in the range of a mandate…

Posted on Sunday 24 March 2013


Opening Pandora’s box: how DSM-5 is coming to grief
by Gordon Parker
Acta Psychiatrica Scandinavica 2013: 1–4. DOI: 10.1111/acps.12110

In mourning, it is the world which has become poor and empty; in depression it is the ego itself.
Freud

Until recently, DSM-5 architects had sought to reposition grief within the depressive disorders: a proposal generating multiple reviews and critiques, and evoking concerns about a risk of ‘pathologising’ bereavement. Friedman captured a second common ‘medicalization’ concern, whereby a diagnosis of ‘major depression’ could be made in those experiencing normal bereavement after only 2 weeks of mild depressive symptoms, and which could then lead to ‘unnecessary treatment with antidepressants and antipsychotics’. This discussion paper considers historical changes in categorizing grief within recent DSM manuals, focuses on broad parameters that differentiate grief and depression, and then considers implications to a DSM-5 website comment written by Professor Kendler, before I offer a revisionist position…

… And so Pandora’s box is further opened. Rather than drawing bereavement within the domain of the clinical depressive disorders (as DSM-5 appears still to favour), we might better lean the other way and consider whether many currently positioned clinical depressive disorders (especially the reactive depressive conditions) might fit more comfortably within a grief paradigm, and benefit more from management weighting such a model.

Many have put a reductionist view that grief is completely normative and depression is always clinical, and that any merging will ensure a wide-scale move to manage bereaved people with psychotropic medication. To be fair, DSM-5 is likely to be addressing a reality – that some bereaved individuals will develop a clinical depressive episode – and that their treatment might then involve a differing management paradigm to that for normative grief. However, the recent DSM-5 annotation or website note appears underpinned by Kendler’s observation that the DSM-IV grief exclusion criterion is ‘not logically defensible’. This essay seeks to broaden the list of logical parameters that invite consideration. In particular, it invites weighting of phenomenological distinction between grief and depression, and consideration of an alternate paradigm that allows some reactive depressive disorders to be more logically modeled and managed as ‘grief’ states.
Unfortunately, only the first page of this 2½ page article is available on the Internet, so I’ll try to summarize Parker’s points [which I’m sure will be my version of his points, since this is something I feel strongly about]. In Mourning and Melancholia [1917], Freud commented on the difference between grief and depression:
    The distinguishing mental features of melancholia are a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of the self-regarding feelings to a degree that finds utterance in self-reproaches and self-revilings, and culminates in a delusional expectation of punishment. This picture becomes a little more intelligible when we consider that, with one exception, the same traits are met with in mourning. The disturbance of self-regard is absent in mourning; but otherwise the features are the same…
    It is easy to see that this inhibition and circumscription of the ego is the expression of an exclusive devotion to mourning which leaves nothing over for other purposes or other interests. It is really only because we know so well how to explain it that this attitude does not seem to us pathological…
In a classic 1944 paper, Symptomatology and Management of Acute Grief, Erich Lindemann followed the survivors of a Boston hotel fire and defined the normative stages of grief in the survivors. He described and  characterized certain morbid or pathological grief reactions and discussed their treatment.

Gordon Parker’s article above is a response to Kenneth Kendler’s rationale for dropping the Bereavement Exclusion from the Criteria for a diagnosis of Major Depressive Disorder posted on the DSM-5 web-site [I’ll leave it up to you to review Kendler’s logic]. Parker argues that Kendler emphasizes the similarities between grief and depression. Parker, however, points to the differences:
  • Phenomenology: This comment summarizes the phenomenologic differences; "the hallmark of grief is a blend of yearning and sadness, along with thoughts, memories and images of the deceased person, while in contrast, depressed people ‘see themselves and/or the world as fundamentally flawed, inadequate or worthless.’ In essence, the psychological pain in ‘normative grief’ emerges from loss of the ‘other’ – and self-esteem is almost invariably preserved in the early stages – while the central characteristic of depressed states is compromised self-worth. The phenomenological distinction is sharp."
  • Natural History: Depressive illnesses tend to recur. He cites ample evidence to show that grief does not recur, nor does it predispose to future depressions.
  • Staging: Another summary quote, well referenced; "Staging is another important distinction. While clinical depression may be presaged by warning signs or symptoms, and it may have a slow or abrupt onset, it generally lacks the stages integral to grief."
  • Treatment Response: "Turning to treatment specificity, Shear expressed a common argument in stating that ‘depression requires treatment and grief requires reassurance and support’. The evidence base for antidepressant medication is convincing in relation to major depression – but is limited for the management of grief and often contingent on other factors, predictably including the presence or absence of a superimposed depression." If I may quote my friend who was prescribed Elavil when he was grief stricken, and I later asked him what it did for him, he replied, "It made me constipated."
I appreciate the clarity of this article. I wouldn’t have been able to parse the differences so crisply. To me, grief and depression are just different things [I think one can often distinguish them without even taking a history, though I’m not sure that such empathic communication is kosher in the DSMs].

