Nathen's Miraculous Escape

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The structure of Panic and Agoraphobia Disorders diagnostic criteria in the DSM-IV-TR is similar to that of Mood Disorders; there are the “ingredients” of Panic Attack (which I have quoted below from p. 432 of the DSM-IV-TR) and Agoraphobia (quoted from p. 433), and then the Disorders are like recipes, including or excluding the ingredients in different ways. The Disorders are Panic Disorder Without Agoraphobia (quoted from p. 440), Panic Disorder With Agoraphobia (quoted from p. 441), and Agoraphobia Without History of Panic Disorder (quoted from p. 443).

Please remember that you cannot ethically or accurately diagnose yourself or anyone you know, even if you are a mental health professional. I am posting these criteria for general interest, not diagnosis:
Criteria for Panic Attack

Note: A Panic Attack is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441]).

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1)    palpitations, pounding heart, or accelerated heart rate

(2)    sweating

(3)    trembling or shaking

(4)    sensations of shortness of breath or smothering

(5)    feeling of choking

(6)    chest pain or discomfort

(7)    nausea or abdominal distress

(8)    feeling dizzy, unsteady, lightheaded, or faint

(9)    derealization (feelings of unreality) or depersonalization (being detached from oneself)

(10)  fear of losing control or going crazy

(11)  fear of dying

(12)  paresthesias (numbness or tingling sensations)

(13)  chills or hot flushes

Criteria for Agoraphobia

Note: Agoraphobia is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia [p. 441] or 300.22 Agoraphobia Without History of Panic Disorder [p. 441]).

A.      Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpe3cted or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crows or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

Note: consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or social Phobia if the avoidance is limited to social situations.

B.      The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C.      The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Diagnostic criteria for 300.01 Panic Disorder Without Agoraphobia

A.      Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)    persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)    a significant change in behavior related to the attacks

B.      The absence of Agoraphobia (see p. 433)

C.      The Panic Attacks 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., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.21 Panic Disorder With Agoraphobia

A.       Both (1) and (2):

(1)    recurrent unexpected Panic Attacks (see p. 432)

(2)    at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a)   persistent concern about having additional attacks

(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

(c)     a significant change in behavior related to the attacks

B.       The presence of Agoraphobia (see p. 433)

C.     The Panic Attacks 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., hyperthyroidism).

D.      The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety disorder (e.g., in response to being away from home or close relatives).

Diagnostic criteria for 300.22 Agoraphobia Without History of Panic Disorder

A.      The presence of Agoraphobia (see p. 433) related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).

B.      Criteria have never been met for Panic Disorder

C.      The disturbance is not due to the direct physiological effects of a substance (e.g.,  a drug of abuse, a medication) or a general medical condition.

D.      If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The DSM-IV-TR devotes 84 pages to how to diagnose Mood Disorders. It’s a complex business, and something diagnosticians can take extremely seriously. The criteria for the actual disorders (Depressive Disorders and Bipolar Disorders) are like recipes. The ingredients for those recipes are Mood Episodes (Depressive, Manic, Mixed, or Hypomanic) and “specifiers.” The following are the criteria for the specifiers, which are about severity, accompanying symptoms, and timing aspects. The Criteria for Severity/Psychotic/Remission Specifiers for the Mood Episodes are quoted from the DSM-IV-TR:

Major Depressive Episodes, p. 413

Manic Episodes, p. 415

Mixed Episodes, p. 416

Hypomanic Episodes, p. 417

And the criteria for other Mood Disorder specifiers:

Chronic Specifier, p. 417

Catatonic Features Specifier is from p. 418

Melancholic Features Specifier is from p. 420

Atypical Features Specifier is from p. 422

Postpartum Onset Specifier is from p. 423

Criteria for Longitudinal Course Specifier is from p. 425

Seasonal Pattern Specifier is from p. 427

Rapid-Cycling Specifier is from p. 428

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Major Depressive Episode. In Partial Remission and In Full Remission can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

.x1–Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

.x2–Moderate: Symptoms between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

 

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Manic Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Manic Episode. In Partial Remission and In Full Remission can be applied to the most recent Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: Minimum symptoms criteria are met for a Manic Episode

.x2–Moderate: Extreme increase in activity or impairment in judgement.

