DSM Dilemma: Issue 4

The American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to much of dissonance of derision and a few applauses in May 2013. The DSM 5 has been ripped apart by the critics who claim that the DSM will lead to over-diagnosis that benefits psychiatrists and drug companies. The DSM's authors counter that the guide reflects the full extent of current knowledge, which they admit is imperfect. Cipla's DSM Dilemma endeavors to bring to light DSM-5's biggest changes and the possible impact they may have on mental health care. The fourth issue of DSM dilemma focuses on 'Is' the 'DSM V' medicalizing grief?: Elimination of exclusion of bereavement in DSM V. This is one of the most controversial topics in DSM V. Read on to learn more about the controversy and the debate on whether the inclusion will indeed medicalise grief.

The term bereavement refers to the grief reaction associated with the loss of a loved one. The mental health community has recognized the qualitative difference between depression and grief since olden times. An exclusion criterion that requires clinicians to not diagnose bereavement as major depressive episode existed ever since DSM III. The intention of the bereavement exclusion was to steer clear of misdiagnosis of individuals who are experiencing normal grief reactions to a loved one's death. The reason for inclusion of the exclusion criteria was based on clinical evidence that suggested that significant majority of subjects grieving the loss of a loved one experienced symptom relief within several weeks (6 to 10), whereas subjects suffering from depression took longer. Further, people with normal bereavement experienced significantly less suicidal ideations and feelings of guilt. Lastly, normal bereavement is signified by three primary symptoms such as depressed mood sleep disturbance, and crying, in conjunction with three secondary symptoms such as difficulty concentrating, loss of interest in television and news, and anorexia and/or weight loss.¹

Accordingly, a person grieving the loss of his loved one can be diagnosed with major depressive episode only if he/she meets DSM-III's description of severity, duration, and clinically significant distress or impairment. Otherwise, the exclusion criterion defined the experience as a normal reaction to loss. The DSM-III-R and the DSM-IV narrowed this criterion by shortening duration of grief to 2 months (previously 1 year), necessitating (previously suggesting) a diagnosis of major depression if a single exclusion symptom was present, and adding psychosis to the list of complicating symptoms.¹

The DSM-5 seeks to amend what previous editions held as a special exception in the clinical presentation of depression. The DSM-5 proposed to eliminate the bereavement exclusion criterion on the basis of clinical studies that found little distinction between bereavement and major depression, evidence that is inconsistent with earlier research into the nature of these two syndromes.¹ Another change included in DSM-5 is the proposed addition of 'adjustment disorder related to bereavement', which represents the first diagnosis to specifically recognize a form of grief as a psychiatric disorder.¹

Eliminating the bereavement exclusion will have an impact on how both bereavement and major

depression are treated. On one hand, diagnosing bereavement as depression would be pathologizing an individual's normal grief toward the death of a loved one. Conversely, it will be precarious to recognize the serious signs of major depression as a normal part of the mourning process.¹ The newsletter gives an overview of both sides of the arguments.

There have been strong objections to this new diagnosis.

First, it is argued that human grief is a ubiquitous condition in so far as death and loss are part of being human; accordingly, the emotional pain that is felt following bereavement is perceived as understandable and should not be medicalised. Second, grief is managed differently across cultures and thus it is not possible for a single diagnostic system to dictate a uniform standard of grieving that applies to all cultures. Third, grief is unlike most other psychological responses in that it is closely interwoven into religious practices, and it is inappropriate for psychiatry to infringe on these rituals. Fourth, grief is adequately described by existing anxiety and depression reactions and there is no need to identify it as a distinct construct.²

In contrast to these views, several major justifications have been put forward that defend the changes included in DSM-5.¹

First, there exists significant evidence in the form of empirical support and a meta-analysis to suggest that bereavement and depression are similar syndromes. There is evidence that both conditions are especially prevalent in young people who have past individual or familial histories of depression, poor social support systems, and poor physical health. Further, both conditions are characterized by impaired psychosocial functioning, comorbidity with other mood disorders, feelings of worthlessness, suppressed immune function, sleep disturbance, psychomotor changes, and suicidality. Second, both conditions elevate adrenal cortical activity and diminish immune system functioning, and respond to antidepressant medication. Third, bereavement is a legitimate etiological contributor to major depression. In comparison with people who suffered from major depression, bereaved participants experienced more severe symptoms of depression. Further, in comparison with people with major depression, people who were excluded from a diagnosis of major depression due to bereavement were more depressed, had more suicidality and thoughts of worthlessness. Last, when bereft people were matched to patients with depression related to another stressful life event, there was no significant difference when comparing the demographics (age, gender, level of education, work status, or marital status). Similarly, when bereavement-related depression to depression without a significantly stressful life event were compared, the only difference was that participants with bereavement were significantly older.¹

This accumulating evidence appears to disprove the argument that it is inappropriate to describe any grief reaction as a psychiatric disorder as it ignores the evidence that there is a constellation of psychological symptoms that persist in a substantial minority of bereaved people which can be treated with evidence-based interventions. ²

The argument and counterargument over appropriateness of removing the exclusion criterion for bereavement bears several implications for clinicians. On one hand, eliminating the exclusion criterion can create an ethical tension for clinicians to be accurate in diagnosis while acknowledging the importance that culture plays in a normal experience like the death of a loved one in human behavior. On the other hand is the evidence that reveals that grief reactions can be extreme, even life-threatening for the bereft individual.1 As the debate continues, it is essential for a clinician to take their decisions on the basis of clinical evidence. Hopefully, a balanced debate about these diagnostic developments that adheres to the current evidence will help clinicians recognize the distinction depression and bereavement.²