1 Boring Old Man

Inertia isn’t just a property of physical bodies. It’s applicable as a concept in a wide range of circumstances. Things in place tend to stay as they are. There are plenty of psychological examples: a substance use that self perpetuates as an addiction; a character trait that endures no matter how maladaptive; a child who ‘takes things’ who grows up to be a thief. Things that repeat or endure are the bedrock of our personae – sometimes the essential structures that support our growth, but at other times, the mechanism of our downfall. In a psychotherapy, it’s not terribly hard to identify what repetitive pattern of living is causing the patient’s discordant life. The hard part is figuring out how to change the pattern – to interrupt the inertia. And when I look back over the medical errors I’ve seen, mine and others, they’re almost always the same – categorical errors. They’re situations where the initial diagnostic category was wrongly chosen and by the time that became clear, it was too late. An anxiety attack that turned out to be a pulmonary embolus; a ruptured retroflexed appendix that eroded through the diaphragm or a ruptured esophagus both presenting as pneumonia; a hysteria that was, in fact, a brain tumor; an alcoholic whose D.T.s were really a symptom of fungal meningitis. Once the wrong categorical diagnosis is made, that initial mistake has an an inertia as strong as that of a resting boulder or an avalanche – a powerful resistance to change.

300.4 Depressive neurosis
^{This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession…}

Primary Affective Disorders.

Depression.

—For a diagnosis of depression, A through C are required.
A. Dysphoric mood characterized by symptoms such as the following: depressed, sad, blue, despondent, hopeless, "down in the dumps," irritable, fearful, worried, or discouraged.
B. At least five of the following criteria are required for "definite" depression; four are required for "probable" depression.
1. Poor appetite or weight loss (positive if 2 lb a week or 10 lb or more a year when not dieting).
2. Sleep difficulty (include insomnia or hypersomnia).
3. Loss of energy, eg, fatigability, tiredness.
4. Agitation or retardation.
5. Loss of interest in usual activities, or decrease in sexual drive.
6. Feelings of self-reproach or guilt (either may be delusional).
7. Complaints of or actually diminished ability to think or concentrate, such as slow thinking or mixed-up thoughts.
8. Recurrent thoughts of death or suicide, including thoughts of wishing to be dead.
C. A psychiatric illness lasting at least one month with no preexisting psychiatric conditions…

Mania.

—For a diagnosis of mania, A through C are required.
A. Euphoria or irritability.
B. At least three of the following symptom categories must also be present.
1. Hyperactivity (includes motor, social, and sexual activity).
2. Push of speech (pressure to keep talking).
3. Flight of ideas (racing thoughts).
4. Grandiosity (may be delusional).
5. Decreased sleep.
6. Distractibility.
C. A psychiatric illness lasting at least two weeks with no preexisting psychiatric conditions…

^{…we have made no effort to subclassify these illnesses. [For example, we have presented criteria to define primary affective disorders, unipolar type, without suggestions for further subdivision into forms of early and late onset, psychotic or nonpsychotic forms, agitated or retarded forms, and so forth. It is clear that primary affective disorder, unipolar type, is a reasonable major classification. The data to support its subclassification are still tentative.] We and other investigators will continue to work toward modification and subclassification. What we now present is our synthesis of existing information, a synthesis based on data rather than opinion or tradition. We hope that such a presentation will help to promote useful communication among investigators.}

I’m not trying to be cryptic here and I hope I’m not being trivial, but I’m playing with the hypothesis that it’s possible that the unitary class, Major Depressive Disorder, was not rooted in either some scientific idea or theoretical position, but was rather just a way of thinking about classification in those early days that got carried along by inertia – something that came to have a meaning well beyond its meaningless or perhaps grammatical origins. It sure developed a massive meaning when the new antidepressants came along because it offered the clinical trial world a huge, unified, diagnostic cohort for testing the cascades of SSRIs that came from the pharmaceutical industry – a ready-made market extraordinaire. But I’m wondering if its beginning was mere convenience.

In Dr. Spitzer’s first article about reliability in 1974, he did put all the older depressive syndromes under one heading after the style of Feighner – Affective Disorders:

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^{These two approaches,structuring the interview and specifying all diagnostic criteria, are being merged in a series of collaborative studies on the psychobiology of the depressive disorders sponsored by the N.I.M.H. Clinical Research Branch.}

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