DSM 5 bereavement exclusion

[blastoise]

Hey everyone,

I finished my psychiatry rotation a few weeks ago and something that my attending was often applauding about the DSM-5 was the bereavement exclusion in the MDD diagnosis. I wanted to know if this opinion is consistent across the psychiatry field, as it didn't make too much sense to me.

I'm not exactly interested in psychiatry as a specialty but my naive and minimally experienced opinion seems to be that any form of grieving can then be diagnosed as clinical depression as it no longer has to extend beyond 2 months. Will this not nurture a society where any regular emotional presentation can be labeled as a pathology/disorder?

I apologize if this was discussed in detail earlier or if my thoughts are very off, I would like to learn what you guys think. Thanks!

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[eli20]

Might be interested in the reasoning behind it here:

http://www.dsm5.org/Documents/Bereavement Exclusion Fact Sheet.pdf

 

[F0nzie]

Try not to take DSM criteria too literally. The art of diagnosis comes with taking a good history and putting it into the context of the patient's experience, present status, and background. If you simply check all the boxes, you're casting a wide net and practicing like an idiot. The future of medicine.

 

[hamstergang]

my naive and minimally experienced opinion seems to be that any form of grieving can then be diagnosed as clinical depression

First, from eli20's link, this was always my biggest issue with the bereavement exclusion: "Research and clinical evidence have demonstrated that, for some people, the death of a loved one can precipitate major depression, as can other stressors, like losing a job or being a victim of a physical assault or a major disaster. However, unlike those stressors, bereavement is the only life event and stressor specifically excluded from a diagnosis of major depression in DSM-IV."
Why should bereavement be singled out? Should we not consider someone to have MDD if we can identify the stressor? That seems more arbitrary and not very reasonable.

Second, this doesn't mean that "any form of grieving can then be diagnosed as clinical depression." There are still criteria for MDD that have to be met -- simply being sad that someone died isn't enough to meet the criteria. If someone is so affected and impaired that they meet the criteria for MDD, then I don't know why you'd want to withhold the diagnosis and consequently treatment (which may or may not include medications; don't forget psychotherapy!). Also, it's important not to read the criteria in the DSM too concretely, as Fonzie warns. If you do that, you'll think that we're diagnosing some ridiculous things that we really aren't.

 

[splik]

One thing to bear in mind is psychiatrists dont tend to pay much attention to the DSM and even when there was DSM-Iv psychiatrists would diagnose MDD even following bereavement. This is a fascinating discussion and we have discussed this before on the forum. Some people like Ken Kendler and Sid Zisook have argued that pathological grief had been ignored and some of this was akin to MDD or in more complicated bereavement, PTSD. Others, like Alan Horowitz who wrote The Loss of Sadness have argued for the the bereavement exclusion to be expanded to all loss events; that there was something distinct about depressive illness or melancholia that occured out of the blue, with not clear external cause, versus reaction to loss events, and that the failure to distinguish between the two was pathologising normal sadness and ruining our ability to understand and treatment a distinct medical illness. There is a long-persisting argument as to whether antidepressants may be more helpful in people who's depression is non-reactive, vs. related to life events, and some people, like Gordon Parker, have argued the reason why antidepressants fare so poorly in clinical trials is because of this failure to distinguish people who have a depressive illness responsive to medication, vs a response to life events. There is evidence and convincing argument on both side. I think it is important that psychiatrists avoid diagnostic creep, and there is a perception that we pathologize everything that moves. That has been a big criticism of DSM. While it is true that there are a number of more dubious psychiatric diagnoses, and the criteria are sometimes too lax for some of these constructs, I do think that it is important to recognize that grief reactions have significant consequences on physical and mental health, and there is a difference between a normal and pathological grief reaction. Freud was one of the first to comparing mourning with melancholia and distinguished between them. Even Freud argued that there appeared to be a biological basis to melancholia, and some of his analytic insights I do find relevant to some patients presenting with pathological grief reactions.

Here is the table I use in my teaching on the topic for residents:

 

[HarryMTieboutMD]

This is a good question and actually one of the (many) difficult issues we face in psychiatry- and I'm glad that as a med student you are asking. And for once I agree with Splik. Basically, anyone can ask checklist DSM questions in a non diagnostic manner and say "this person is depressed" (this is what non psychiatrist MDs, midlevels, and social workers do- sorry I have no filter). I find Freud largely useless for inpatient psychiatry, but Mourning and Melancholia is actually a very important read and clinically useful. The question I constantly have in the back of my mind is, "can I characterize this patient has entering into a fully fledged, debilitating EPISODE of major depression, with, as Splik highlights, emotional reactivity, psychomotor movement, ability to function, and tendency to suicide being key points from history and exam. I think "depressed mood" or "low mood" as it relates to expected sadness vs true melancholia must be investigated more than simply asking "do you feel down or depressed most of the day every day?" If that patient says something to the effect of "the weight of the world is on my shoulders" or "I'm numb to everything" that points more toward a melancholic state than one of mourning (I just feel sad).