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes  of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Mixed Episodes

Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe With Psychotic Features can be applied only if the criteria are currently met for a Mixed Episode. In Partial Remission and In Full Remission can be applied to a Mixed Episode  in Bipolar I Disorder only if it is the most recent type of mood episode.

.x1–Mild: No more than minimum symptom criteria are met for both a Manic Episode and a Major Depressive Episode.

.x2–Moderate: Symptoms or functional impairment between “mild” and “severe.”

.x3–Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.

.x4–Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic or depressive themes.

Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic or depressive themes. of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.

.x5–In Partial Remission: Symptoms of a Mixed Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Mixed Episode lasting less than 2 months following the end of the Mixed Episode.

.x6–In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.

.x0–Unspecified.

Criteria for Chronic Specifier

Specify if:

Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.

Criteria for Catatonic Features Specifier

Specify if:

With Catatonic Features (can be applied to the current or most recent Major Depressive Episode, Manic Episode, or Mixed Episode in Major Depressive Disorder, Bipolar Disorder, or Bipolar II Disorder)

The clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movements as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Criteria for Melancholic Features Specifier

Specify if:

With Melancholic Features (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)

A. Either of the following, occurring during the most severe period of the current episode:

(1) loss of pleasure in all, or almost all, activities

(2) lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

B. Three (or more) of the following:

(1) distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)

(2) depression regularly worse in the morning

(3) early morning awakening (at least 2 hours before usual time of awakening)

(4) marked psychomotor retardation or agitation

(5) significant anorexia or weight loss

(6) excessive or inappropriate guilt

Criteria for Atypical Features Specifier

Specify if:

With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current Major Depressive Episode in Major Depressive Disorder or in Bipolar I or Bipolar II Disorder when a current Major Depressive Episode is the most recent type of mood episode, or when these features predominate during the most recent 2 years of Dysthymic Disorder; if the Major Depressive Episode is not current, it applies if the feature predominates during any 2-week period)

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events)

B. Two (or more) of the following features:

(1) significant weight gain or increase in appetite

(2) hypersomnia

(3) leaden paralysis (i.e., heavy, leaden feelings in arms or legs)

(4) long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

C. Criteria are not met for With Melancholic Features or With Catatonic Features during the same episode.

Criteria for Postpartum Onset Specifier

Specify if:

With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder)

Onset of episode within 4 weeks postpartum

Criteria for Longitudinal Course Specifiers

Specify if (can be applied to Recurrent Major Depressive Disorder or Bipolar I or II Disorder):

With Full Interepisode Recovery: if full remission is attained between the two most recent Mood Episodes

Without Full Interepisode Recovery: if full remission is not attained between the two most recent Mood Episodes

Criteria for Seasonal Pattern Specifier

Specify if:

With Seasonal Pattern (can be applied to the pattern of Major Depressive Episodes in Bipolar I disorder, Bipolar II Disorder, or Major Depressive Disorder, Recurrent)

A.      There has been a regular temporal relationship between the onset of Major Depressive Episodes in Bipolar I or Bipolar II Disorder or Major Depressive Disorder, Recurrent, and a particular time of the year (e.g., regular appearance of the Major Depressive Episode in the fall or winter).

Note: Do not include cases in which there is an obvious effect of seasonal related psychosocial stressors (e.g., regularly unemployed every winter).

B.      Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).

C.      In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period.

D.      Seasonal Major Depressive Episodes (as described above) substantially outnumber the nonseasonal Major Depressive episodes that may have occurred over the individual’s lifetime.

Criteria for Rapid-Cycling Specifier

Specify if:

With Rapid Cycling (can be applied to Bipolar I Disorder or Bipolar II Disorder)

At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a Major Depressive, Manic, Mixed, or Hypomanic Episode.

Note: Episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., Major Depressive Episode to Manic Episode).

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

I usually post a prevalence-rate map from Wikipedia along with diagnostic criteria. For Bipolar Disorder, though, Wikipedia currently has a map of “age-standardised disability-adjusted life year (DALY) rates.” (Yellow countries have something like two-thirds the DALY rates from Bipolar Disorder of the red countries.)

DALY is basically trying to measure how costly an affliction is, as opposed to just how many people experience it. Perhaps this is why it looks so much worse in poorer countries than rich ones, quite the opposite of how Major Depressive Disorder prevalence map looks. I’d still like to look at prevalence. Can anyone point me to a good prevalence map?

