1 Boring Old Man

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.}

^{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…}

• 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."

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."