{"id":34549,"date":"2013-03-26T13:05:08","date_gmt":"2013-03-26T17:05:08","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=34549"},"modified":"2013-03-26T13:15:08","modified_gmt":"2013-03-26T17:15:08","slug":"the-rabbit-hole","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/03\/26\/the-rabbit-hole\/","title":{"rendered":"the rabbit hole&#8230;"},"content":{"rendered":"\n<div align=\"justify\">There&#8217;s a thread here that deserves to be tied together. The topic is the Bereavement Exclusion that the DSM-5 Task Force removed from the diagnosis of Major Depressive Disorder [DSM-IV]:<\/div>\n<div align=\"justify\">\n<ul>\n<div><sup><strong>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.<\/strong><\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\">It&#8217;s a peculiar deletion&nbsp; because the stated clinical reason for removing it makes little sense &#8211;  something like reminding clinicians that for some, Bereavement triggers a  Major Depression. So why not just say that? Since when is a Diagnosis a  post-it note reminder, as if we wouldn&#8217;t notice a Major Depression? Kenneth Kendler, speaking for the Task Force <a href=\"http:\/\/www.dsm5.org\/about\/Documents\/grief%20exclusion_Kendler.pdf\" target=\"_blank\">adds<\/a>:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>&#8230; a broad range of evidence agreed to by both sides of this debate show s that there are little to no systematic differences between individuals who develop a major depression in response to bereavement and in response to other severe stressors&#8230; Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable.<\/strong><\/sup><\/div>\n<\/ul>\n<div>He&#8217;s referring to research by Jerome Wakefield et al from 2007:<\/div>\n<blockquote>\n<div align=\"center\"><a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17404120\">Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey.<\/a><br \/>                           <sup><strong>by Wakefield JC, Schmitz MF, First MB, and Horwitz AV<\/strong><\/sup><br \/>                           <strong><font color=\"#200020\">Archives of General Psychiatry<\/font><\/strong>. 2007 64[4]:433-40.<\/div>\n<p>                           <\/p>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">CONTEXT<\/font><\/u>:  Symptoms  of intense bereavement-related sadness may resemble those of  major  depressive disorder [MDD] but may not indicate a mental disorder.  To  avert false-positive diagnoses, DSM criteria for MDD exclude   uncomplicated bereavement of brief duration and modest severity.   However, the DSM does not similarly exempt depressive reactions to other   losses, even when they are uncomplicated in duration and severity.<\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">OBJECTIVE<\/font><\/u>:  To  test the validity of the DSM exclusion of uncomplicated depressive   symptoms only in response to bereavement but not in response to other   losses. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">DESIGN<\/font><\/u>: Community-based epidemiological study <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">PARTICIPANTS<\/font><\/u>:  From  the National Comorbidity Survey [NCS] of 8098 persons aged 15 to  54  years representative of the US population, we identified individuals  who  met MDD symptom criteria and whose MDD episodes were triggered by   either bereavement [n = 157] or other loss [n = 710].  <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">INTERVENTION<\/font><\/u>:  We  divided the bereavement and other loss trigger groups into  uncomplicated  and complicated cases by applying the NCS algorithm for  uncomplicated  bereavement to the reactions to other losses. We then  compared  uncomplicated bereavement and uncomplicated reactions to other  losses on  a variety of disorder indicators and symptoms. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">MAIN OUTCOME MEASURES<\/font><\/u>:  Nine  disorder indicators, as follows: number of symptoms, melancholic   depression, suicide attempt, duration of symptoms, interference with   life, recurrence, and 3 service use variables. