DSM-V Part 1: Especially for me

It was really a touching moment for me.  There I was muddling my way through the draft revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (the document without whose authority psychiatrists daren’t give a patient a tissue to blow their nose), and I suddenly realised that the ever-thoughtful revision committee had come up with a diagnosis that could have been hand-crafted just for me:

300.4 – Chronic Depressive Disorder

A. Depressed Mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.  Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

  1. Poor appetite or overeating
  2. Insomnia or hypersomnia
  3. Low energy or fatigue
  4. Low self-esteem
  5. Poor concentration or difficulty making decisions
  6. Feelings of hopelessness

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder

G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)

H. The symptoms cuase clinically significant distress or impairment in social, occupational, or other areas of functioning

Specify if:

Early Onset: if onset is before age 21 years

Late Onset: if onset is at age 21 years or older

Specify (for most recent 2 years of Dysthymic Disorder):

With Atypical Features

This is a direct quotation, by the way – I have no idea what happened to Criteria E and F.  Also, the reference to ‘Dysthymic Disorder’ in the last Specify section is most likely a cut-&-paste error, since Chronic Depressive Disorder is a conflation of two diagnoses in DSM-IV: Dysthymic Disorder, and Major Depressive Disorder with a Chronic specifier.

So, yes, I am, to paraphrase what psychiatrists are always made to say in a bad Austrian accent in dodgy films, a ‘classic case’ of Early Onset Chronic Depressive Disorder.  I wasn’t formally diagnosed with depression until I was in my mid-20s, but I first had treatment for the same suite of problems when I was 12 (under the old-fashioned, wise, system it was considered best not to pigeonhole kids with specific diagnoses), and I’d been experiencing them for years before then.  Regarding Criterion C, frankly I would have been weeping with undisguised joy if I had experienced a break of two months in symptoms over the last two years (two weeks would have been cause for celebration), and it would be a rare day indeed in which I didn’t have 4 or 5 of the 6 symptoms specified in Criterion B.  This is because I am, as regular sufferers readers of this blog know, pretty badly depressed a lot of the time.  It’s not actually the depth of the depression that bothers me, though, (I’m used to it: I’ve learned how to deal with it: it’s pretty much ‘my’ version of normal), it’s the unrelenting nature of it, the way it just goes on and on and on, sometimes a little worse, sometimes a little less-worse, but never better.

On that level, this diagnosis is a step-up I think, since, for people like me, it may help to re-focus attention from the severity of depression to its chronicity.  (Yes that is a real word, honest – it means ‘chronic-ness’.)  In DSM-IV, ‘Chronic’ was only an additional specifier attached to Major Depressive Disorder, and it often didn’t seem that important to people involved in treating me.  (In fact, I’ve only inferred from indirect comments that the ‘Chronic’ specifier has even been applied to me.)  Their questions would always focus on the severity of the depression, and because I am reasonably high-functioning, and am rarely inclined to blab about what things really feel like to a doctor in a 10-minute consultation (I may be a poof, but I’m still a bloke, goddamn it), it’s always been presumed that I can’t actually be all that badly off.  Very often concentrating on severity is absolutely the right thing to do, of course, because the majority of people with Major Depressive Disorder experience periods of low mood interspersed with longer periods of normal mood, and for them the defining feature of their illness is the severity of each depressive episode.  That’s why I can actually see the sense of creating a separate diagnosis in which chronicity is the characteristic feature.

Of course, the other way of looking at the decision to integrate Dysthymic Disorder (a ‘mild’ condition for which most people wouldn’t have been prescribed medication) with chronic cases of the more serious Major Depressive Disorder (for which medication is usually prescribed) is that it’s probably increased the likelihood that people with a relatively benign symptom profile will be given drugs.  This is perhaps significant, because one of the big worries around the revision of the DSM has been that it might be very heavily influenced by the pharmaceutical industry, and create a whole slew of new conditions, all of which can have pills prescribed for them.  I think it’s entirely possible that the pharmaceutical companies will fairly rapidly ‘discover’ that a number of pre-existing medications – probably, by coincidence, the ones that are still under patent – are ‘effective’ against Chronic Depressive Disorder, and I think therefore also possible that some categories of patients who were previously med-free will be prescribed pills.  Who knows, maybe some of them will even benefit from them.

Sorry, I can’t help but be a little snarky about the DSM, I’m afraid.  But actually, my impression, having cast my wildly inexpert eye over (some of) the proposed revisions, is that there isn’t overwhelming evidence that the various committees have set about ensuring that there’s ‘an ill for every pill’.  Quite a few of the revisions seem sensible to me, and some seem specifically aimed at reducing rather than encouraging over-diagnosis.  For example, the proposal to do away with Asperger’s Syndrome as a separate diagnosis seems to have been influenced by the realisation that the criteria for the condition are rather vague, and that this had led to the diagnosis being used too ‘loosely’ (click on the ‘Rationale’ tab on the link for details).  That said, there are plenty of cases where it seems as though the pharmaceutical companies will be pleased with what they find in the draft revisions.

For example, there’s the wholly new diagnosis, ‘Mixed Anxiety Depression’ (which, rather wonderfully, has the acronym MAD).  What’s particularly worrying about it is that it’s proposed that the diagnosis can be made if symptoms have been present for as little as two weeks.  It strikes me that a person worried about, say, an upcoming exam, or an operation, might well meet the criteria for being diagnosed MAD, even though, assessed over a longer period and particularly after the immediate stressor has been removed, they would seem to be perfectly healthy.  Since MAD is inevitably going to be a medication-treatable condition – SSRIs and SNRIs are already marketed as being especially effective in treating patients who have co-morbid anxiety and depression – it strikes me it’s quite hard to see the ludicrously short qualifying period as anything other than an opportunity to create lots of lucrative new prescriptions.

