Pain? Are You a Bit of a Nut Bar?

I know you often get this feeling when you leave the house and pat your pockets to make sure the keys are there, yeah, but what else have I forgotten?

I got this feeling when I was reading Eugenio Tanzi’s Textbook of Psychiatry (Trattato delle malattie mentali), written in 1905. He was the professor of psychiatry in Florence. He calls depression “painful.” “The perception of the present, the contemplation of the past, the vision of the future . . . become a source of pain that begins with a dulled and stubborn dysphoria and can end in desperation.” (184-185)

Wow! Pain in depression. One is supposed to be down, but psychic and even physical pain? Who knew.

Don Klein at Long Island Jewish Hillside Center knew. In some kinds of depression, he said in 1974, the “pleasure center” is out of action: “If the pleasure mechanism is malfunctioning, [the normal glow of pleasure] does not occur and the person simply has the cold experience of anticipating a situation that does not evoke any warm affective response." "In a certain proportion of these patients, the inhibition of such an hypothesized pleasure center seems accompanied by disinhibition of an equally hypothetical pain evaluation center, resulting in marked fearful anticipations and agitation”. (Klein, “Endogenomorphic Depression,” ArchGen Psych, 31, 1974, 447-454, 449)

Klein suggested the concept of “endogenomorphic depression”. "In a proportion of endogenomorphic cases, a secondarily disinhibited pain evaluation center would lead to an overresponse to pain images and anticipations." As one of the drafters of DSM-3 in 1980, he tried to get it into the Manual because it was a distinctive kind of depression characterized by loss of ability to feel pleasure plus being thrown completely for a loop by some shock (“demoralization”).

You know what happened? Klein’s effort failed. Bob Spitzer, the great arbiter of DSM-3, had no time for the endogeno-whatever and thought “major depression” a much finer concept. (I know this because I studied the files of the DSM-3 Task Force in the archives of the American Psychiatric Association.)

And we wound up with a concept of depression in the DSM series that makes no mention of pain. In the DSM-5 that has just come out, “major depression” has all kinds of “diagnostic criteria” that are very real: insomnia, recurrent thoughts of death, and so forth, but there’s nothing on pain.

There is a kind of depression called “psychotic depression,” one of whose chief symptoms is pain: the patients are in agony from it, they writhe and twist from pain; only suicide will bring relief from the terrible, unremitting pain. Someone has said that, after rabies, it’s the second worst illness in medicine. (Swartz & Shorter, Psychotic Depression, 2007)

Psychotic depression had been in earlier DSM volumes so I picked up my copy of DSM-5, looked for psychotic depression, and thought that some of the pages must accidently have been omitted at the bindery. It’s not there! Psychiatry has completely lost interest in pain.

Tanzi, blown away. Don Klein, still a respected senior figure, but his pain diagnosis, blown away. In 1994 Bernard Carroll, then chair of psychiatry at Duke, proposed “central pain dysregulation” as one of the main mechanisms in understanding depression (Carroll, “Brain Mechanisms in Manic Depression,” Clinical Chemistry, 402, 1994, 303-308)

So what do you think happened to “central pain dysregulation”?

Blown away.

There is a larger narrative here. It is that in psychiatry interest in mechanisms such as central pain dysregulation has been replaced by a preoccupation with naming things, or the “nominalist fallacy,” if you will: “I name, therefore I know,” as Carroll scathingly put it.

In naming most depression “major depression” we act as though we understand it, as though it were a highly specific and unique form of depression. But all we have done is create an incredibly profitable target for the pharmaceutical industry to shoot at, in its marketing of “major depression” as though it were a disease as specific as mumps.

But guess what. It ain’t mumps. It’s an advertising concept. Meanwhile, all these patients who are struggling with the pain that Tanzi – by no means the first -- identified in 1905, are sort of abandoned: Their clinicians look carefully for the DSM diagnostic criteria, but if you’ve got something not in DSM you may be seen as a bit of a nut bar.