Saturday, December 1, 2012

DSM-5: Grieving Over the Loss of the Bereavement Exclusion


Have you been tearful and sad after the death of a loved one?  Did you notice changes in appetite, difficulty sleeping, troubles concentrating, and decreased energy for at least two weeks after the loss? Did you think that was a normal, healthy, and adaptive response to a major loss? Well, if you believe the new DSM-5 criteria approved today by The American Psychiatric Association's (APA) board of trustees, you would be wrong, as your reaction would now fit the criteria for Major Depression.

Under the current DSM-IV criteria, you would have been right, as the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.   It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to months following a loss is associated with significant distress.

Times are changing though.  Even though the final manual is not out yet, the APA Board of Trustees released a statement that noted the newly approved DSM-5 will remove the "bereavement exclusion."

Now there are some persuasive arguments for this change. Probably strongest is that there is little difference between the development of depression from that of bereavement versus other life stressors, such as being diagnosed with advanced cancer or having gone through a marital breakup.  In other words, if you have an exclusion for bereavement, shouldn't you also have an exclusion for other significant losses in life?

In addition, grief seen in bereavement is not completely benign.  There are a minority of bereaved individuals (approximately 10-20%) in which grief can become complicated and prolonged. For these individuals, complicated grief has been shown to have a significant detrimental impact on their ability to function and quality of life.  There are also individuals who truly developed profound depressive episodes shortly after the loss of a loved one.  However, the current DSM-IV criteria clearly allows a diagnosis of Major Depression to be made in these instances, although the bar is set higher.

I can’t help but see this as a broad overreach by the APA.  Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.  Yes, uncomplicated grief may cause significant distress, but for the majority of bereaved, it is an adaptive and healthy reaction to the loss of a loved one.   Furthermore, there is no evidence that medical interventions significantly improve outcomes or symptoms in the bereaved, outside of those with prolonged or complicated grief disorders.  Most bereaved individuals will adjust to a new life without their loved one, but this takes time - certainly longer than 2 weeks.

by: Eric Widera (@ewidera)

5 comments:

Julie Bruno MSW LCSW said...

As a social worker who has worked with the bereaved and in the field of hospice and palliative care, I concur that taking out the bereavement exclusion unnecessarily pathologizes a normal healing process after a significant loss.
The potential good news? Bereavement counseling can/could be coded and billed by 3rd party insurers providing often helpful support to those who are bereaved.

under cover waitress said...

This is simply about understanding the client and helping the client. Nothing wrong with defining grief as a diagnostic category. If people get so hot under the collar about labels, perhaps we should remove the word "disorder" and replace with "description" so that we can describe and define mental health without people arguing over political correctness.

whatisasocialworker said...

Yes, there might be more billing options for therapist working with bereaved people and perhaps making grief a descriptive disorder will help decrease the stigma of major mental health disorders, but I wonder how we remove this diagnosis and disorder when it no longer affects a person in an adverse way? Someone is given a mental health disorder perhaps early in life and this person is confined to this diagnosis for a lifetime. Who and how do we assess when the grief disorder is no longer applicable? Do we tell our employers who might treat us differently? Is it considered an "existing medical condition" and it may cause insurance companies to turn us down? Are we going to be scrutinized by every doctor, social worker and therapist bc of this disorder? Grief is the result of a major life event and a significant emotion that sometimes turns into a mood disorder, but a mental diagnosis? I do not know if I agree that making grief a disorder is more helpful than harmful to the person that is afflicted.

Anonymous said...

I remember telling the psychologist I was seeing as a client after my husband's death that depression and grief for me were very different. In feeling depressed, blue or down in the dumps it was hard to tell what exactly caused it or how it could be overcome. Grief had a direct cause and the remedy was obvious - the dead person could come back to life. In other words the cure was impossible to accomplish. Couple this lack of control without further recourse (some words of Lorna Benjamin, PhD)with the constant advice, questions and innane questions of friends and strangers and the tasks to complete and you have a real struggle to overcome the grief and exhaustion following a loved one's death. The ignorance in the helping professons is just one more stumbling block to recovery.

Francis Piccadilly said...

In a way I kind of understand where those doctors are coming from. Not everyone has the same capacity to cope with bereavement in a way that they can get over it over a few days. Still, I'm sure they could make further revisions to this paper; again, not all cases of bereavement are the same, so maybe they should quantify that point as well.