Still, probably the most blatant example of pharmaceutical influence in the revision process is—

…something to be discussed tomorrow.  Sorry, the post was getting ludicrously long, even by my standards, so I decided to sub-divide it.  Plus I haven’t finished writing it all yet.  Anyway, be sure not to miss the next thrilling instalment

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7 Responses to DSM-V Part 1: Especially for me

  1. J. Wibble says:

    I’ve been following the DSM revisions on gender identity disorder, which is an interesting one as it’s one the drug companies don’t have any investment in whatsoever. They’ve finally removed the sub-division referring to sexual attraction, thus expunging what (I think) is the final reference to homosexuality left in the DSM, as well as acknowledging that there is no evidence base for the time barriers imposed on people seeking treatment (though I do agree with their decision that persistence for 6 months to require a diagnosis has some merit, not least because most trans people meet that for a good decade or more before they even get as far as the shrinks).

    The paradox with the soon-to-be-renamed ‘gender incongruence’ is that whilst many activists want it removed from the DSM entirely so we can’t be classified as mental any more (at least not just for that reason :p) there needs to be some form of medical recognition in order for people to be able to get treatment on the NHS. This, now I think about it, is probably where the interest lies, though for the psychiatrists rather than the drug companies. The NHS gender psychs charge a fortune to the PCTs (one document from 2004 cites a charge of over £200 for a 15-minute appointment) – L-rd only knows what the American psychs charge their ‘clients’. There are drug companies in this equation, but they are far more disjointed from the process than those in real psychiatry – I don’t think Organon take the GIC psychs for many free lunches.

  2. gun street girl says:

    Clearly criteria E and F were overwhelmed by the whole thing and unable to get out of bed.


  3. Wibble – a friend of mine has looked through the new DSM’s trans provisions with a fine toothcomb and apparently autogynephilia is still in there. It would appear that the gender psychs working on DSM were…. characters whose motivation for specialising in gender was not necessarily that they wanted to help transpeople, if you know what I mean (of the Dr. Green variety, if that makes any sense to you).

  4. I bet the subject of your next post Aethelred is paediatric bipolar disorder…. am I right?

  5. aethelreadtheunread says:

    Thanks for the comments.

    J Wibble – Good, as always, to see your name crop up in my comments. :o) I hope the fact that you’re out and about in the blogosphere a little bit more means things are getting slightly easier for you.

    I read through the stuff on DID (i’ve read through all of the sex and gender stuff, as will become painfully apparent in parts 2 & 3 of this ever-expanding post…), but i didn’t really want to get into it in too much detail because it’s an area i don’t know a great deal about and i don’t want to cause offence through ignorance. That said, i’m reassured to see you say that the inclusion of trans issues in the DSM is something of a Catch 22, because that’s what my instinct was – on the one hand, good because it provides a way for trans people to access and demand the medical services they need; on the other bad, because it’s inclusion as a ‘psychiatric disorder’ suggests that it needs to be responded to with psychiatric treatment rather than a referral for hormones and surgery.

    At the moment there’s still a possibility there will be one reference to sexual orientation in the DSM-V – they haven’t yet agreed what changes, if any, to make to 302.9 ‘Sexual Disorder Not Otherwise Specified‘, which includes ‘persistent and marked distress about sexual orientation’. I’d quite like them to drop the reference, because, although the majority of psychiatrists will treat the distress not the orientation, it does leave a small window for ex-gay therapy.

    gun street girl – you made me laugh out loud. Thank you. :o)

    DeeDee Ramona – I decided not to get into Paediatric Bipolar Disorder because Zarathustra has already said everything that needed to be said about it, and better than i would have done. The subject of the next part of the post is actually ‘Sexual Interest/ Arousal Disorder in Women’, which i am not exactly convinced by… ;o)

  6. J. Wibble says:

    DeeDee Ramona – I can certainly vouch for that, as I have met Dr. Green (my first CX appt was with him) and I can tell you now that everything that people say about him is entirely true. I think there are a few who genuinely want to help – I have met some good ones – but some of them seem to have very questionable motivations for their work. I actually got approved by Green (and Barrett), which seems to give me some brownie points in the trans community.

    Aethelread – One of the major criticisms of the inclusion of GID in the DSM has always been that it is the only ‘psychiatric’ disorder that is treated with endocrinology and surgery rather than psychopharmacology and therapy. The purpose of psychiatrists seems to be to act as gatekeepers to physical treatment, and obviously this means that the more obstructive they are the more money they get for each patient. They’re not all bad, but the worst ones tend to be the ones with very senior positions who get consulted on things like this, hence the problems.

  7. aethelreadtheunread says:

    Hi again J,

    Thanks for the extra information. I absolutely get your point about gatekeepers. I can understand that there needs to be some way of making sure that people understand what they’re asking for, and for making sure that they’re not making the decsions under pressure or duress. But those issues come up in lots of other forms of elective surgery too (is the woman asking for a breast enlargement doing it for herself, or because her boyfriend wants her to, and she doesn’t want him to leave?), and no-one suggests that psychiatrists have to be involved in the process of approving those surgeries.

    I’m glad you’ve come across at least some psychs with a helpful and positive attitude. :o)

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