DSM-5 and Bereavement: The Loss of Normal Grief?
Fox, Jesse, Jones, K. Dayle, Journal of Counseling and Development : JCD
The American Psychiatric Association (APA, 2012) mood disorder work group has proposed to eliminate the bereavement exclusion from the criteria for classification of a major depressive episode in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to be published in May 2013. The term bereavement refers to the grief reaction associated with the loss of a loved one. The aim of the bereavement exclusion was to help counselors identify individuals who are experiencing normal grief reactions to a loved one's death and avoid misdiagnosing them with major depression.
The mental health community has recognized the qualitative difference between depression and grief since antiquity, long before the exclusion criterion surfaced in the DSM terminology (Wakefield, Schmitz, First, & Horwitz, 2007). However, the DSM-5 mood disorder work group proposed to revise the current distinction between bereavement and major depression, arguing that there is insufficient evidence to suggest that bereavement is a unique stressor (Zisook & Kendler, 2007). On the other hand, notable figures like Allen Frances, Chair of the DSM-IV Task Force, have warned that revising over 30 years of clinical work may not only lead to the medicalization of normal grief, but also exacerbate mental health costs because of overdiagnosis of major depression (Frances, 2010).
Eliminating the bereavement exclusion has implications for how counselors conceptualize and treat both bereavement and major depression. Diagnosing bereavement as depression may run the risk of pathologizing the cultural norms established for individuals who grieve the death of a loved one. However, counselors who fail to recognize the sometimes harmful extremes of a grief response risk dismissing the serious signs of major depression as a normal part of the mourning process.
Despite this revision's potential to introduce great change in the delivery of mental health services, it has yet to receive any attention in the peer-reviewed counseling journals. Furthermore, the counseling profession lacks a voice in the research and decision-making process of the DSM-5, and advancing this discussion within the counseling literature may help resolve this dilemma for the profession. The purpose of this article is to present information related to the DSM-5 mood disorder work group's proposal to eliminate the bereavement exclusion. This article will review the development of the bereavement exclusion criterion, discuss the evidence and arguments for both eliminating and retaining the criterion, and offer some implications for counselors awaiting the release of the DSM-5.
* Bereavement Exclusionary Criterion
Since its first appearance in the DSM-III (APA, 1980), the criteria for a major depressive episode has included an exclusionary criterion that requires counselors to not diagnose major depressive episode if an individual's depressive symptoms can be better accounted for by bereavement. Lamb, Pies, and Zisook (2010) observed that the DSM-III and subsequent editions sought to create a diagnostic system that was not partial to any theory of psychopathology and instead focused on the "intensity and duration of symptom patterns and on significant distress or dysfunction" (p. 20). Unless the bereft individual's symptoms matched the DSM-III's description of "severity, duration, and clinically significant distress or impairment" (Lamb et al., 2010, p. 20) for a major depressive episode, then the exclusion criterion defined the experience as a normal reaction to loss. The exclusion criterion narrowed between the DSM-III-R (APA, 1987) and the DSM-IV (APA, 1994), by shortening the time frame to 2 months (previously 1 year), requiring (previously suggesting) a diagnosis of major depression if a single exclusion symptom was present, and adding psychosis to the list of complicating symptoms (Wakefield, Schmitz, & Baer, 2011). …