As you will see, there are a bunch of versions of Bipolar Disorder. The basic ingredients of them are called Mood Episodes (which I have here): Depressive, Manic, Mixed, and Hypomanic Episodes. There are also a whole bunch of “specifiers,” which are used to describe severity, extra features, and timing (which I will link to at some point). The criteria quoted in this post are basically recipes of Episodes and specifiers.

Here are the diagnostic criteria, directly quoted from the DSM-IV-TR, for Bipolar I Disorders (pp. 388-392), Bipolar II Disorder (p. 397),  and Cyclothymic Disorder (p. 400). There is a final Bipolar Disorder Not Otherwise Specified available to diagnosticians who suspect a Bipolar Disorder in a client that doesn’t fit any of the diagnostic criteria. I can’t post criteria for BD NOS, though, because there aren’t any.

Diagnostic criteria for 296.0x Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode (see p. 362) and no past Major Depressive Episodes.

Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.

B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if:

Mixed: if symptoms meet criteria for Mixed Episode (see p. 365)

If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, specify the current clinical status of the Bipolar I Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

A. Currently (or most recently) in a Hypomanic Episode (see p. 368).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.4x Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode (see p. 362)

B. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Manic Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Manic Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Manic Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed

A. Currently (or most recently) in a Mixed Episode (see p. 365).

B. There has previously been at least one Major Depressive Episode (see p. 365), Manic Episode, (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Mixed Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Mixed Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode:

In Partial Remission, In Full Remission (see p. 414)

With Catatonic Features (p. 417)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed

A. Currently (or most recently) in a Major depressive Episode (see p. 365).

B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode:

In Partial Remission, In Full Remission (see p. 414)

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.7 Bipolar I Disorder, Most Recent Episode Unspecified

 A. Criteria, except for duration, are currently (or most recently) met for a Manic (see p. 362), a Hypomanic (see p. 368), a Mixed (see p. 365), or a Major Depressive Episode (see p. 356).

B. There has previously been at least on Manic Episode (see p. 362) or Mixed Episode (see p. 365).

C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abus, a medication) or a general medical condition (e.g., hypothyroidism).

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 296.89 Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes (seep. 356).

B. Presence (or history) of at least one Hypomanic Episode (see p. 368).

C. There has never been a Manic Episode (see p. 362) or a Mixed Episode (see p. 365).

D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify current or most recent episode:

Hypomanic:  if currently (or most recently) in a Hypomanic Episode (see p. 362)

Depressed:  if currently (or most recently) in a Major Depressive Episode (see p. 356)

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a Hypomanic or Major Depressive Episode, specify the current clinical status of the Bipolar II Disorder and/or features of the most recent Major Depressive Episode (only if it is the most recent type of mood episode):

In Partial Remission, In Full Remission (see p. 414)     Note: Fifth-digit codes specified on p. 413 cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic (see p. 417)

With Catatonic Features (p. 417)

With Melancholic Features (see p. 419)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 242)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425)

With Rapid Cycling (see p. 427)

Diagnostic criteria for 301.13 Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 368) and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.     Note: In children and adolescents, the duration must be at least 1 year.

B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

C. No Major Depressive Episode (p. 356), Manic Episode (p. 362), or Mixed Episode (see p. 365) has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorders may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

E. 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).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

Major Depressive Disorder is one of the most common diagnoses given in the mental health field, almost 15 million adults at a time in the US, according to NIHM. The DSM-IV-TR says that it occurs equally throughout ethnicities, education and income strata, and for married and unmarried people. It does not occur equally by gender, however, with something like three times as many women as men carrying the diagnosis. It’s also not spread equally by nationality. Here’s a Wikipedia map of the distribution. The red countries have twice as much Major Depressive Disorder:

Here are the diagnostic criteria for Major Depressive Disorder, first Single Episode then Recurrent, word for word quoted from the DSM-IV-TR, pages 375 and 376. Note that most of the diagnostic action happens in the criteria for Major Depressive Episode, not Major Depressive Disorder. Also, it is interesting (and frustrating, in my case) that most prescribers and a great many diagnosticians use Major Depressive Episode’s criteria A and B, but disregard criteria C, D and E. That is, the symptom lists are considered important but the disqualification by environmental and historical factors are not.

Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode

A.      Presence of a single Major Depressive Episode (see p. 356)

B.      The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.3x Major Depressive Disorder, Recurrent

A.      Presence of two or more Major Depressive Episodes (see p. 356)

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B.      The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizzophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

These “Mood Episodes” are the building blocks for the DSM‘s major “Mood Disorders”: Major Depressive Disorder, Bipolar I Disorder, and Bipolar II Disorder. That is, the experiences described below are necessary but not necessarily sufficient to get you one of the big Mood Disorder diagnoses. Please do not use this post to diagnose yourself or anyone else you know. (Read my disclaimer here.)

These are word-for-word from the DSM-IV-TR, page 356 for Major Depressive Episode, page 362 for Manic Episode, page 365 for Mixed Episode, and page 368 for Hypomanic Episode.

Criteria for a Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1)    depressed mood most of the day, nearly every day, as indicated by either subsjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2)    markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3)    significant weight loss when not dieting or weight gain (e.g., a  change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4)    insomnia or hypersomnia nearly every day

(5)    psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6)    fatigue or loss of energy nearly every day

(7)    feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8)    diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9)    recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B.      The symptoms do not meet criteria for a  Mixed Episode (see p. 365).

C.      The symptoms are not due to the direct distress or impairment in social, occupational, or other important areas of functioning

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

E.       The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for a Manic Episode

A.      A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration of hospitalization is necessary).

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention to easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The symptoms do not meet criteria for a Mixed Episode (see p. 365)

D.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

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

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Mixed Episode

A.      The criteria are met both for a Manic Episode (see p. 362) and for a Major Depressive Episode (see p. 365) (except for duration) nearly every day during at least a 1-week period.

B.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others., or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

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

Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Hypomanic Episode

A.      A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four of the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The episode is associated with an  unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D.      The disturbance in mood and the change in functioning are observable by others.

E.       The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

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

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

The Diagnostic and Statistical Manual of Mental Disorders is a giant catalog of behaviors and other complaints that cause people to suffer psychologically. If a person claims or admits to having a constellation of problems which fits one of the categories in the DSM, they can be diagnosed with that Mental Disorder. Most people who make these diagnoses as part of their living take this process very seriously, distinguishing between subtypes of ADHD in a client with the same seriousness as a doctor distinguishing between subtypes of breast cancer in a patient. This book has the answers. It is like the Bible for mental health diagnosticians.

Every decade or so, we get a new version of our Bible. Here are the six versions we’ve had since 1958.

We are about to get a new version this spring. This change-over is both exciting and awkward in a way that I don’t imagine new versions of other Bibles can be. When a new version of the Christian Bible come out, I imagine that the impact is mostly academic, and the new version may or may not catch on. With a new DSM, there is no choice for diagnosticians or their clients. In 1973, you could diagnose someone with Homosexuality Disorder. In 1975, you could not. The debate was over.

More often than disappearing, new disorders become available. Asperger’s Disorder, for example, appeared in version IV, in 1994. At other times the categories change in big ways, such as the much-talked-about removal of Asperger’s Disorder in the upcoming version V in favor of a more inclusive “Autism Spectrum.”

The awkwardness of this process is especially salient to me, just starting my internship as a family therapist. Since I live in California, I must do my 3,000 client-contact hours for licensure at a community clinic, which means I have to diagnose each of my clients with a qualifying Mental Disorder. To that end, I have been boning up on my diagnostic criteria in the DSM-IV-TR. I have to be really good at this to get the resources flowing for my clients. At the same time, I am aware that in a matter of weeks I will be learning not only new criteria and new Mental Disorders, but a whole new diagnostic process spelled out in the DSM-V.

I resumed heart-rate training this fall, after several years of recovering from a back injury. I wrote this summary of heart-rate information in part to remind myself of the major concepts:

Your resting heart rate is as slow as your heart naturally beats. Measure it right when you wake up, still lying in bed. My resting heart rate is about 50 beats per minute. This number increases with age and can decrease if you get more fit. If you are working out it’s good to measure your resting heart rate every morning, because if it jumps by 10% or more it’s a sign that you may have overdone it in yesterday’s workout. For example, I overdid it last Friday and my resting heart rate was 61. I took the day off.

Your heart beats faster as you get more active, of course, to serve your more active muscles. My heart rate gets to 60 or so just sitting, and 70 or so walking around.