 

[smalltownpsych]

We should be cautious about prescribing treatments for depressed mood that is the result of a significant loss. Our society has a tough time with sadness. The Wall Street Journal had a nice little article about the myth of "closure" written by an oncologist. My experience with patients is that death and loss and the experience of it is dependent on many variables, but almost invariably they have internalized erroneous beliefs from these types of myths and messages from society. Normalize don't pathologize should be the first response to a patient who has experienced a significant or traumatic loss. Also, although there is a consensus that the stages of grief by Kubla-Ross are not useful if applied rigidly which led to many professionals discounting them altogether, patients can still benefit from using them as a means to help them understand the conflicting and contradictory emotions and thoughts that they are having.

 

[MacDonaldTriad]

The best psychiatrists do use diagnostic criteria. They form an opinion about what the diagnosis is, and they have the criteria in mind. If someone doesn’t strictly meet full criteria, they may argue that it still warrants appropriate treatment that is evidenced based for that diagnosis. If they see enough target symptoms to be clear that an intervention is successful, and there is distress, we should try and help. If someone does meet full criteria, they may argue that other symptoms make the presentation so atypical; the best treatment may lie within a different diagnostic category. If you believe in check box psychiatry, you might as well be a computer algorithm. Diagnostic criteria are an obvious place for beginning students to focus and they lend themselves well to tests, but don’t forget to talk to the patient. Diagnostic evaluations are conversations, not interrogations. 🙁

 

[HarryMTieboutMD]

Another thing: If you read Mourning and Melancholia, Freud, like his nemesis Kraepelin, conceptualized Melancholia as being a spectrum illness with the potential to switch into Mania (ie, all depression is part of a bipolar spectrum illness), which would differentiate it from mourning/bereavement. Today we know that is not true (bipolar depression is a separate beast from unipolar depression), but it's helpful to think about, especially in the elderly where they can have agitated depressions that look like irritable manic/mixed states.

I personally find the 1972 Feighner Criteria to be the most helpful in distinguishing primary (ie, the distinct clinical syndrome with no antecedent psychiatric or non psychiatric illness) and secondary with distinct, antecedent illness. This does not exclude life stressors causing a depressive episode; but the clinical focus is on the gestalt of the syndrome. I also like the diagnostically agnostic tone; we are not omniscient and do not have clear and convincing proof of the causality of depression from some psychiatric/medical illnesses, just strong association.

 

[thoffen]

I like it because it provides a rationale for removal of the bereavement exclusion. Basically, the established criteria they had for the exclusion could not distinguish pathology that requires action from normalcy, so they removed it. The mistake is in thinking this implies that all people who meet criteria for a major depressive episode in this setting (or any other setting) have such an illness as objective fact.

McDonaldTriad's point about criteria is highly important. I think the need for a systematic approach that is informed from data cannot be removed from diagnostic evaluations simply because we know it is fallible.

One thing that tends to help in approaching the concern of tending to over-pathologize is to consider the "then what". People tend to immediately imagine SSRI for life instead of considering treatment approaches including psychotherapy and supportive interventions, or sometimes even "come back in a week to check in."

 

[Ibid]

Every diagnosis is a misdiagnosis.

And the moral of the story is if you decide to kill yourself make sure are successful or its just a cry for help.

 

[smalltownpsych]

Every diagnosis is a misdiagnosis.

And the moral of the story is if you decide to kill yourself make sure are successful or its just a cry for help.

The first statement has some real truth to it and knowing the limitations of classification systems is part of being an effective clinician. As has been said by several posters on this board, the DSM in the hands of a concrete thinker can be a dangerous thing.

The second statement describes a common minimization that is often characteristic of non-professionals or unlicensed staff more than it describes the thinking of any clinician I have ever known. A well-trained clinician knows that suicidal ideation, plan, practicing, intent, gesture, attempts, and lethality are all part of the assessment process that goes into determining the level or type of intervention. If one was to say, "it was just a cry for help", that would not be standard of care. It could relate to level of intent to die or lethality of attempt, but that statement is not specific or useful and often if a patient hears it, they will escalate their next attempt to demonstrate how much they really do want to die.

 

[Ibid]

The first statement has some real truth to it and knowing the limitations of classification systems is part of being an effective clinician. As has been said by several posters on this board, the DSM in the hands of a concrete thinker can be a dangerous thing.