The pandora’s box in this article is highlighted in red above. Parker suggests that many reactive depressions would fit better with grief than Major Depressive Disorder – that instead of broadening MDD, we should be moving in the other direction and limiting the use of this diagnostic category. He says this a suggestion, "Rather than drawing bereavement within the domain of the clinical depressive disorders (as DSM-5 appears still to favour), we might better lean the other way and consider whether many currently positioned clinical depressive disorders (especially the reactive depressive conditions) might fit more comfortably within a grief paradigm."

I would see this as more than a suggestion, rather something in the range of a mandate – an imperative. The removal of the Bereavement Exclusion is more than just a another goofy change to the DSM-5, it represents a bias that pervades the whole enterprise – diagnostic expansions that don’t medicalize the DSM-5, they dehumanize it…
  1.  
    wiley
    March 24, 2013 | 11:13 PM
     

    What I had that fits the description of “depression” was two raging iron deficiencies, a little over ten years apart.

    What was first diagnosed as “depression” in me was grief following a protracted case of PTSD. Loss of innocence, loss of time, loss of control, friends distancing themselves and sometimes judging, loss of the usual sense of self. If I knew then, what I know now, I would have been much more patient with myself so that I could have recovered from the plunge into the abyss and process my feelings about having done so (unwillingly and seemingly out of nowhere).

  2.  
    Bernard Carroll
    March 25, 2013 | 1:52 AM
     

    The DSMs never did lay claim to phenomenological subtlety, and the bereavement exclusion never was the exception that proved the rule. Rather it was the sad little secret that outed DSM-III Major Depressive Disorder (MDD) as a sham. The bereavement exclusion allowed the notion of process to get a foot in the door, countermanding a simple listing of symptoms as the way to understand clinical disorders.

    The DSM-5 folks are hoist on the petard of generic MDD. If the reference disorder MDD disallows considerations of process, then of course the bereavement exclusion must go. Gordon Parker’s discussion turns Kenneth Kendler’s position on its head and sensibly argues for extension of the grief model to other reactive dysphoric states.

    Looking back, one has to give a hat tip to Donald Klein’s 1974 construct of endogenomorphic depression. This construct allows for a distinctive depressive illness in the context of bereavement or of other adversities, that requires more than just a hug and a helping hand. At the same time, it does not encompass all nominal MDD episodes after bereavement or other significant losses.

    http://www.ncbi.nlm.nih.gov/pubmed/4420562

  3.  
    berit bj
    March 25, 2013 | 10:59 AM
     

    Wiley, I was thinking of your words as I watched a documentary about women who trained as Red Cross nurses and worked for the German occupier during WWII. Thousands of citizens made a living by employment with German authorities and firms in Norway. But the RC nurses were sent to the Eastern front, subjected to horrors they had no idea of, when they signed up as political ignorants and naifs at the age of 19 -20 years. In 1945 they were arrested, humiliated, judged and sentenced to prison terms, in spite of objections from the IRC, Norway the only country doing this.
    The documentary from 2012 was heartwrenching. Images of worn faces, low voices few words spoken by women who said they look forward to death, punished for nursing wounded enemy soldiers.
    “Loss of innocence, time, control, friends,” then lifelong loss of status at the hands of the victors, their own kind. The women were shadows, locked inside a place of unimaginable grief.

  4.  
    Bernard Carroll
    March 25, 2013 | 11:42 AM
     

    To continue my earlier comment, good evidence for extending the grief model to other losses was developed by Jerome Wakefield in 2007, using data from the National Comorbidity Survey. See PubMed ID #17404120 here.
    http://www.ncbi.nlm.nih.gov/pubmed/17404120

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