{"id":8891,"date":"2011-05-14T10:08:08","date_gmt":"2011-05-14T14:08:08","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=8891"},"modified":"2011-05-15T14:17:55","modified_gmt":"2011-05-15T18:17:55","slug":"depression-dsm-iii-4","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/05\/14\/depression-dsm-iii-4\/","title":{"rendered":"Major Depression: the orphanage&#8230;"},"content":{"rendered":"\n<ul>\n<div align=\"justify\"><sup><strong><font color=\"#400040\">DSM-III [Introduction p. 6]: &quot;In DSM-III there is no assumption that each Mental Disorder is a discrete entity with sharp boundaries [discontinuity] between it and other mental disorders, as well as between it and No Mental Disorder. For example, there has been a continuing&nbsp; controversy as to whether or not severe depressive disorder and mild depressive disorder differ from each other qualitatively [discontinuity between diagnostic entities] or quantitatively [a difference on a severity continuum]. The inclusion of Major Depression With and Without Melancholia as separate categories in DSM-III is justified by the clinical usefulness of the distinction. This does not imply a resolution of the controversy as to whether or not these conditions are in fact quantitatively or qualitatively different.&quot;<\/font><\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">Recall that Melancholia was a 5th digit add-on to <a href=\"http:\/\/1boringoldman.com\/index.php\/dsm-iii-affective-disorders\/#depression\" target=\"_blank\"><u><strong><font color=\"#990000\">major depressive episode<\/font><\/strong><\/u><\/a>. That doesn&#8217;t seem like a separate category to me [296.22 and 296.23]:<\/div>\n<ol>\n<div align=\"justify\"><strong><sup>3- With Melancholia<\/sup><\/strong>                                    <\/p>\n<ul>\n<div align=\"justify\"><strong><sup>A. Loss of pleasure in all or almost all activities<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>B. Lack of reactivity to usually  pleasurable stimuli [doesn&#8217;t feel much better, even temporarily, when  something good happens].<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>C. At least three of the following:<\/sup><\/strong>                                   <\/p>\n<ol>\n<div align=\"justify\"><strong><sup>[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<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>[b] the depression is regularly worse in the morning<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>[c] early morning awakening [at least two hours before usual time of awakening]<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>[d] marked psychomotor retardation or agitation<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>[e] significant anorexia or weight loss<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>[f] excessive or inappropriate guilt<\/sup><\/strong><\/div>\n<\/ol>\n<\/div>\n<\/ul>\n<\/div>\n<\/ol>\n<div align=\"justify\">So Melancholia got buried. Likewise, saying &quot;<em>whether or not severe depressive disorder and mild depressive disorder differ from each other<\/em>&quot; reveals his [or somebody&#8217;s] actual opinion [&quot;<em>severe<\/em>&quot; and &quot;<em>mild<\/em>&quot; sure sound like a severity continuum to me]. &quot;<em>This does not imply a resolution of the  controversy as to whether or not these conditions are in fact  quantitatively or qualitatively different<\/em>&quot; is in the range of a &quot;non-denial denial.&quot;<\/div>\n<p>             <\/p>\n<div align=\"justify\">As the name implies, <strong><font color=\"#400040\">Melancholia<\/font><\/strong> [&#8216;black bile&#8217;] has been recognized since the dawn of recorded time &#8211; sometimes as profound mourning, sometimes as a pathological state, and sometimes as a physical disease. Karl Abraham and later Freud pointed to a continuum between mourning and melancholia by suggesting that the latter was a different kind of grief &#8211; a loss in fantasy rather that in fact. But in their formulations, the basic reaction [physical and emotional symptoms] were biologic &#8211; a built in human reaction to loss. There is no course in psychoanalytic training that addresses &quot;Neurotic Depression&quot; &#8211; depression is just a symptom. And <strong><font color=\"#400040\">Melancholia<\/font><\/strong> proper is certainly not in the domain of clinical psychoanalysts [or for that matter, any other psychotherapy disciplines]. When Kraepelin came along and noted the periodicity of people with affective [mood] illnesses, he created a class, Manic Depressive Illness, with subclasses &#8211; recurrent Mania, recurrent Depression, and recurrent episodes of both. That way of thinking continued in both DSM and DSM-II.