The second statement describes a common minimization that is often characteristic of non-professionals or unlicensed staff more than it describes the thinking of any clinician I have ever known. A well-trained clinician knows that suicidal ideation, plan, practicing, intent, gesture, attempts, and lethality are all part of the assessment process that goes into determining the level or type of intervention. If one was to say, "it was just a cry for help", that would not be standard of care. It could relate to level of intent to die or lethality of attempt, but that statement is not specific or useful and often if a patient hears it, they will escalate their next attempt to demonstrate how much they really do want to die.

A diagnosis in mental health is more of a political device than anything else. Less a guide to treatment than a signal to commence pre-existing institutional arrangements.

I was being flippant with the second statement. With regard to ideation,plan, intent, gesture and so on... the truth is that people rated as low risk are just as likely to complete the act of suicide as those rated as high risk. In essence its a waste of time except in retrospect it provides a handy way of justifying ones actions and in the present functions to help reduce the anxiety of practitioners. Risk assessment for suicide has zero predictive value.

Edit: waste of time is probably a bit harsh becasue those two items are of some utility but I stand by the point about zero predictive value.



You have to take what I say with a pinch of salt. I'm jaundiced.

 

[smalltownpsych]

A diagnosis in mental health is more of a political device than anything else. Less a guide to treatment than a signal to commence pre-existing institutional arrangements.

I was being flippant with the second statement. With regard to ideation,plan, intent, gesture and so on... the truth is that people rated as low risk are just as likely to complete the act of suicide as those rated as high risk. In essence its a waste of time except in retrospect it provides a handy way of justifying ones actions and in the present functions to help reduce the anxiety of practitioners. Risk assessment for suicide has zero predictive value.

Edit: waste of time is probably a bit harsh becasue those two items are of some utility but I stand by the point about zero predictive value.



You have to take what I say with a pinch of salt. I'm jaundiced.

Political device? Huh? Are you just criticizing how the state treats the seriously mental ill? Number one, they don't really listen to us. Number two, the vast majority of my patients come here to talk about difficulties with coping with life stressors which often does include how to deal with the states systems.

 

[hamstergang]

Political device? Huh?

I'd recommend checking out his other posts so you know what you're getting into. Also, if I'm not mistaken Ibid is not actually in the mental health field; he's simply well educated and opinionated.

 

[Ibid]

Political device? Huh? Are you just criticizing how the state treats the seriously mental ill? Number one, they don't really listen to us. Number two, the vast majority of my patients come here to talk about difficulties with coping with life stressors which often does include how to deal with the states systems.

Psychiatric diagnosis as a political device Joanna Moncrieff Department of Mental Health Sciences, University College London, Gower Street, London, W1W 7EJ, UK. E-mail: [email protected]

http://www.palgrave-journals.com/sth/journal/v8/n4/pdf/sth200911a.pdf

From the abstract

In particular they demonstrate that, in contrast to the idea that diagnosis should determine treatment, diagnoses in psychiatry are applied to justify predetermined social responses, designed to control and contain disturbed behaviour and provide care for dependents. Hence psychiatric diagnosis functions as a political device employed to legitimate activities that might otherwise be contested.

Yes, it is fair to say that I am critical of the way some people are treated, especially those designated seriously ill. Which to me is the salient point, that is the way a diagnosis legitimatizes a particular response rather than the headline grabbing problematic nature of diagnosis in mental health.

 

[HarryMTieboutMD]

I'd recommend checking out his other posts so you know what you're getting into. Also, if I'm not mistaken Ibid is not actually in the mental health field; he's simply well educated and opinionated.

Since beginning residency, I have learned to discount the "positions" (more like opinions) on psychiatry related issues of anyone without professional experience in the mental health fields . The only other MDs whose opinions I will take seriously, as derisive as they may be, are neurologists.

 

[Shikima]

Since beginning residency, I have learned to discount the "positions" (more like opinions) on psychiatry related issues of anyone without professional experience in the mental health fields . The only other MDs whose opinions I will take seriously, as derisive as they may be, are neurologists.

Dr. google needs malpractice insurance.

 

[smalltownpsych]

I'd recommend checking out his other posts so you know what you're getting into. Also, if I'm not mistaken Ibid is not actually in the mental health field; he's simply well educated and opinionated.

It is frustrating because there are often valid criticisms from people outside the field but they tend to be overstated and also neglectful of the real tragedy of mental ilness and how hard we work to try and help those who are suffering despite a culture and political system that sees mental illness as something to fear, control, and eradicate. Sure there are ways that our profession has been sucked right into that, but psychiatry and psychology are not really the problem. If we all quit tomorrow, then would things really be better? Or would we could go back to the way it was before humane treatment. Bedlam.