{"id":16885,"date":"2011-12-05T16:56:12","date_gmt":"2011-12-05T21:56:12","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=16885"},"modified":"2011-12-05T17:13:06","modified_gmt":"2011-12-05T22:13:06","slug":"as-precisely-as-possible","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/05\/as-precisely-as-possible\/","title":{"rendered":"as precisely as possible…"},"content":{"rendered":"
Major Depressive Disorder<\/em> <\/div>\n
    <\/p>\n
  1. \n
    Depressed mood most of the day, nearly every day, as indicated by either subjective report [e.g., feels sad or empty] or observation made by others [e.g., appears tearful]. [In children and adolescents, this may be characterized as an irritable mood.] <\/em><\/div>\n<\/li>\n
  2. \n
    Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day <\/em><\/div>\n<\/li>\n
  3. \n
    Significant weight loss when not dieting or weight gain [e.g., a change of more than 5 of body weight in a month], or decrease or increase in appetite nearly every day.<\/em><\/div>\n<\/li>\n
  4. \n
    Insomnia or hypersomnia nearly every day <\/em><\/div>\n<\/li>\n
  5. \n
    Psychomotor agitation or retardation nearly every day <\/em><\/div>\n<\/li>\n
  6. \n
    Fatigue or loss of energy nearly every day <\/em><\/div>\n<\/li>\n
  7. \n
    Feelings of worthlessness or excessive or inappropriate guilt nearly every day<\/em><\/div>\n<\/li>\n
  8. \n
    Diminished ability to think or concentrate, or indecisiveness, nearly every day<\/em><\/div>\n<\/li>\n
  9. \n
    Recurrent thoughts of death [not just fear of dying], recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.<\/em><\/div>\n<\/li>\n

    <\/sup><\/ol>\n

    Several years ago, I saw a man in one of the clinics where I volunteer who was depressed. He had a history of lifelong substance abuse and had been in a single car wreck a year before with a fractured pelvis resulting in persistent neurological damage to his lower extremities. He became drug and alcohol free in a twelve step program after the wreck. I started him on an antidepressant, and after about a month, he responded – "too much." He was followed by a local therapist who was alarmed and called me. When I saw him, he was hypomanic. We stopped the medication, and within a week or so, he became euthymic. He’s someone I see in my life from time to time in this small rural community and he seems fine on a regular day. He had another episode last year, treated successfully by a psychiatrist I sent him to in the metro area. He moved recently about a hundred miles away, and during the move became depressed again. He drove up here and we sat on those benches at the top of this page to talk. Same thing. I started him on medication and found him a psychiatrist in his new town [on his "panel"]. His family is "riddled with alcoholics." His history was suggestive of previous mood-swings, but to be honest, the story was so clouded by his substance abuse it was hard to tell for sure if there were true episodes of mood dysregulation. I suspect there were others. He’d never been treated for them before. <\/div>\n

    My reason for mentioning him has to do with the DSM-5 Revision process. This man has Manic-Depressive Illness, the same kind Kraepelin wrote about a long time ago. It’s in his history – substance abuse, family history of substance abuse. It’s in his course – recurrent episodes, hypomania at the end of a depressive episode, etc. But it was somewhere else too – in his clinical presentation. I thought about it the first and only time I saw him as a patient based on how he described his symptoms and his thinking. The way he was. It was more than "Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others<\/em>."<\/p>\n

    His "depression" won’t fit into a sentence. It’s a paragraph. He doesn’t appear "sad." He looks worried, brooding. He’s driven to talk about how he feels or doesn’t feel but has trouble putting it into words. He’s self flagellating, including about his symptoms. He seems to have no memory that he ever felt differently from how he feels right now and has no concept of "better." He doesn’t want to "do" anything or go anywhere. While there are several things that might explain his symptoms – moving, his marriage, etc, none of them seem related and are quickly incorporated into his self attacking. I’ve spent my days talking to unhappy people and am fairly good at it, but talking to this man isn’t getting anywhere. His mind returns to talking about how he feels [or doesn’t feel] as soon as there’s a lull in the conversation like it’s affixed with a rubber band. Words like "sad" or "guilty" don’t capture what he is experiencing. "Bad" is closer, as a noun, an adjective, and an adverb. And, speaking of nouns, he’s not "depressed" – he is "depression."<\/p>\n

