The American Psychiatric Association (APA) is in the process of revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the psychiatrist’s bible. Its last incarnation — known as DSM IV — was published in 1994, with a “text revision” in 2000. The new version will be DSM V.
Psychiatrist Daniel Carlat described some of the initial arguments over revisions as a bar room brawl. Now that the APA has moved the publication date forward from 2011 to 2013, the number of publically traded insults appears to have died down.
One item in dispute is whether bereavement – the grieving process that follows the loss of a loved one – might qualify a patient for the DSM label Major Depressive Episode. Many symptoms of bereavement are similar to those of depression, such as feeling sad, poor appetite, weight loss, and insomnia.
Here’s one of the APA’s needlessly obscure arguments for including bereavement.
The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.
In other words: Bereavement symptoms should be included because bereavement is a source of stress. Just as divorce, job loss, illness, and disability cause stress, so does the loss of a loved one. The assumption here is that stress can lead to depression.
Grieving is universal; Pharmas are greedy; What’s normal can be treated
This proposed change apparently hit a hot button among psychiatrists. Critics point out that grieving is a universal practice in all cultures. That’s why there are time-honored rituals to support the healing process following a death – wakes, funerals, memorials.
Other critics complain that pharmaceutical companies will convince the public to avoid grieving by taking a pill. The counter-argument to this is: Well, yes, but there’s nothing we can do about that.
Then there’s medicalization — turning a natural process such as grieving into a disease, which invites overdiagnosis, expense, harm, and stigma.
In his recent book, Unhinged, Carlat readily admits that psychiatry expands by medicalizing the problems of living. Other medical specialties expand by creating new knowledge and procedures, but psychiatry grows by bringing “existing disorders [sadness, anxiety, pre-menstrual depression] into its sphere of influence.” (Of course, other medical specialties also medicalize, e.g., childbirth and pregnancy, menopause, erectile dysfunction, short stature.)
Universal ritual, greedy pharmas, medicalization — these are all reasonable arguments against the APA’s proposed change to which I’m sympathetic. But I’ve also come across an argument in support of the APA’s position that makes sense to me.
Normal grieving vs. severe depression
in an article called “DSM5 Criteria Won’t ‘Medicalize’ Grief, if Clinicians Understand Grief,” psychiatrists Ronald Pies and Sidney Zisook discuss the “phenomenology of grief” – how it actually feels to grieve.
The authors argue that psychiatrists pay too little attention to the patient’s sense of his or her “self” – the thoughts and feelings one has while grieving. The implication is that psychiatrists normally direct their attention only to externally observable behavior — and fail to understand grief.
In ordinary or “productive” grief and bereavement, the authors write,
the individual typically maintains her emotional connection with others; believes that the grief will end some day; maintains her self-esteem; and experiences positive feelings and memories along with painful ones. Guilt, if present, is focused on “letting down” the deceased person, rather than on being “worthless” or useless. In ordinary grief, loss of pleasure is related to longing for the deceased loved one, as opposed to the pervasive anhedonia** often seen in severe depressions; and suicidal feelings are more related to longing for reunion with the deceased than to thoughts of not deserving to live. … [I]n ordinary grief, an individual is capable of being “consoled” by friends, family, music, literature, etc.
** Anhedonia refers to the inability to feel pleasure from normally pleasurable events such as eating, exercise, social interaction, and sexual activity.
This is how “normal” grieving feels. That experience is markedly different from grief that resembles severe depression:
[T]he individual tends to be extremely “self-focused”; feels outcast or alienated from friends and loved ones; has the sense that the depression will “never end”; experiences profound self-loathing and guilt; experiences few if any positive feelings or memories; and is often “inconsolable.”
Anyone with a family member who has suffered from major depression will recognize these symptoms.
The title of Pies and Zisook’s article – “If Clinicians Understand Grief” – suggests that not all psychiatrists will be able to make the necessary distinction. It’s too subjective – “phenomenological” – for the thoroughly modern and scientific practice of psychiatry these days.
If, in assessing a patient’s grief, psychiatrists are no longer expected to consider how patients think and feel about themselves, then something very important has been lost from the art of psychiatry.
Grief and Depression: When Science and Terminology Get Confused (PsychiatricTimes)
Further discussion of this issue, which argues that the disagreement stems from confusing terminology.
But here’s in fact where things get more complicated and science seems to confuse us. The problems emerge in terminological distinctions that appear thoroughly clouded. The confusion begins with the DSMs. “Uncomplicated bereavement” in DSM-III, and “bereavement” in DSM-IV, may or may not reach the level of MDD [major depressive disorder]. The instruction from DSM-IV is, in its contorted language, not to diagnose the bereaved person with major depression if the MDD symptoms are mild, even though meeting criteria of a major depressive episode, but to diagnose MDD if the symptoms are severe.
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Daniel Carlat, DSM-5’s Rough Draft: The Carlat Take, The Carlat Psychiatry Blog, February 11, 2010
Ronald Pies, MD, and Sidney Zisook, MD, DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief, Psychiatric Times, February 16, 2010
Sidney Zisook, Katherine Shear, And Kenneth S Kendler, Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode, World Psychiatry, June 2007 6 (2), pp 102-107