{"id":40172,"date":"2013-09-21T11:49:49","date_gmt":"2013-09-21T15:49:49","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=40172"},"modified":"2013-09-22T00:48:28","modified_gmt":"2013-09-22T04:48:28","slug":"in-this-case","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/09\/21\/in-this-case\/","title":{"rendered":"in this case…"},"content":{"rendered":"\n
Remember the DSM-5? the controversy over removing the Bereavement Exclusion? <\/div>\n
\n
Grief, Depression, and the DSM-5<\/a><\/div>\n
by Zisook S, Pies R, and Iglewicz A.<\/div>\n
Journal of Psychiatric Practice<\/font><\/strong>. 2013 19:386-396.<\/div>\n

<\/p>\n

Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a somewhat arbitrary 2-month period of time, the DSM-5 Task Force recommended eliminating the "bereavement exclusion" [BE] from the diagnosis of major depressive disorder. This article reviews the initial rationale for creating a BE in DSM-III, reasons for not carrying the BE into DSM-5, and sources of continued controversy. The authors argue that removing the BE does not "medicalize" or "pathologize" grief, "stigmatize" bereaved persons, imply that grief morphs into depression after 2 weeks, place any time limit on grieving, or imply that antidepressant medications should be prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from major depressive disorder deserves and allows the clinician to provide appropriate education, support, hope, care, and treatment.<\/div>\n<\/blockquote>\n
the article ends with: <\/div>\n
\n
Moving Forward<\/font><\/strong><\/u><\/div>\n
After the death of a loved one, grief almost always occurs, often accompanied by sadness, loneliness, and other features of dysphoria. Acute grief is a difficult, emotionally taxing process that often lasts much longer than 2 months, whether or not there is a co- occurring MDD. And, like other very stressful life events, the death of a loved one may precipitate a full MDE in a vulnerable person. When this happens, the MDE generally appears soon after the loss as an unwelcome companion to the bereaved’s grief. The individual then faces the double burden of grief and MDE. The major rationale for removing the BE was to remove a roadblock to diagnosing MDD, a serious, highly recurrent, potentially fatal disorder, regardless of its apparent cause or precipitant.  <\/font><\/strong>Diagnosing MDD does not “medicalize” or “pathologize” grief, nor does it “stigmatize” the bereaved person, imply that grief morphs into depression after 2 weeks, or place a time limit on grieving. Nor does diagnosing MDD in the context of bereavement imply that antidepressant medication should be immediately prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from MDD deserves, and it allows the clinician to provide appropriate education, support, hope, care, and treatment. We recognize that clinical judgment — even when guided by the most “evidence-based” diagnostic criteria — is not infallible, and mistakes will be made. But we believe that the risks to the patient of “missing” MDD are far greater than the risks of being given a diagnosis of MDD and drawn into the mental health treatment milieu, even if the diagnosis ultimately proves to be “wrong” over the ensuing weeks.<\/font><\/strong> It is time for proponents of both sides of the BE argument to collaborate in learning more about grief and MDD — their commonalities and their differences — so that we may better serve those in need.<\/div>\n<\/blockquote>\n
What was all of that about – that endless debate about the Bereavement Exclusion? Was it a discussion about something that mattered? or a battleground for some other issue? In retrospect, does the march of the DSM manuals mean anything at all?<\/div>\n

<\/p>\n

The relationship between depression, loss, and grief has long been noted and a source of some of the more important theorizing about the human condition and relationships. A general assumption is that what we call grief is the expected human response to a loss of some kind, most intense when the loss involves someone of personal importance. The psychoanalysts postulated that grief and depression were intimately related, the latter being the result of a loss in fantasy rather than fact. Other psychological theories about grief pointed to its usual course, and looked on the fact that some people developed protracted symptoms as a disruption of normal processes. Cognitive theorists, noting that depressed people have a particular type of cognition, applied learning and behavioral techniques to the problem – a cognitive behavioral approach.<\/div>\n

There is another thread in the story of depression reaching into antiquity. There are people who become periodically depressed independent of life experiences. The classic version is melancholia which has physiological changes suggesting a physical origin. It occurs is single episodes or a recurrent form, and may be accompanied by episodes of mania – the classic Manic Depressive illness described by Emil Kraepelin often with a family history suggesting a genetic cast to the illness. Kurt Schneider proposed the terms Endogenous Depression for this group of illnesses and Reactive Depression for those related to the personality or life events.<\/p>\n