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">RESULTS<\/font><\/u>:  Episodes  of uncomplicated depression triggered by bereavement and by  other loss  have similar symptom profiles and are not significantly  different for 8  of 9 disorder indicators. Moreover, uncomplicated  reactions, whether  triggered by bereavement or other loss, are  significantly lower than  complicated reactions on almost all disorder  indicators <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u><font color=\"#200020\">CONCLUSION<\/font><\/u>:  The  NCS data do not support the validity of uniquely excluding   uncomplicated bereavement but not uncomplicated reactions to other   losses from MDD diagnosis. <\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">however, Wakefield positioned himself on the other side of the debate:<\/div>\n<blockquote>\n<div align=\"center\"><a target=\"_blank\" href=\"http:\/\/www.psychweekly.com\/aspx\/article\/articledetail.aspx?articleid=1538\">After Removal from DSM-5, Why Clinicians Should Remember the Bereavement Exclusion<\/a><br \/>             <sup><strong>by Jerome C. Wakefield, PhD, DSW<\/strong><\/sup> <br \/>             <strong><font color=\"#200020\">Psychiatry Weekly<\/font><\/strong>. 8[4] February 18, 2013<br \/>             [<a href=\"http:\/\/www.psychweekly.com\/aspx\/article\/articledetail.aspx?articleid=1538\" target=\"_blank\">full text online<\/a>]<\/div>\n<div align=\"justify\"><sup><strong>           <\/p>\n<p>After  undergoing its first major overhaul in nearly 20 years, the fifth  edition of the American Psychiatric Association&rsquo;s Diagnostic and  Statistical Manual of Mental Disorders (DSM-5) is slated for a May 2013  release. Of the many changes in DSM-5, one of the most controversial is  the  removal of the DSM-IV&rsquo;s &ldquo;bereavement exclusion&rdquo; (BE) to major  depressive  disorder (MDD), which allows clinicians to defer making a  clinical  diagnosis of MDD when certain depressive symptoms occur within  the  context of recent bereavement and do not last more than 2 months.  Under  this exception, such an episode is classified as a &ldquo;V-code,&rdquo;  signifying  the absence of mental illness&#8230;<\/p>\n<p>Dr.  Wakefield&rsquo;s research indicates that the BE&rsquo;s rules have much to   recommend them. He finds that uncomplicated bereavement-related&mdash;or other   stressor-related&mdash;depressive syndromes generally have markedly lower   levels of pathological features than complicated or endogenous\/psychotic   depressions.1,2 Also, uncomplicated depressions do not recur  like  other depressions; persons who experience a single episode of   uncomplicated bereavement-related depression are no more likely to have a   recurring depressive episode by 3-year follow-up than persons with no   lifetime history of depression.<\/p>\n<div>&ldquo;In light of solid evidence  that uncomplicated bereavement-related  depression is similar to  uncomplicated reactions to other stressors,  I and other researchers  suggested expanding the BE in DSM-5 to apply to  uncomplicated  stressor-related depressions generally,&rdquo; says Dr.  Wakefield. &ldquo;However,  extension of the BE was rejected out of hand.  Instead, based on the  similarity evidence, the DSM-5 Mood Disorders  Work Group argued that  bereavement is not special, so the BE should be  eliminated. This latter  argument ultimately won the day&rdquo;&#8230;<\/div>\n<p><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">This more properly frames the recent <a href=\"http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/acps.12110\/abstract\" target=\"_blank\">paper<\/a> by Gordon Parker [see <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/03\/24\/in-the-range-of-a-mandate\/\" target=\"_blank\">in the range of a mandate&hellip;<\/a>]. After discussing the significant qualitative differences between grief and depression [phenomenology, natural course, staging, and treatment response], Parker argues:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>&hellip; And so Pandora&rsquo;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.<\/strong><\/sup><\/div>\n<p>      <\/p>\n<div align=\"justify\"><sup><strong>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 &ndash; that some bereaved individuals will develop a  clinical depressive episode &ndash; 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&rsquo;s observation  that the DSM-IV grief exclusion criterion is  &lsquo;not logically defensible&rsquo;. 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 &lsquo;grief&rsquo;  states.<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">In the comments, Bernard Carroll elaborates <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2013\/03\/24\/in-the-range-of-a-mandate\/#comment-239116\">further<\/a> on  that theme:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>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&rsquo;s discussion  turns Kenneth  Kendler&rsquo;s position on its head and sensibly argues for  extension of  the grief model to other reactive dysphoric states.