sounds chaotic if I lay it all out end to end, but not from where I sit because there’s a consistent way of thinking that runs through it all – what people call "the medical model of disease." It goes like this: There are things that one sees and hears [signs and symptoms]. They are manifestations of a known or unknown underlying cause [disease]. The task is to find that cause. If it can be treated, that’s the first order of business. You only treat symptoms when you’re sure you won’t miss or mask the cause. If you do treat the symptoms, the standard is ‘do no harm.’ It’s the only way I know how to think – as an Internist, or as a Psychiatrist, or as a Psychoanalyst.

And I can’t find a way to think in DSM-III. I’ve tried repeatedly – unsuccessfully. And I don’t really understand other people when they speak DSM-III. So there’s something fundamental about the DSM-III way that obviously bothers me. It doesn’t seem "medical." Spitzer and his committee set out to be atheoretical. I think what they ended up with turned out acausal [to coin a phrase] and un-medical [to use another].

^{It is estimated that over 50% of individuals with a Major Depression, Single Episode, will eventually have another major depressive episode, thus meeting the criteria for Major Depression, Recurrent. Individuals with Major Depression, Recurrent, are at greater risk of developing Bipolar Disorder than are those with a single episode of Major Depression.}

^{In Bipolar Disorder the initial episode is often manic. Both the manic and the major depressive episodes are more frequent and shorter than the major depressive episodes in Major Depression.}

^{Most individuals who have a disorder characterized by one or more manic episodes [Bipolar Disorder] will eventually have a major depressive episode.}

^{The course of Major Affective Disorders is variable. Some individuals have episodes separated by many years of normal functioning; others have clusters of episodes; and still others have an increased frequency of episodes as they grow older. Usually the functioning returns to the premorbid level between episodes. However, in 20% to 35% of cases there is a chronic course with considerable residual symptomatic and social impairment. This is more likely when there are frequent recurrent episodes.}

^{Major Affective Disorders are more common among family members than in the general population. This is particularly true for family members of individuals with Bipolar Disorder}

While one expects variability in the clinical presentation of any disease or syndrome, that variability orbits around a central theme. I think that’s why the DSM-III was so impossible for me. In their zeal to be atheoretical they added so many qualifiers that my mind couldn’t find the center – not even close. And while they spoke authoritatively, their chronic use of vague, relativistic language made me question if they even knew what they were talking about [I now think they didn’t]. I didn’t end up knowing if Bipolar Disorder had a unifying cause known or unknown, or was part of something else, or had parts itself. It seemed like an arbitrary category whose definition I could only memorize but not understand.

And Major Depression was even worse. I sure sure I found nothing unifying there. Even if I partitioned it by the add-ons – with or without Melancholia, with or without Psychosis – it still felt like alphabet soup. I couldn’t get my mind to put people who became depressed after some life event in the same category as people who just got depressed out of the blue. I couldn’t say age didn’t matter. I couldn’t ignore the fact of a new baby. It seemed like the category contained more differences than similarities. It was closer to "shortness of breath" than "heart failure" and nowhere near "Mitral Stenosis." It didn’t feel like the end of anything – more like a place to start. There were a bunch of trees, but no forest. And then there were the OTHER SPECIFIC AFFECTIVE DISORDERS and the ATYPICAL AFFECTIVE DISORDERS. They differed from the main diagnoses by not quite living up symptom-wise or they had odd time qualifiers to take on faith. Were they lesser versions of the big Disorders or discrete entities? Who knows? How were those cut-offs decided? The very thick book didn’t say.

I’ve been in the medical world for almost a half a century in a number of different ways and specialties. I guess "medical thinking" becomes automatic in that time-frame. I can’t not do it. And I could never make the DSM-III fit. When I hear others talking in DSM-III talk, I used to feel "lost." More and more, I began to feel frustrated, because what they were saying felt off-point. I’m tempted to say that it sounds like a person with Obsessive Compulsive thinking, picking at the details, but never getting to the heart of the matter [I would say that, but I swore to put the analyst to sleep]. What it comes down to is that the DSM-III felt and feels non-medical to me rather than the advertised more medical. And to be honest, if I were to let the analyst wake up for a second, I’d say it feels "neurotic" – a tangle of unacknowledged and unresolved conflicts.