Tag Archives: bereavement exclusion

12/18/18

The Death of Grief

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The field of psychiatric diagnosis suffered a significant loss in the spring of 2013 with the death of the bereavement exclusion. It was not a peaceful ending, as several experts fought desperately to keep it alive within DSM-5. But the efforts of psychologists like Joann Cacciatore and psychiatrists such as Allen Frances were not successful. The American Psychiatric Association published the DSM-5 without the bereavement exclusion and effectively eliminated any diagnostic distinction between bereavement and major depression. Grief, for all intensive purposes, was dead.

Dr. Joann Cacciatore, a psychologist who specializes in counseling individuals affected by traumatic death, lamented this passing in her article, “The Death of Grief, the Birth of Mental Illness.” She said: “Grief is not a disease, it is not an illness, it is not depression. It is in fact, an expression of love. Grief can only be a disease if love is.” She noted how the change increased the likelihood that grief would be misdiagnosed as Major Depressive Disorder and then mistakenly treated with psychotropic medications. “There is no sound evidence that they are effective for grief. Research shows that bereaved parents are already medicated earlier than can be justified by current evidence.”

We are saddened and disappointed by the recent announcement that the DSM-5 task force has finalized the decision to eliminate the bereavement exclusion from the Major Depressive Disorder diagnosis in the upcoming edition of the manual. This move will allow clinicians, including counselors, general physicians, social workers, and psychiatrists, to diagnose a major mental disorder in bereaved parents and other grieving individuals as early as two weeks following the death of a loved one should they meet the DSM-5’s criteria for depression. Importantly, many of you will recognize these criteria which include sadness, feelings of emptiness, crying, sleep and weight changes, guilt and regrets, and loss of interest or energy. Yet, all of these symptoms are quite common in grief, and particularly after the death of a baby or child which evokes enduring and intense reactions in parents.

Allen Frances, a psychiatrist and chair of the DSM-IV, repeatedly pleaded with the APA to not medicalize grief in “Last Plea to DSM 5: Save Grief from the Drug Companies.” He even ranked it as the second worst mistake within the DSM-5. He noted it would be a “bonanza for drug companies, but a disaster for grievers.” Frances referenced and quoted the concerns of Joann Cacciatore, Russell Friedman (the co-founder of The Grief Recovery Institute Educational Foundation) and Jerry Wakefield, a professor of Social Work. Frances said: “The DSM 5 medicalization of grief has been opposed by editorials and scientific papers in the major medical and scientific journals, by hundreds of newspaper  articles.”

After 40 years and lots of clinical experience, I can’t distinguish at two weeks between the symptoms of normal grief and the symptoms of mild depression- and I challenge anyone else to do so. This is an inherently unreliable distinction. And I know damn well that primary care doctors can’t do it in a 7 minute visit. This should have been the most crucial point in DSM 5 decision making because primary care docs prescribe 80% of all antidepressants and will be most likely to misuse the DSM 5 in mislabeling grievers. . . . Grief is a normal and inescapable part of the human condition, not to be confused with psychiatric illness. Let us respect the dignity of mourning and treat it medically only when it becomes melancholia.

Another eminent psychiatrist, Ronald Pies, disagreed with Allen Frances. He believes eliminating the bereavement exclusion was a reasonable decision. Pies said grief and depression are distinct constructs and bereavement does not “immunize” the person from major depression. He said the bereavement exclusion was removed from the DSM-5 for two main reasons: 1) major depression is potentially a lethal disorder, “with an overall suicide rate of about four percent”; and 2) there is no clinical or scientific evidence to distinguish bereavement-related grief from major depression. “Disqualifying a patient from a diagnosis of major depression” after the death of a loved one “closes the door on potentially life-saving interventions” (meaning medication).

It is important to understand that the DSM-5 criteria merely allow the diagnosis of MDD when the recently bereaved person meets all required symptom, severity, duration, and impairment criteria for MDD. Nothing in the manual compels a diagnosis of MDD shortly after bereavement.

In conclusion, Pies said while normal grief should not be medicalized, neither should major depression be normalized simply because it occurred “in the context of recent bereavement.” Dr. Pies seems to be arguing that the problems of a “falsely positive” in diagnosis of major depression in the context of bereavement are outweighed by the dangers from a “false negative” in diagnosis. Yet there are some who would strongly dispute this conclusion. Instead they see removing the bereavement exclusion as an example of how psychiatry relentlessly seeks to expand its reach.

