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Who's Crazy Now?

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In ancient Greece, Hippocrates might have told someone with depression that his yellow bile was out of whack. Traditionally, practitioners of Ayurvedic medicine have diagnosed depressives by studying their (im)balance of vata, pitta, and kapha. Freud would have analyzed their dreams.

For the last 60 years, most western doctors have relied on the symptom-based Diagnostic and Statistical Manual of Mental Disorders (DSM).

The first edition, published in 1952 by the American Psychiatric Association, was 130 pages and described 106 disorders. The new DSM-5 is 900+ pages and has over 300 diagnoses.

DSM-5 is causing an extraordinary amount of controversy. One concern is that diagnoses have been added. Those who rail against the "over-medication" of society say this gives the medical industrial complex an excuse to push more pills. The DSM, of course, might consider this evidence of Paranoid Personality Disorder (DSM Code #301.0).

The more significant controversy involves the relative importance of behavior vs. brain chemistry in diagnosis. The DSM is undeniably subjective. It's based on what we tell our doctors and their observations of us. The science of neurobiology, on the other hand, is developing extraordinary techniques to evaluate mental illness based on what's going on in our brains. This combination of symptom- and scientific-based diagnosis is common in medicine.

In April, however, the National Institute of Mental Health announced that it can no longer support the American Psychiatric Association's DSM model because they believe the future lies mainly in brain imaging, genetics, and other scientifically verifiable information.

The fact that the NIMH made this announcement only a month before the DSM-5's release is clearly a sign of Oppositional Defiant Disorder (Code #313.81). The fact that any organization would stubbornly adhere to any diagnostic approach is an undeniable manifestation of Narcissistic Personality Disorder (Code #301.81). Most importantly, for the two most important psychiatric organizations in America to have this rift in the midst of our national conversation about mental health is an episode of Shared Psychotic Disorder (Code #297.3) which could have serious consequences for patients whose doctors get caught between these two worlds or whose health insurance becomes even more unfathomable.

Depressives don't have the luxury of fixed opinions. When you're mired in dysfunctional hopelessness, you can't pledge your allegiance to any diagnostic system.

My official DSM diagnosis is Major Depressive Disorder, Recurrent, In Partial Remission (Code #296.35). In neurobiological terms, my constant agitation during my 2005-2007 breakdown was probably related to over- or under-stimulation of certain serotonin and norepinephrine receptors. From a hereditary perspective, I might have tapped into some genetic melancholia. In terms of ancient diagnostics, I imagine my blood was congealed and my black bile was working overtime. And, while I usually have a decent amount of pitta and a touch of kapha, back then I was a totally over-the-top vata. I don't remember my dreams...

Fortunately, I've been extremely stable and good humored for five years. My doctor prescribes my medications based on conversation, observation, intelligence, experience, and a touch of intuition. Just like all good doctors. In fact, just like Hippocrates.

Some day, my meds might "fall out," and we might not be able to find effective new ones.. I might turn to an acupuncturist, naturopath, behavioral therapist, geneticist, or practitioner of magnetic stimulation.

These health professionals may diagnose my condition in various ways. But for those of us on the other side of the looking glass, the validity of a diagnosis is only as good as the success of the remedy.

One thing I won't be concerned with is the behavior of organizations who, due to a severe case of Dissociative Identity Disorder (Code #300.14), seem to have forgotten how important it is for all of us -- patients, practitioners, researchers, and advocacy groups -- to work together to help people find relief. One individual at a time.

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