Your maximum heart rate is the fastest your heart naturally beats. This number comes down as you age. Measure it by working out really really hard with a heart rate monitor on and seeing how high you can get it. Alternatively, if you are not in good enough shape to really push it yet, you can calculate a theoretical maximum heart rate by subtracting your age from 220 if you’re male or 226 if you’re female. There is some controversy about the accuracy of this equation, but I looked into it and the controversy looks like hair-splitting to me. The main thing to keep in mind is that if you calculate a theoretical maximum heart rate, it is not your actual maximum heart rate. My theoretical maximum heart rate at 41 is 179 beats per minute, which I hit during the aforementioned Friday workout, but the highest I’d seen it go before that this year was 165.

You can see that your range of heart rates you can narrows as you age, from the bottom and the top. I wonder if measuring your range of heart rates would be a good way to measure your biological versus chronological age, the way focal length is.

Heart rate recovery: One way to measure how in shape you are is to check how fast your heart rate descends once you’ve got it up by exercising. (Some do use this measurement as a real-versus chronological age indicator.) Just get it up pretty high, stop exercising, and see what it gets down to in one minute. My heart rate comes down about 40 beats in a minute, which is considered good.

Training zones: Exercises that cause your heart to beat at different rates have different physiological effects on your body:

Between 60 and 70% of your maximum heart rate is a mild aerobic “zone,” which increases your number of mitochondria, your capillary network density, and your efficient use of energy. According to the system I use (laid out in the book SERIOUS Training for Endurance Athletes), about 80% of your training hours are done in this zone. For me, it is between 108 and 125 beats per minute, which I experience as real exercise (I can’t get to it by walking, even very quickly) but pretty easy. I can follow the narrative of a podcast with no problem, for example, and in university I read many of my journal articles on an elliptical machine in this zone. (While I’ll give you my experience of these zones, keep in mind that you cannot use your subjective experience to judge your heart rate. Even the pros have to measure it.)

The rest of my training hours are divided in different ways between three other zones, depending on where I am in my year. Early on is mostly in the first zone and I gradually add in more of the other three.

The first of those is between 71 and 75% of maximum heart rate, and is a more intense aerobic zone than 60-70%, and has similar physiological effects, increasing endurance. I experience it as a sustainable pace, but not easy. I can no longer read and have more trouble following any narrative.

The second is between 81 and 90% of maximum heart rate, and is quite intense, used for short periods, like in sprints or interval training. That’s 144-161 beats per minute for me. I have trouble keeping it up for more than a few minutes. One thing that this kind of exercise does is essentially teach your fast-twitch muscle fibers to burn oxygen better, which lets them last longer. Exercise in this zone is called “anaerobic threshold training,” because it is the zone just before you hit the point that your heart and lungs really can’t keep up with your muscles. Staying in this zone can increase the heart rate at which you “go anaerobic,” or largely stop burning oxygen.

The third is the “anaerobic zone,” between 91 and 100%, which feels like all-out effort. Your heart and lungs can’t keep up the oxygen supply and can’t take the lactic acid away from the muscles quick enough. Your arms and legs get rubbery feeling pretty quickly. Training here is exhausting but can increase your speed and coordination.

I am now working at Morongo Basin Mental Health, as a therapist for their Military Services and Family Support Program in Twentynine Palms. It’s a cool program, offering free and confidential individual, couple, and family therapy for active duty or recently retired military personnel and their families–basically anyone with a military ID.

I had no idea that this kind of thing was going on. It’s fully funded (by San Bernardino County, I believe) so that cost is no bar to getting help for military families, who can sometimes struggle financially. And it’s fully confidential, unlike the mental health services on base. There is a widespread and not necessarily irrational belief among service members that seeking support is not good for your career.

I’m happy to be part of this program. (And it’s a trip to be working down the street from my alma mater, 29 Palms Jr. High!) The only downside is that MSFSP is severely underused right now. We could be helping several times the number of people we are now. If you are in the Morongo Basin, please spread the word!

Morongo Basin Mental Health Services

Military Services and Family Support Program

5910 Adobe Road, Suite A

Twentynine Palms, CA 92277

(760) 361-7124

Congratulations on winning a second term. I was really pulling for you. I even gave money to your campaign, breaking a lifelong rule. I used to think that the person in the presidency did not make a big difference, but that has changed a lot since your predecessor’s term. I appreciate how well you speak, that you lean a bit left, that you can take and synthesize multiple perspectives, and that I have been at worst less embarrassed and at best quite proud of you as our representative to the world. Thank you.

