1 Boring Old Man

I ordered a DSM III online a month or so ago [I couldn’t locate an online version]. Since I got it, I’ve periodically looked through it and my reaction is always the same. I start moving back and forth through the pages, thumbing for an anchor to what I’m reading, confused [actually a bit anxious]. The part about depression is limited to one chapter, some 19 pages long – Affective Disorders*. I’m amazed that after thirty years, my reaction is the same as it was the first day I read through it – something like bewildered. I’m going back through the evolution of these criteria in depression to try to understand how we ended up with the category Major Depressive Disorder because it’s such a heterogeneous group – and the whole point of nosology is to refine diagnoses in the service of understanding disease and arriving at effective treatment strategies. I’ve been convinced that we’ll never do that with such an all-inclusive category. My recent reviews of the research and clinical trials of treatments has only strengthened that belief. But now that I’ve gotten to the DSM III, I find myself drawn back to that confusing time in my own life when it came out, and my reaction to it.

The essential feature of this group of disorders is a disturbance of mood, accompanied by a full or partial manic or depressive syndrome, that is not due to any other physical or mental disorder. Mood refers to a prolonged emotion that colors the whole psychic life; it generally involves either depression or elation. The manic and depressive syndromes each consist of characteristic symptoms that occur together. In other classifications these disorders are grouped in various categories, including Affective, Personality, and Neurotic Disorders.
Subclassification of Affective Disorders. The classification of Affective Disorders in DSM-III differs from many other classifications based on such dichotomous distinctions as neurotic vs. psychotic or endogenous vs. reactive. In this manual the class Affective Disorders is divided into Major Affective Disorders, in which there is a full affective syndrome; Other Specific Affective Disorders, in which there is only a partial affective syndrome of at least two years duration; and finally, Atypical Affective Disorders, a category for those affective disorders that cannot be classified in either of the two specific subclasses…

• Which one do you have right now
• Do you have the full deal or a lite version
• What did you have before

Are we to think of this as one great big disease? a bunch of separate diseases? do we think they [it] are biologic? psychologic? Is the effort to separate them because they have different treatments? Why are they separated this way in the first place? why is a person who has had only manic episodes Bipolar? I didn’t get it in 1980 and I don’t get it now. And I don’t get how it’s either more medical or more scientific than what we had before. Other than removing any vestiges of the relationship of depression to mental life or life itself, it seems mighty arbitrary to me.

^{C. At least three of the following:}
^{[a] distinct quality of depressed mood, i.e. the depressed mood is perceived as distinctly different from the kind of feeling experience following the death of a loved one}
^{[b] the depression is regularly worse in the morning}
^{[c] early morning awakening [at least two hours before usual time of awakening]}
^{[d] marked psychomotor retardation or agitation}
^{[e] significant anorexia or weight loss}
^{[f] excessive or inappropriate guilt}

^{A term from the past, in this manual used to indicate a typically severe form of depression that is particularly responsive to somatic therapy. The clinical features that characterize this syndrome have been referred to as "endogenous." Since the term "endogenous" implies, to many, the absence of precipitating stress, a characteristic not always associated with this syndrome, the term "endogenous" in not used in DSM-III.}