<\/strong><\/sup><\/div>\n<\/ul>\n<p>And just as a reminder, here&#8217;s one more reference for the road:<\/p>\n<table width=\"95%\" cellspacing=\"0\" cellpadding=\"2\" border=\"0\" align=\"center\">\n<tr>\n<td align=\"center\"><a target=\"_blank\" href=\"http:\/\/www.psychiatryonline.com\/DSMPDF\/dsm-ii.pdf\">DSM II<\/a><strong><font color=\"#200020\">&nbsp; [1968]<\/font><\/strong>                      <\/p>\n<hr size=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td>\n<div align=\"justify\"><strong><font color=\"#200020\">300.4 Depressive neurosis<\/font><\/strong><\/div>\n<div align=\"justify\"><sup>This  disorder is manifested by an excessive reaction of depression due to an  internal conflict or to an identifiable event such as the loss of a  love object or cherished possession. It is to be distinguished from  Involutional melancholia and Manic-depressive illness. Reactive  depressions or Depressive reactions are to be classified here.<\/sup><\/div>\n<\/td>\n<\/tr>\n<\/table>\n<p align=\"justify\">So the debate about removing the Bereavement Exclusion is more fundamental than just the issue of pathologizing normality [which is in itself pretty important]. It also reopens the problem created when the various depressive diagnoses were inappropriately lumped as Major Depressive Disorder in 1980 for the DSM-III. I&#8217;ll skip over the stated reasons as I don&#8217;t believe they were central [see <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2012\/05\/28\/a-mistake\/\">a mistake&hellip;<\/a>, <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2012\/05\/28\/23879\/\">further thoughts on the mistake&hellip;<\/a>, <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2012\/05\/29\/yet-another-mistake\/\">yet another mistake&hellip;<\/a>]. There seemed to be two related agendas in that change: removing psychoanalytic formulations from psychiatry and convincing third party carriers that we were scientists treating <em>medical<\/em> diseases, not life problems. Both were successful. The collateral damage was removing Melancholia &#8211; the classic psychiatric disease that was a major target for biological research. An unintended consequence was creating a mythical disorder [MDD] that became prime real estate for the pharmaceutical industry, corrupted science, and rampant overmedication. Another consequence was moving most practicing psychiatrists to the role of medication managers.<\/p>\n<div align=\"justify\"><img decoding=\"async\" hspace=\"2\" height=\"195\" border=\"0\" align=\"left\" src=\"http:\/\/1boringoldman.com\/images\/alice.gif\" \/>I suppose one could see this issue of reactive depressions as an&nbsp; inconvenient truth that has haunted psychiatry throughout the last  three decades. The Bereavement Exclusion is a portal like the rabbit hole in Alice in Wonderland that leads to a place where the current frame of reference no longer makes any sense, and calls for &quot;<em>consideration of an alternate paradigm that allows some reactive   depressive disorders to be more logically modeled and managed as &lsquo;grief&rsquo;   states.<\/em>&quot; Eliminating the Bereavement Exclusion from the code book hasn&#8217;t succeeded in maintaining the status quo so far, nor is it likely to after the book is released in a couple of months. In fact, though the DSM-5 Task Force set out to effect a paradigm shift to a biological diagnostic system, it looks as if the only shift they&#8217;ve created is a shift away from the DSM-5 itself as the diagnostic standard&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>There&#8217;s a thread here that deserves to be tied together. The topic is the Bereavement Exclusion that the DSM-5 Task Force removed from the diagnosis of Major Depressive Disorder [DSM-IV]: 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 [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-34549","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34549","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=34549"}],"version-history":[{"count":36,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34549\/revisions"}],"predecessor-version":[{"id":34586,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34549\/revisions\/34586"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=34549"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=34549"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=34549"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}