<\/div>\n<ul>\n<div><strong><sup>DSM [1952]:<\/sup><\/strong>                     <\/p>\n<ol>\n<div align=\"justify\"><strong><sup>&bull; 000-xll Manic depressive reaction, manic type:<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; 000-xl2 Manic depressive reaction, depressed type:<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; 000-xl3 Manic depressive reaction, other:<\/sup><\/strong><\/div>\n<\/ol><\/div>\n<div><strong><sup>DSM-II [1968]:<\/sup><\/strong>                     <\/p>\n<ol>\n<div align=\"justify\"><strong><sup>&bull; 296.1 Manic-depressive illness, manic type:<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull;     296.2 Manic-depressive illness, depressed type:<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; 296.3 Manic-depressive illness, circular type:<\/sup><\/strong><\/div>\n<\/ol><\/div>\n<\/ul>\n<div>Likewise, there was another kind of depression &#8211; <u>precipitated<\/u> by a life event or an internal conflict. It came in two flavors separated by the presence of <u>psychotic<\/u> symptoms:<\/div>\n<ul>\n<div><strong><sup>DSM [1952]:<\/sup><\/strong>                     <\/p>\n<ol>\n<div align=\"justify\"><strong><sup>&bull; 000-x06 Depressive reaction:<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; 000-xl4 Psychotic depressive reaction<\/sup><\/strong><\/div>\n<\/ol><\/div>\n<div><strong><sup>DSM-II [1968]:<\/sup><\/strong>                     <\/p>\n<ol>\n<div align=\"justify\"><strong><sup>&bull; 300.4 Depressive neurosis<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; 298.0 Psychotic depressive reaction:<\/sup><\/strong><\/div>\n<\/ol><\/div>\n<\/ul>\n<div>And where was <strong><font color=\"#400040\">Melancholia<\/font><\/strong>? What was <strong><font color=\"#400040\">Melancholia<\/font><\/strong>? Clinically, it&#8217;s a discrete syndrome:<\/div>\n<ul>\n<div align=\"justify\"><strong><sup>&bull; profoundly depressed mood<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; no convincing precipitant<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; changes in appetite<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; changes in sleep<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>&bull; loss of interest in life [and perhaps living]<\/sup><\/strong><\/div>\n<\/ul>\n<div align=\"justify\">Psychosis is sometimes there and sometimes not. The psychotic symptoms, if seen, are usually mood congruent &#8211; &quot;I&#8217;m rotting inside.&quot; If the patient had had it before, or had been Manic before, people were comfortable calling it Manic-depressive illness and giving it a subtype name. If the patient was old, it was called Involutional Melancholia. If the patient was new mother, it was called Post-partum Depression. But what if it was an isolated occurrence? Was it the first instance of a Manic-depressive illness? That&#8217;s the way we thought of a new case of Mania, but not of <strong><font color=\"#400040\">Melancholia<\/font><\/strong> because there are patients who present with this syndrome as a one shot deal &#8211; and don&#8217;t go on to have recurrent episodes [at least that&#8217;s the way I thought of it]. And <em>no convincing precipitant<\/em> is the usual part of the story. So in the DSM and DSM-II, patients with <strong><font color=\"#400040\">Melancholia <\/font><\/strong>were orphans [and pretty sick orphans at that].<\/div>\n<ul>\n<div align=\"justify\"><sup><strong><font color=\"#400040\">DSM-III  [Introduction p. 7]: &quot;The major justification for the generally  atheoretical approach taken in DSM-III with regard to etiology is that  the inclusion of etiological theories would be an obstacle to the use of  the manual by clinicians of varying theoretical orientations, since it  would not be possible to present all reasonable etiologic theories for  each disorder&quot;&#8230;<\/font><\/strong><\/sup><\/div>\n<p>           <\/p>\n<div align=\"justify\"><sup><strong><font color=\"#400040\">&quot;Because DSM-III is generally <\/font><\/strong><strong><font color=\"#400040\">atheoretical<\/font><\/strong><strong><font color=\"#400040\">  with regard to etiology, it attempts to describe comprehensively what  the manifestations of the mental disorder are, and only rarely attempts  to account for how the disturbances come about, unless the mechanism is  included in the definition of the disorder. This approach can be said to  be &#8216;descriptive&#8217; in that the definitions of the disorders generally  consist of descriptions of the clinical features of the disorders&quot;&#8230;<\/font><\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">So the charge to the DSM-III Committee was to eliminate&nbsp; theory [like psychoanalysis] and stick to the facts, categorizing mental illness by observable criteria &#8211; symptoms and course [family history didn&#8217;t count as observable for reasons unknown to me]. Here&#8217;s what they came up with. I&#8217;ve left out the &quot;other specific&quot; and &quot;atypical&quot; categories because I don&#8217;t understand them and\/or they felt like wastebaskets]:       <\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" height=\"240\" border=\"0\" width=\"299\" vspace=\"5\" src=\"http:\/\/1boringoldman.com\/images\/dsmiii-4.gif\" \/><\/div>\n<div align=\"justify\">They explain the move of <strong><font color=\"#660066\">Manic-Depressive Illness [Depressed Type]<\/font><\/strong> as follows:       <\/div>\n<ul>\n<div align=\"justify\"><sup><strong>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.