    I mention him for two reasons. First, this is not the kind of person treated in those clinical trials we keep talking about – maybe a few, but certainly not the majority. I see those people in the clinics frequently, the ones described by the criteria above. This is something else, a different entity not described by a "dimension" or an add-on. Saying he has MDD "with melancholia" or "with psychotic features" implies a continuity with other patients that doesn’t exist. He was not "psychotic," so the differential diagnosis was Melancholia or a Depressive Episode in the context of Manic Depressive Illness [if we still used Reserpine to treat high blood pressure, Reserpine induced Depression would be on the list too]. The diagnostic system we have now doesn’t have the depth to separate him out from other depressed people. We need that back in the DSM – and not just as a "dimension." Dimensions are fine for other things, I guess. But not this.<\/p>\n

    My other reason for mentioning him is the difficulty getting him treated. These days, I rarely see a depressed person who doesn’t say, "I’ve been told that I might have bipolar" or "I’m on Depakote for the bipolar."  I hear it so often I want to scream. It’s widely over-diagnosed and unnecessarily medicated. It’s so common that it’s lost its valence – just another bipolar<\/em>. Manic Depressive Illness is not that common, and it’s a big deal that has a powerful effect on the course of life and the person’s family. The episode itself needs treating. The treatment is biologic – medication, and sometimes ECT. He may need hospitalization for treatment as well as his own protection. And I haven’t been able to get that for him. This particular patient needs to be followed and tried on long term preventive treatment instead of driving 100+ miles to see a retired acquaintance in his front yard. Patients with this illness may endure their episodes, but are also vulnerable to suicide when they feel another one coming on ["I just can’t do it again"], at its depths ["this is too bad and I’m worth nothing anyway"], and when they are are improving ["it was too much"]. He’s also a set-up for a substance abuse "relapse" during an episode. The last time I referred him, he got "lost in the crowd" and wasn’t followed. This time, I sent a mega-explicit-letter to his new psychiatrist, but I worry he’ll be just another "med eval" case on "the panel."<\/p>\n

    In my last post, I kept suppressing a rant. The rant was about my sense that the DSM-5 Task Force is dancing around the edges and playing with pet projects without strengthening the diagnoses of known diseases like Psychotic Depression, Melancholia, Depressive Episodes in Bipolar Disorder, Involutional Depression, Pseudodementia, Depressive Reactions [I said it and I’m glad!] in the course of life, the unique depressions associated with various Personality Disorders, etc. I understand why they might have worried about such things in 1980 [afraid that they would be tagged with the dreaded psychodynamic interpretations]. But we’re beyond that now and even dyed-in-the-wool analysts like me have come around. But those clinical distinctions are real. They didn’t disappear just because psychiatry wanted to get all neuroscientific. There are important ancillary findings – subtle distinctions in mood, course, and prognosis. There are family historical factors and "real" comorbidities like Alcoholism with Manic Depressive Illness. Syndromatic diagnoses have many "dimensions" – and they matter in plotting out a treatment plan. That’s what diagnosis means, not as a way to further the agenda of the ACNP’s Task Force, but as a way to define the condition as precisely as possible. And certainly not as a way of testing hypotheses… <\/div>\n","protected":false},"excerpt":{"rendered":"

    Major Depressive Disorder Depressed mood most of the day, nearly every day, as indicated by either subjective report [e.g., feels sad or empty] or observation made by others [e.g., appears tearful]. [In children and adolescents, this may be characterized as an irritable mood.] Markedly diminished interest or pleasure in all, or almost all, activities most […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-16885","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16885","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=16885"}],"version-history":[{"count":18,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16885\/revisions"}],"predecessor-version":[{"id":16903,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/16885\/revisions\/16903"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=16885"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=16885"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=16885"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}