As a new trainee, I never questioned that distinction. The clinical differences were striking to me, though like many before me, I explored the history of this second group, but it never went anywhere – the depression had a life of its own. I didn’t realize that this difference was matched by a deep divide in psychiatry itself until later when the DSM-III rewrote that distinction by creating a unitary category called Major Depressive Disorder. The forces at work have been rehashed endlessly here and everywhere else in the ensuing three decades<\/em>. On the surface, the reason given was that the evidence for that distinction was weak or speculative. Not very far under the surface was the feeling that physicians should stick with matters medical, more biological. But that solution generated a new problem, identifying the whole domain of symptomatic depressed people as targets for biologic therapy – yet another topic rehashed endlessly here and everywhere else<\/em>.<\/p>\n

Personally, I only vaguely knew about the Bereavement Exclusion in Major Depressive Disorder – because MDD never made it into my understanding of depression. When I came across a case of melancholic depression, I referred the person to experts. In turn, many of them referred me cases from the other group. My concept of protracted grief was likewise unchanged by those manuals which I treated as code books rather than textbooks. So, in my case, the controversy over the Bereavement Exclusion in Major Depressive Disorder came down to the symbolic – it was one of the few places where the manuals conceded non-biological causes of mental discomfort. For others, the controversy was more concrete – based on the facts.<\/p>\n

All of that is a long introduction to my personal take of Zisook’s article above which focuses on two of his comments, comments that clarified for me why I had such a negative visceral reaction to the DSM-5 process:<\/div>\n
    \n
  • \n
    "The major rationale for removing the BE was to remove a roadblock to diagnosing MDD, a serious, highly recurrent, potentially fatal disorder, regardless of its apparent cause or precipitant."<\/font><\/strong><\/div>\n<\/li>\n
  • \n
    "But we believe that the risks to the patient of “missing” MDD are far greater than the risks of being given a diagnosis of MDD and drawn into the mental health treatment milieu, even if the diagnosis ultimately proves to be “wrong” over the ensuing weeks."<\/font><\/strong><\/div>\n<\/li>\n<\/ul>\n
    The first comment seemed fanciful on first reading. Dr. Zisook apparently thinks that practitioners see the DSM-anything as something like dogma and might withhold treatment or other measures because of something it says – confusing a code book with a papal decree. It seemed an odd comment, and an odd position to come from the APA. But the second comment drew more emotion. His "we believe<\/font><\/strong>" is way beyond something that belongs in a diagnostic manual. He apparently does think that his opinion rises to the level of dogma. Worse, he’s basing the category itself in this supposedly evidence based manual not on some consensus derived from the evidence, but on the implications of the diagnostic criteria. He’s directing clinical decisions by altering diagnostic criteria, or at least trying. And as I fumed about that, it dawned on me that that kind of manipulation underlies a lot of the DSM decisions – including the original choice to create MDD in the first place.<\/div>\n

    When I step back from all of this, I realize that the framers of the DSM-III had an agenda to remove psychoanalysis and other psychologizing from psychiatry for a variety of reasons. That goal was achieved and has long been a settled matter. But I’m now thinking that their method of reaching that goal by changing the DSM-III has had some long-lasting consequences with significant collateral damage. One example is creating a fiction, MDD, that has contributed heavily to the collusion with PHARMA, a standstill in focused depression research, and the current overmedication problems. But this article by Zisook may be another example. It assumes that the DSM defines not only mental illnesses but also directs treatment. The Bereavement Exclusion was no "roadblock." There are few people I know that worry about "’missing’ MDD." I don’t actually know many people who see MDD as a discrete entity anyway. Nor do I know any people who will "miss" it when it’s finally gone.<\/p>\n

    But it’s not his opinion that I’m decrying here, it’s the fact that he thinks that this opinion is so important that it should be encoded in a diagnostic manual. One of the major criticisms of psychiatry is elevating opinion to the level of fact. In this case, that it is a valid criticism… <\/div>\n","protected":false},"excerpt":{"rendered":"

    Remember the DSM-5? the controversy over removing the Bereavement Exclusion? Grief, Depression, and the DSM-5 by Zisook S, Pies R, and Iglewicz A. Journal of Psychiatric Practice. 2013 19:386-396. Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the […]<\/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_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-40172","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40172","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=40172"}],"version-history":[{"count":8,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40172\/revisions"}],"predecessor-version":[{"id":40185,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40172\/revisions\/40185"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=40172"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=40172"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=40172"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}