a fundamental flaw…

Posted on Saturday 18 February 2012

DSM-5 To The Barricades On Grief
Defending The Indefensible
DSM-5 in Distress: Psychology Today
by Allen Frances
February 18, 2012

The storm of opposition to DSM 5 is now focused on its silly and unnecessary proposal to medicalize grief. DSM 5 would encourage the diagnosis of ‘Major Depressive Disorder’ almost immediately after the loss of a loved one- having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the MDD label [and all too often an unnecessary and potentially harmful pill treatment]. This makes no sense. To paraphrase Voltaire, normal grief is not ‘Major’, is not ‘Depressive,’ and is not ‘Disorder.’ Grief is the normal and necessary human reaction to love and loss, not some phony disease.

All this seems perfectly clear to just about everyone in the world except the small group of people working on DSM 5. The press is now filled with scores of shocked articles stimulated by two damning editorial pieces in the Lancet and a recent prominent article in the New York Times…

It does seem like the DSM-5 Task Force is going down to the wire on grief. The documents of the day are:
Dr. John Oldham, the current president of the APA, comments:
    "When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case," he said. Dr. Oldham also made the point that in general, people who are under a lot of stress or are going through a rough period are not necessarily going to be diagnosed with depression.

    "Even if you meet the criteria for depression, it doesn’t mean that you’re going to have treatment slapped on you. It just means that maybe you’d have a conversation about it with your doctor and perhaps agree to a watchful waiting period and be alert to how things go and maybe check in a little more frequently. Nothing is automatic; there are lots of options." The bottom line, Dr. Oldham said, is "we want people to get treatment who need it."

    "What we know," Dr. Oldham said, "is that any major stress can activate significant depression in people who are at risk for it. It doesn’t make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."

My response to Dr. Oldham starts with this comment: "The bottom line, Dr. Oldham said, is ‘we want people to get treatment who need it.’" Well, that’s a laudable sentiment. Me too. The part that’s so hard for me to follow is that he and the DSM-5 Task Force seem to think that the DSM-5 is obligated to tell us that if a grieving person becomes depressed, he/she may need treatment. What psychiatrist doesn’t know that? or doctor? or mother? or son? The DSM-5 isn’t a treatment manual, it’s a diagnostic manual – not a guideline, not an algorithm, not a treatment recipe book. In fact, the whole rationale for the radical DSM-III revision was that previous versions confused diagnosis and treatment. "Depressive Neurosis" was discarded because it implied a treatment – some kind of psychotherapy. That the APA and the DSM-5 Task Force "want people to get treatment who need it" is superfluous to their task – diagnostic criteria. They can put that into their Treatment Manual. It doesn’t belong in our Diagnostic Manual.

As long as we’re parsing his words, "What we know is that any major stress can activate significant depression in people who are at risk for it." He doesn’t "know" that. If I get depressed after a severe stress, I was at risk for it? It’s a tautology – the definition contains itself. A psychoanalyst might interpret that as based on my previous life experience. A biologist might think it’s in my genes. A neuroscientist may point to my brain pathways. But all are assuming predisposition based on my reaction. Maybe. Maybe not. It’s an assumption, not something anyone "knows." For all I know, the rest of you have something wrong – too much denial, or a faulty brain pathway, or a missing gene. But I wander from my point. Back to the thread. If depression in response to a severe stress is, in fact, a particular syndrome as opposed to depression in the absence of a severe stress, the sensible thing to do would be to make that distinction in our diagnostic criteria of depression rather than remove any sign of it, or for that matter, remove "depression" as part of a normal, human process eg bereavement.

It is the Task Force itself that has "misinterpreted" its role. They think that we are asking for directions on how to approach the problems our patients bring to our offices – how and when to treat. That’s not what they’re being asked to do. Their assignment is to give us a classification that helps us make those decisions in concert with our patients, informed by everything we’ve ever learned from a wide range of experience, and what we’ve learned of the specific patient in front of us. This misinterpretation is a fundamental flaw in the current DSM-5 effort, and will likely spell its doom as they show no signs of even dawning self reflection
    February 19, 2012 | 11:32 AM

    I know of a psychiatrist who thought everyone in love was suffering from a psychosis, until he fell in love himself in his late 30s. Is it possible that some of these guys have never experienced grief, and therefore believe it is, in fact, some form of depression?

    February 20, 2012 | 5:01 PM

    I still don’t get how grief converts into major depressive disorder after 2 weeks.

    February 20, 2012 | 5:24 PM

    “I still don’t get how grief converts into major depressive disorder after 2 weeks.”

    That one’s easy. It doesn’t.

    They’re so far off base that it’s laughable. And they’re ignoring a rather well established tradition of understanding pathological grief. After the Coconut Grove fire in Boston in 1944, Lindemann followed the survivors of the people killed in the fire and characterized the “stages” of grief as we know them today [see http://www.nyu.edu/classes/gmoran/LINDEMANN.pdf]. But he had some whose grief that was prolonged. It was called pathological grief, and explained in interesting ways. An example, people who are unable to experience anger might get “stuck” in the phase of grief characterized by anger. These days, since psychiatry lost its mind, you rarely hear such things. It’s a pity, because it’s been a very useful tool for me. I can’t tell you how many times it has turned out to be true. We used to say that grieving is normal. Not grieving makes you sick. The other thing to note is that like everyone else, I’ve seen cases where I decided to try an antidepressant to “take the edge off.” It has never worked – never. Including grief greater than two weeks in with depression is like something out of a satirical comedy.

    February 21, 2012 | 1:46 PM

    Thanks for clearing that up, Dr. Mickey. I thought I missed something.

    What I glean from the DSM-5 committee’s defense is that grief is just like any other unhappiness, all unhappinesses being alike, biopsychoneurologically (??), therefore same diagnosis (and drug treatment, unstated) applies.

    They are on a grand crusade to stamp out unhappiness of any sort. Kinda reminds me of the treatment in Eternal Sunshine of the Spotless Mind: ”Technically, it is brain damage.”

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