My Alternative Depression Diagnosis - Part II
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Let's acknowledge that depression is complex, not simple.
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The People's DSM. In Part I of my Alternative Diagnosis to Depression, I scrapped the antiquated and arbitrary depression symptom checklist and replaced it with something I haven’t given it a name for yet, that nevertheless actually offers clues to our real mental state.
Clinicians or patients would tick off contrasting items on a six-part survey organized according to domains. Thus: Emotion (too much feeling or too little); Perception or Sense of Self (wholly negative or some positives); Thinking (overthinking or underthinking); Behavior (wholly passive or some active); Mental (speeded up or slowed down); Physical (high or low).
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Symptom (characteristic) patterns or anomalies would resolve into three types of depressive states:
- Vegetative depression (Too little emotion, Negative perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low).
- Agitated depression (Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening).
- Mixed depression (subject displays roughly equal vegetative and agitated qualities).
But that is merely the beginning. The DSM serves up various “specifiers” (such as “recurrent”) to add variety to its single plain vanilla depression flavor, and it’s useful to borrow the technique.
A heads up or two:
The Atypical Depression/Melancholic Depression dichotomy as specifiers to DSM depression has been scrapped. Those specifiers were based on the antiquated DSM depression symptom list, resulting in considerable confusion and suspect validity. It is submitted that the Vegetative/Agitated distinction as separate diagnoses is more closely aligned to reality.
Considerable emphasis here is placed on dimensional/spectrum considerations to depression. The current DSM acknowledges psychosis in depression and the DSM-5 would acknowledge “mixed/anxiety depression,” but with little attempt to explain their dynamics or their interaction. In this presentation, elements of anxiety, psychosis, mania, and personality are presented as bearing a relationship to various depression characteristics.
In particular, close regard is paid to depressions that behave as bipolar depressions, including “Agitated (or Mixed) Depression with Mania” and “Agitated (or Mixed) Depression, Highly Recurrent or Cycling.” The combination of these two forms the basis of a separate diagnosis of “Bipolar Spectrum Depression.”
The diagnosis of "Dysthymia" (low grade chronic depression) has been eliminated. Instead, severity criteria are used to distinguish "moderate" from "severe" from "very severe" depression. Moderate depression may have similarities to dysthymia, but the threshold is higher, removing any ambiguity.
Let’s got on with it:
Depression Specifiers
A. Variable Characteristics (at least one item must be checked)
Vegetative, Agitated, or Mixed Depression, Pleomorphic
There has been an observable change over time in domain characteristics (such as from agitated to mixed or mixed to vegetative) between episodes or during an episode.
Vegetative, Agitated, or Mixed Depression, Constant
There has been no observable change over time in domain characteristics between episodes or during an episode.
Vegetative, Agitated, or Mixed Depression, Pleomorphic/Constant Undetermined
The clinician has had no opportunity to observe change or lack of change over time, or cannot make a determination based on history or patient reports.
B. Dimensional Characteristics (at least one item must be checked):
Vegetative Depression With Anxiety
Various vegetative domain characteristics (such as exaggerated worthlessness) may manifest as fearful anxiety, an immobilizing state characterized by an irrational unwillingness to engage with others or in tasks (such as leaving the house or completing an important project).
Agitated (or Mixed) Depression with Anxiety
Various agitated domain characteristics (such as irrational worry) may manifest as anxious distress, a state of nervous tension characterized by over-reacting to events (such as obsessing over a perceived insult).
Vegetative (or Mixed) Depression with Psychosis
Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).
Agitated (or Mixed) Depression with Psychosis
Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).
Agitated (or Mixed) Depression with Mania
Various agitated domain characteristics (such as racing thoughts) may manifest as highly energized distress that may include an irrational (but nonpsychotic) sense of persecution, extreme impatience with one’s own situation or in dealing with others, irritability, and explosive outbursts.
Vegetative (or Mixed) Depression with Catatonia
Various vegetative domain characteristics (such as psychomotor slowing) may manifest as physical and mental stupor.
Vegetative (or Mixed) Depression with Personality Complications
Various baseline personality traits (such as introversion) may amplify certain vegetative depression characteristics (such as isolating) and impede recovery. Opposite personality traits (such as extraversion) may interact with vegetative depression characteristics in unexpected ways.
Agitated (or Mixed) Depression with Personality Complications
Various baseline personality traits (such as novelty seeking) may amplify certain agitative depression characteristics (such as reckless behavior) and impede recovery. Opposite personality traits (such as harm avoidance) may interact with agitated depression characteristics in unexpected ways.
Vegetative, Agitated, or Mixed Depression, No Dimensional Characteristics
Are you sure?
C. Chronicity (Check one):
Vegetative, Agitated, or Mixed Depression, Chronic
Lasting most of the day, most days, for at least two years.
Vegetative, Agitated, or Mixed Depression, Recurrent
History of at least one prior depression.
Vegetative, Agitated, or Mixed Depression, Highly Recurrent or Cycling
Depressions come and go, generally of short duration at short intervals, as if part of the same depression cycling up and down. “Up” merely needs to be higher than “down.” Subject in “up” may feel less depressed than usual, perhaps “normal” or “better than normal” for two days or more before cycling down into deep depression.
“Up” in the context of a depression diagnosis is not elevated enough to be mistaken for bipolar hypomania.
Vegetative, Agitated, or Mixed Depression, Chronicity Undetermined
The clinician has had no opportunity to observe a pattern over time, or cannot make a determination based on history or patient reports.
D. Suicidality (Check one):
Vegetative, Agitated, or Mixed Depression with Suicidal Ideation:
- Subject obsesses on thoughts of dying or taking his or her own life, may feel an intense need to escape intense psychic pain or stop becoming a burden to others, or may see death as a release from life.