That said, I am painfully aware how little my vote communicates what I actually think and care about to you and the rest of the world. You, your opponent, your parties, and the media do not talk about it, and I understand why. A small-time blogger can say this stuff in public, but not a viable candidate for the presidency. Still, I thought it better to tell you than not.

As a preface, I’d like you to know that I am a data-analysis and outcomes kind of guy. I couldn’t care less about the size of government, tax rates, or the continued existence of any particular government institutions as long as we get the right outcomes. At the same time, this is not a utopian vision, some infinitely good future which justifies any means. I believe that both narrow, status-quo or partisan thinking, and utopia-through-destruction thinking are naive and inefficient.

Economics

I want the elimination of negative externalities from our economy. Markets do a lot of great things, but they cannot accurately value or even see many of the social and environmental costs of their behavior. It is important to me that people and planet get treated in ethical, sustainable ways, especially when those ways are less efficient and profitable than pure market behavior.

It seems to me, for example, that government has to be the one to set accurate discount rates for non-immediate events, like the value in the future of doing something today about climate change.

One way to accomplish that (and a lot of other good things) is shift our tax revenues completely away from income and profit and largely onto externalities like pollution. Just make sure to jigger it some way to make it progressive.

Some consequences for the behavior that caused the recent crash. I’m a rare agnostic on the morality of your bailouts but I’m bummed about how little teeth came with the money. The argument that regulation is bad for the financial industry is completely hollow from people who had to get bailed out by taxpayers and show no consciousness of having personally played a part in the problem. I want one of the following to happen: Either there was a bunch of illegal activity and bunch people should go to jail, or things that they did should become illegal. That might look like resurrecting Glass-Steagall and/or expanding monopoly laws to make too-big-to-fail equal to a monopoly worth busting.

Environment

I want a massive, worldwide conservation effort. Any old growth forest, wilderness and wetlands that remain to us should be sacrosanct. Wherever we have the leverage, I want reforestation and habitat restoration projects. For a good example, look at what John and Margaret Jones are doing in Camp Myrtlewood, Oregon, implementing a multi-century plan to steward the land to old growth forest. You can think of it as a long term carbon sequestration, or you can think of it as a way to increase our resilience through biodiversity during the kinds of large-scale catastrophic events that hit us over thousand-plus year periods. But it is also just the right way to live in relation to our ecology: respectful, with a long-term view.

Solve the engineering problems we have with nuclear fusion. NASA and our other groups of super smart physicists and engineers can go back to their pet projects once they have figured out how to power it all with perfectly clean energy.

In the meantime, efficiency. Put Amory Lovins in charge of efficiency in the US and take it all the way. It’s embarrassing that we are excited about new cars that get gas mileage in the same range that my old 1970s Honda Civic got.

Social

In health care, focus on preventative care, research on prevention, and epidemiology. I’d love for us to be able to cure all of the big diseases, but what I’d love even more is preventing them in the first place. The money is in pills or surgeries for people who have developed emergency-level conditions. The money should be in keeping people from developing those conditions in the first place. 

The elimination of child abuse and neglect. The research has been done and we know what we need to know to largely eliminate child abuse and neglect. This would increase the quality of life for so many of us who are currently children, with a multiplier effect for all generations to come. It would reduce our tome of mental disorders back to the size of a pamphlet. The pilot program for this effort is 90by30, in Lane County, Oregon.

The real availability of education to women, worldwide. This isn’t just a humanitarian issue. It’s an issue of global development, peace, and stability.

If taxpayers pay for research, we should get the data. All of it. For free. As it stands, we don’t even get free access to the journal-articles that are published to summarize it.

Political

Real campaign finance reform, along the lines of Lawrence Lessig‘s $50 tax voucher plus $100 per person, period. Amend the constitution. The current system of campaign finance reduces politicians to extortionists and hobbles their long term thinking and statesmanship, and it is not working.

Not that I need to tell you that, Mr. President. Or maybe any of this–maybe you think about all of this and just don’t see the movement that will allow you to talk about it. I just wanted to let you know that I’m part of the movement and willing to go public about it.

Thanks for reading,

Nathen Lester