In “Elimination of the Bereavement Exclusion: History and Implications,” psychologist Philip Hickey gave a history of the DSM and how the bereavement exclusion was first added, then whittled away over time. He noted how the DSM-I did not suggest its “disorders” were chemical imbalances or “illnesses-just-like-diabetes.” Rather, the “disorders” were conceived as reactions of the personality and believed to be of  “psychogenic origin.” Hickey then gave a couple of quotes from the DSM-I illustrating his point.

The emphasis on psychological explanations was not merely a reflection of Adolf Meyer’s influence, but a reflection of the fact that a great many psychiatrists at that time (1952) subscribed to this position and were entirely comfortable with these types of psychoanalytic explanations.

But the introduction of antipsychotic and antidepressant medications in the 1950’s changed things. They offered a pathway to “prima facie medical legitimacy.” What was needed was a label that posed as a diagnosis; time for a 15-minute med check; and a quickly-written prescription. “No longer would it be necessary to delve collaboratively and time-consumingly into a client’s childhood conflicts, current fears, or counter-productive relationships.” Don’t be too quick to dismiss Hickey’s rhetoric. In an address to the American College of Neuropsychopharmacology in 2000, Allen Frances said the DSM system and psychopharmacology grew up together “and have had a strong influence upon one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

Hickey said as more psychiatric drugs came to market in the 1960s, “it became increasingly clear the psychogenic framework of the DSM-I had to go.” Thus a movement to develop a cause-neutral diagnostic system began with the DSM-II and continued on through the DSM-III under the guidance of Robert Spitzer.  The concept of cause-neutrality, according to Hickey, meant that: “regardless of why a person is despondent, if he scores five or more yeses on the checklist, he has major depression, the ‘illness,’ and therefore needs medical treatment.” Over time, as the use of DSM diagnostic criteria became central to the conceptualization of depression and grief, the bereavement exclusion included by Robert Spitzer in the DSM-III seemed more and more problematic for mainline psychiatry. And bereavement as a cause of grief-related depression became increasingly irrelevant.

The death of grief is inversely related to the birth and growth of what Hickey called the biological-pathology perspective. The bereavement exclusion was finally pronounced dead with the publication of DSM-5 in 2013. “The bogus cause-neutral perspective (in reality the bogus biological-pathology perspective) was now the de facto psychiatric position, with no exceptions.”

The notion that one can gain an understanding of a person’s sadness by ignoring its causes and contexts, and simply bumping his superficial presentation against a fabricated checklist, and seeing if he scores hits on at least five, is simply inane. It’s like trying to understand a poem by counting the words. Anyone with the slightest compassion or understanding of human experience can see this.

For more on the concerns with psychiatric diagnosis see: “Where There’s Smoke …” and “Psychiatric Huffing and Puffing.” For more on the APA actions on bereavement, see: “Pathologizing Grief.”

 

07/15/15

Pathologizing Grief

© Kzenon | stockfresh.com

© Kzenon | stockfresh.com

In January of 2015, an article on “Complicated Grief” was posted in The New England Medical Journal blog. The author described complicated grief as “intense grief after the death of a loved one that lasts longer than expected according to social norms and causes functional impairment.” While it was said that psychotherapy is a first-line treatment, the author reported that antidepressant medication is commonly used. This is just the latest stage in a rather complicated refashioning of grief from a normal human experience into a mental disorder.

The symptoms of complicated grief were said to be: “persistent, intense yearning, longing, and sadness.” Along with these “symptoms” can be a sense of disbelief or failure to accept the reality of the person’s death. Persistent thoughts or images of the deceased can occur. Ruminating on the circumstances of the death, with feelings of anger or guilt was said to be common. Avoiding situations that remind the person of the loss is common. Holding on to the deceased by repeated reminiscing, viewing, touching or smelling the deceased person’s belongings can occur as well.

People with complicated grief often feel shocked, stunned, or emotionally numb, and they may become estranged from others because of the belief that happiness is inextricably tied to the person who died. They may have a diminished sense of self or discomfort with a changed social role and are often confused by their seemingly endless grief.

Complicated grief is not a psychiatric diagnosis, although you wouldn’t know that from reading the above description. It explicitly uses diagnostic-like language in its discussion in an attempt to gain legitimacy for “Prolonged Grief Disorder” to be included in the International Classification of Diseases, 11th edition, due for release in 2017. The boat has passed on inclusion in the DSM, which went through its own controversy over grief when the DSM-5 removed the bereavement exclusion (BE) from the existing Major Depression Disorder (MDD) in 2013.