<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">So people with <strong><font color=\"#660066\">Bipolar Disorder<\/font><\/strong> had to have a manic episode somewhere along the way, otherwise they stayed in the <strong><font color=\"#660066\">Major Depression<\/font><\/strong> category. They added some other distinctions in their narrative:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>Most individuals who have a disorder characterized by one or more manic episodes [Bipolar Disorder] will eventually have a major depressive episode.<\/strong><\/sup><\/div>\n<p>    <\/p>\n<div align=\"justify\"><sup><strong>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.<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\"><strong><font color=\"#660066\">Involutional Melancholia<\/font><\/strong>, a syndrome I thought was pretty solid myself [an anxious, agitated depression in late life], apparently was not different enough and didn&#8217;t make the cut. I guess it died from old age. Both <strong><font color=\"#660066\">Depressive Neurosis<\/font><\/strong> and <strong><font color=\"#660066\">Psychotic Depressive Reaction<\/font><\/strong> were doomed on two fronts &#8211; Freud&#8217;s psychoanalysis and Meyer&#8217;s psychobiological &quot;reactions&quot; &#8211; and died ideological deaths [<strong><font color=\"#660066\">Depressive Neurosis<\/font><\/strong> Lite became an <strong><font color=\"#660066\">Adjustment Disorder<\/font><\/strong>]. The orphan, <strong><font color=\"#660066\">Melancholia<\/font><\/strong>, and people with depression that had psychotic symptoms became add-ons in <strong><font color=\"#660066\">Major Depression<\/font><\/strong> [see above].<\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" vspace=\"5\" title=\"Alois Alzheimer, Eugen Bleuler\" alt=\"Alois Alzheimer, Eugen Bleuler\" src=\"http:\/\/1boringoldman.com\/images\/dsmiii-5.gif\" \/><\/div>\n<div align=\"justify\">By my read, the old men of psychiatry&#8217;s ranks were dramatically thinned by the DSM-III. While the framers saw themselves as going back to the classification of Emil Kraepelin, it wasn&#8217;t the Kraepelin that I knew [maybe he was a cousin from Saint Louis?]. Based on symptoms, course, and family history, Kraepelin had proposed an <u>illness<\/u> that presented with episodic pathological emotional states [that appeared to run in families]. The DSM-III deconstructed it into Bipolar <u>Disorder<\/u> &#8211; the Mania of old, with only a flavoring from the old Kraepelin. Freud and Meyer had theorized about the mind and life in mental illness and were removed as just that &#8211; theorists. Alois Alzheimer&#8217;s demonstrable brain disease, presenile dementia, survived as did Eugen Bleuler&#8217;s post-Kraepelin version of the many facets of Schizophrenia.<\/div>\n<p>   <\/p>\n<div align=\"justify\"> All of the depressive syndromes drifted into one category. Major Depression became the orphanage for those de-parentified depressions. As we will see later, the various depressive syndromes would make a few attempts at a come-back as the DSM-III was revised, and new versions would come and go, but the changes made by Robert Spitzer&#8217;s surgery on depressive illness in 1980 remain the primary paradigm to the present. There was a new face in the clouds after 1980:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" height=\"148\" border=\"0\" width=\"417\" vspace=\"5\" src=\"http:\/\/1boringoldman.com\/images\/dsmiii-6.gif\" alt=\"Alois Alzheimer, Eugen Bleuler, Robert Spitzer\" title=\"Alois Alzheimer, Eugen Bleuler, Robert Spitzer\" \/><\/div>\n<div align=\"justify\">How did what began as a war on ideology escalate into a war on the clinical syndromes? Specifically, why did Melancholia become part of the chorus rather than a soloist? Now, thirty years later, those questions remain center stage, joined by the host of confusing consequences that arose from those decisions&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>DSM-III [Introduction p. 6]: &quot;In DSM-III there is no assumption that each Mental Disorder is a discrete entity with sharp boundaries [discontinuity] between it and other mental disorders, as well as between it and No Mental Disorder. For example, there has been a continuing&nbsp; controversy as to whether or not severe depressive disorder and mild [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","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-8891","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/8891","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=8891"}],"version-history":[{"count":59,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/8891\/revisions"}],"predecessor-version":[{"id":8982,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/8891\/revisions\/8982"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=8891"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=8891"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=8891"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}