Research Paper: Removal of Bereavement Exclusion in the DSM

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The Diagnostic and Statistical Manual for mental disorders -- third edition (DSM -- III; American Psychiatric Association [APA], 1980) initiated the breakthrough approach to diagnosing mental disorders based on the patient's experiential or phenomenological self-reported behavior as well as the clinical observations of the diagnosing mental health professional. Prior this edition the DSM relied more on psychoanalytic formulations of mental disorders as the foundation for their diagnosis. The current edition of the DSM, the DSM -- 5 (APA, 2013), continues this tradition in spite of criticisms of this approach by such organizations as the National Institute of Mental Health (NIMH, 2011). Organizations criticizing this approach typically cite that across other areas of medicine biological data such as cell biology (e.g., neural circuits), genomics, and pathophysiology are the standards for diagnosing diseases and disorders. Nonetheless, attempts to apply these types of biological criteria to mental disorders has indicated that the biology of mental disorders is relatively nonspecific such that for example, neural circuits identified as associated with mental disorders are common to more than one disorder and these disorders are often indifferent diagnostic categories (e.g., bipolar disorder and schizophrenia; NIMH, 2011). Thus, the release of the DSM -- 5 resulted in predictable controversy and outcry from some clinicians not only for its inability to specify biological markers of mental illness but also for changes in many of the diagnostic criteria that had been standards in previous editions (NIMH, 2011).

One might wonder why the diagnostic criteria for mental disorders change from edition to edition given that there are no biological markers for most of these disorders. The answer to that is quite simple. First, millions and millions of dollars are spent on researching the various diagnostic categories and disorders in the DSM series and this research uncovers new information about the reliability and validity of the current diagnostic criteria, suggests or disconfirms the presence of new or previously used diagnostic criteria or disorders, and the DSM series is not designed to be an end-all statement regarding mental disorders but a current reflection of research and the understanding of mental disorders in both adults and children; therefore, as new information is gained changes to the existing specifiers and criteria for the diagnosis of mental disorders will also change. However, like all changes, changes to the DSM are typically not unanimously received by mental health workers and research scientists. In the case of the DSM -- 5 there were several major changes that sparked quite a bit of debate and controversy. One of the reasons that the DSM -- 5 changes were considered radical is that the actual diagnostic criteria for the mental disorders had been in place since 1995 with the DSM -- IV. The updated DSM -- IV -- TR released in 2000 only updated the text in the manual without changing any of the diagnostic criteria (APA, 2000).

Perhaps one of the changes from the previous edition (DSM -- IV -- TR; APA, 2000) to the most current edition of the DSM (DSM -- 5; APA, 2013) was the removal of the bereavement exclusion and the diagnosis of major depressive disorder. The bereavement exclusion criteria for major depressive disorder and the DSM -- IV indicated that clinicians should not diagnose a depressive disorder in individuals who could be grieving over the loss of a loved one or some other issue for two months or less following that event. The reasoning here was that bereavement was a natural reaction to a loss, perceived loss, or traumatic event and that the diagnosis of a clinical psychiatric disorder and such individuals would be inappropriate (APA, 2000). In the DSM -- IV -- TR the bereavement exclusion criteria was to be used when the focus of the person's clinical presentation is a normal reaction to the death of a loved one that includes depressive symptoms such as sadness, weight loss, reduced appetite, etc. In addition, there are several features of bereavement that were believed to be distinguishing characteristics between the grieving over a loss and an actual depressive disorder that included: 1) the bereaved person typically regards to depression is normal and often seeks treatment for associated symptoms such as reduced sleep; 2) the depression diagnosis was generally not given unless the symptoms lasted two months after the loss, but; 3) depression could be considered before this time period if there were the presence of certain systems that were not to be associated with "normal" grieving such as guilt about other things or that the person was having suicidal ideations/intentions, psychomotor retardation, feelings of worthlessness etc. (APA, 2000). Thus, the major consideration in previous versions of the DSM was that bereavement closely resembled the features of a major depressive disorder and that a specific time period (two months) was needed for this process to run its normal course before clinician could diagnosis psychiatric disorder in these individuals.

One of the major issues with this particular exclusion criteria was that the two-month time period was believed by many to be too short, the process of bereavement often is variable in length depending on many different demographic characteristics of individuals, and that there were some concerns that people grieving the loss of a loved one would not receive interventions that could lessen their discomfort (Horwitz & Wakefield, 2007). The DSM -- IV -- TR did list bereavement disorder as a potential disorder that was under current study; however, bereavement was not considered to be a clinical disorder (APA, 2000). In the time between the publication of the DSM -- IV -- TR in the DSM -- 5 empirical findings regarding the differentiation between the bereavement and major depression suggesting the need for a reevaluation of the bereavement exclusion criteria that had been used in the past. The overwhelming majority of these studies found that the features of bereavement were not clinically distinguishable from the symptoms of major depressive disorder and that individuals whose grieving process resembled the diagnostic criteria for clinical depression were at increased risk of developing severe depression (e.g., Corruble et al., 2009; Zisook, Shear, & Kendler, 2007). This research resulted in the removal of the bereavement exclusion criteria in the diagnostic criteria for major depression and the DSM -- 5 and the continued study of bereavement as a potential disorder when it presents to the mixed presentation (symptoms of mania and depression). Other than the removal of the bereavement exclusion from the diagnosis of major depressive disorder the criteria basically remained unchanged from the DSM -- IV -- TR.

Those who supported eliminating the exclusion argued that based on the research grief does not protect a person from developing full -- blown depressive and that the research indicates that grief predisposes a person to develop a major depressive disorder. Moreover, the exclusion criteria wrongly assume that no person can become seriously depressed while grieving. These proponents of removing the exclusion continue to state that a clinician should be able to make a judgment call regarding a patient's presentation and whether or not the person is merely grieving "normally" or whether their presentation may warrant treatment (Corruble et al., 2009; Zisook et al., 2007). On the other hand, many found that removing the exclusion criteria for bereavement was akin to pathologizing a normal reaction and that the scientific evidence for removing the exclusion criteria was nonexistent (Horwitz & Wakefield, 2007; Wakefield & First, 2012). The focus of the removal of the bereavement exclusion criteria from the major depression category stirred quite a bit controversy and debate when the DSM -- 5 diagnostic criteria were released.

One can certainly understand that there will always be reactions to change and when something as long -- standing as the diagnostic criteria for a very prevalent form of mental illness is revised these reactions will be magnified.… [END OF PREVIEW]

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APA Format

Removal of Bereavement Exclusion in the DSM.  (2014, April 20).  Retrieved May 21, 2019, from

MLA Format

"Removal of Bereavement Exclusion in the DSM."  20 April 2014.  Web.  21 May 2019. <>.

Chicago Format

"Removal of Bereavement Exclusion in the DSM."  April 20, 2014.  Accessed May 21, 2019.