Within the DSM, the bereavement exclusion meant that a diagnosis of MDD could not be made if the loss of a loved one was a better explanation for the observed symptoms of depression. However, the time frame to avoid the grieving process from qualifying as MDD has been progressively shrinking. Within the DSM-III, the BE was one year; within the 4th edition, it was two months. Now in the DSM-5, bereavement is no longer an excuse. If you meet the diagnostic criteria for MDD over a two-week time period, you are just as depressed as anyone else, according to the DSM.

Joanne Cacciatore, who has specialized in the psychotherapeutic treatment of grief and bereavement for almost twenty years, has been an outspoken critic of these changing guidelines and pseudo-diagnoses. In March of 2012 she wrote an essay opposing the proposed elimination of the BE from the DSM-5. Her eloquent essay reached 100,000 readers in two weeks. She stated her opposition to both of the above ‘time limits’ for grief, and pointed to the historical movement of the DSM to medicalize normal human emotion. She said:

We should not, ethically or morally, medicalize grief.  To do so is to medicalize love.  We rarely mourn for that which we do not love. I can only begin to imagine what the sages, and mystics, and shamans of the past might think of a society which does so.

Allen Frances was also openly critical of the DSM-5 and its changes with regard to bereavement. In his own blog on the Huffington Post in March of 2012, he published Dr. Cacciatore’s open letter to the Board of Trustees of the American Psychiatric Association. She pointed to the arbitrariness of the two-week time frame, stating that it not only contradicts common sense, but rests on weak scientific evidence. To her knowledge there was no empirical evidence to support it.

One thing in which the literature is clear: long-term psychological distress is common in this population and other populations suffering traumatic deaths. In my experience both as a researcher and clinician in the field and also as a bereaved parent, the DSM-5 proposal is radical, unnecessary, challenges what it means to be human, and for some may be dangerous.

But the APA was not moved. Frances tried again in January of 2013, as the DSM-5 was preparing to go to press at the end of the month. He said: “The American Psychiatric Association has just four more weeks to reverse this dreadful mistake that flies in the face of clinical common sense and is unsupported by the limited available science.” He put together his own top ten list of harmful changes in the DSM-5, and medicalizing grief was number two. In case you aren’t aware, Dr. Frances’ credibility in voicing these concerns come from his long career as a psychiatrist and as the person selected by the APA to chair the DSM-IV. He said:

After 40 years and lots of clinical experience, I can’t distinguish at two weeks between the symptoms of normal grief and the symptoms of mild depression — and I challenge anyone else to do so. This is an inherently unreliable distinction. And I know damn well that primary care doctors can’t do it in a 7-minute visit. This should have been the most crucial point in DSM-5 decision-making because primary care docs prescribe 80 percent of all antidepressants and will be most likely to misuse the DSM-5 in mislabeling grievers.

Returning now to the essay “Complicated Grief,” let’s look at Dr. Cacciatore’s response. She commented how the bereaved were again at risk of being diagnosed and “treated” for “absolutely normal feelings and experiences” after a painful and traumatic loss. Responding to the above description of complicated grief, she said:

Ha! Social norms? Around grief? Talk about pathology! Western culture’s “social norms” and expectations around grief, especially when traumatic, are as abnormal and avoidant as any society could get. The average bereavement leave is three days, many bereaved parents are medicated within days or weeks after a traumatic loss (even in the presence of data to suggest these medications can be harmful and iatrogenic), and mourners are expected, and then pressured, to get back to ‘life-as-usual’ often within weeks or mere months, even after traumatic death. And our social networks often fail as others’ tolerance wanes in the months and years that follow.

Perhaps there is better guidance for conceiving a time frame for grief and bereavement in the book of Ecclesiastes (3:1-8) than in the DSM. There the Preacher said there is a season and a time for everything under heaven. Notice that he doesn’t try and quantify “season” or “time.” A time to be born and a time to die; a time to weep and a time to laugh; a time to mourn and a time to dance; a time to keep silent and a time to speak. When weeping turns to laughing, when mourning is replaced by dancing, then the season of grief has run its course. However, when individuals attempt to pathologize human emotion by blurring the line between grief and psychiatric disorder, it is a good thing that people like Joanne Cacciatore and Allen Frances choose to speak up and not remain silent.