- Subject has either formed a clear plan or is strongly considering his or her options, and appears prone to carry out his or her stated intentions.
- Subject's suicidal thinking and bahavior may lack focus, but need to be taken seriously.
Vegetative, Agitated, or Mixed Depression, No Suicidal Ideation:
Suicidal thoughts and self-harm behavior may be present, but there is a clear lack of intention to act on these thoughts or escalate self-harm.
Spectrum Depression
Various types of Agitated or Mixed Depression may present as the above diagnosis.
Existence of both of the following:
- Agitated (or Mixed) Depression with Mania Features
- Agitated (or Mixed) Depression, Highly Recurrent or Cycling
May also include:
- Agitated (or Mixed) Depression, Pleomorphic
Severity
(Check one):
Severity is about functionality, not counting symptoms. Thus, for a depression diagnosis, the episode must significantly impair the subject’s ability to work, relate to others, and enjoy life.
Moderate:
Subject is able to function at work and in relationships, and in general is able to meet obligations, but is in a state of constant struggle, finds little joy in life, and may be fearful of the future.
Severe:
Subject is unable to function effectively at work and in relationships, is unable to meet many obligations, may have reached the conclusion that struggle is not worth the effort, finds no joy in life, and may lack the capacity to have regard for the future.
Very Severe:
Subject is unable to function at all at work and in relationships, is unable to meet any obligations or look after him or herself, may have reached the conclusion that life is not worth the effort, and may have lost all hope in the future.
Depression Modifiers
These involve environmental, lifetime, cultural, and gender issues that may either trigger or compound the course of an episode. Typically, we cannot prove cause and effect. Coincidence is our only clue.
A. Depression Coincident with Stress and Trauma:
Reactive
Depression that anticipates, coincides with, or follows soon after a major personal loss (such as of a loved one, a loving relationship, or employment), hardship (such as financial), interpersonal difficulties (such as a toxic family situation), or traumatic event (such as a danger to one’s physical safety or an extreme change in personal circumstances).
Reactive depression may also result from the culmination of negative personal events and circumstances over time.
The depression appears to bear a relationship to the coinciding event (such as evidence of a long period of high functionality followed by low functionality in the wake of a messy divorce).
The subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to negative or stressful events in general, or a particular negative or stressful event.
The depression shows no sign of abating after four weeks or after the resolution of the coinciding event (such as finding new employment after being downsized).
Traumatic
Subject may appear overwhelmed or functionally impaired by unresolved trauma issues, such as early abuse or neglect.
The depression appears to bear a relationship to recollections of the traumatic event or events (such as evidence of flashbacks, nightmares, emotional triggers, or obsessive ruminations).
Subject appears to display an inherent lack of resiliency, or of finding an adaptive response, to his or her traumatic recollections.
B. Depression Coinciding With Age (Check One):
Note: Age ranges are approximate and may overlap.
Child and Adolescent Onset
From early childhood to early teenhood (ages 5 to 15). Symptoms may be masked or exacerbated by developmental issues or hormonal changes, or life transitions particular to children and adolescents.
Youth Onset
From late teenhood to early adulthood (ages 15 to 25). Symptoms may be masked or exacerbated by developmental issues, hormonal changes, or life transitions particular to those entering adulthood.
Adult Onset
From young adulthood to middle age (ages 21 to 45). Symptoms may be masked or exacerbated by life transitions particular to those settling in to adulthood.
Mature Onset
From midlife to retirement age (ages 40 to 65). Symptoms may be masked or exacerbated by hormonal changes or life transitions particular to those in their middle years.
Late Onset
From retirement age upward (ages 60 and above). Symptoms may be masked or exacerbated by hormonal changes, life transitions, or medical and neurological conditions particular to those in late life.
C. Depression Coincident with Female Hormonal Fluctuations
Postpartum Onset
The depression occurs within one year of childbirth.
The depression appears to bear some relationship to the childbirth (such as evidence of other emotional difficulties surrounding the birth).
The subject displays unexpected difficulty in adapting to the demands of the new child.
Premenstrual Onset
Depression coincides with the second half of a woman’s menstrual cycle, and ends when menstruation begins or soon after. Subject may also manifest difficulties in managing emotions, and may feel intense mental anguish and physical discomfort. The condition is far more severe than PMS.
D. Gender (Check one):
“Female” Features
Depression manifests in a way consistent with “western” social expectations of female behavior.
Subject may over-ruminate, may express emotional pain by appearing sad (such as breaking into tears), may seek out others, may see her condition as a situation of her own making and blame herself, may seek comfort in indulgences (such as satisfying a sweet tooth or impulse buying), may reach out for help in indirect ways (such as expressing a wish to die), or may engage in suicidal gestures (such as taking a non-fatal dose of pain-killers).
“Male” Features
Depression manifests in a way consistent with “western” social expectations of male behavior.
Subject may lack the capacity for ruminative introspection, may express emotional pain by appearing angry and aggressive or sullen, may not seek out others, may deny anything is wrong and blame others, may seek comfort in alcohol or drugs or risk-taking activities (such as venturing into dangerous neighborhoods), may alienate those in a position to help, and may be planning a suicide attempt.
Gender Features Mixed or Undetermined
E. Cultural Identity
Within any given social or ethnic group regarded as a “minority,” depression features may be masked or exacerbated by cultural norms particular to that group (such as distrust in confiding to outsiders or an emphasis on keeping emotions in check), by language barriers, or by different ways of interpreting similar phenomena (such as seeing depression as a disease of the soul).
On the other side of the coin, behavior that perfectly accords with the cultural norms of a particular social or ethnic “minority” group (such as demonstrable displays of grief or apparently submissive gestures) may be mistaken by western observers as signs of depression.
April 7, 2010, reviewed Jan 3, 2011
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