Good Grief: Why the DSM-V Is Wrong About Bereavement and DepressionFebruary 4, 2013 • By Sarah Noel, MS, LMHC, Person Centered / Rogerian Psychotherapy Topic Expert Contributor
Imagine losing someone very close to you; perhaps your partner dies. How might you feel and behave in the weeks following this death? You might feel a sense of sadness and emptiness so intense that it is difficult to hold back tears. Perhaps you would have little interest in activities that you usually enjoy. Maybe you would find it difficult to sleep after sharing a bed with your partner for so many years. You might begin eating more or less and either gain or lose a significant amount of weight. It might be difficult to concentrate on your work. You might be preoccupied with a sense of guilt, wondering whether you could have done something to prevent your partner’s death. You might even wish for the day that you and your partner are reunited in death.
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These kinds of feelings and behaviors, while certainly difficult, probably seem like pretty normal and appropriate responses to a significant loss. They certainly don’t seem indicative of a diagnosable mental illness, right? Well, until the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is released in May, your hunch is correct. Currently, these feelings and behaviors aren’t considered evidence of mental illness.
In order to meet the diagnostic criteria for major depressive disorder (MDD), five out of nine specific symptoms must be exhibited, more often than not, for two weeks or longer, and they must impair your ability to function. The example above actually includes seven of the nine symptoms of MDD. These symptoms would probably be present much of the day for several weeks and would certainly impair normal functioning.
Currently, however, there is an exemption for bereavement in the diagnostic criteria that allows for such symptoms to persist for up to two months after the death of a loved one. Only after two months of persistent and pervasive depressive symptoms can a diagnosis of MDD be made in the context of bereavement. This exemption acknowledges that while grieving can look and feel virtually identical to depression, it is, quite simply, not depression. Unfortunately, the new version of the DSM will remove the bereavement exemption from the diagnostic criteria, and come May, the very appropriate reaction to the death of a loved one described above will be pathologized and diagnosed as MDD.
The world looks to the field of psychology to understand normal versus abnormal behavior, and the field of psychology uses the DSM as its guide for drawing the often fine line between what is normal and abnormal. This is a responsibility that should not be taken lightly. Labeling someone as mentally ill has significant implications. In the best case, a person who receives a diagnosis is given a lens through which to better understand himself or herself. It can be deeply empowering for someone to understand that the thoughts, feelings, and behaviors that have plagued him or her have a name, and that there are not only treatment options, but hope as well—hope for healing, hope for growth, and hope to become the person he or she has always wanted to be.
However, in cases where a perfectly healthy person is labeled as mentally ill, the implications can be devastating—just ask the gay man who was considered mentally ill in the early 1970s before homosexuality was removed from the DSM. To be labeled as sick, to be pathologized, for being who you are, or for being appropriately devastated by the loss of a loved one, serves no purpose and may be quite harmful.
Imagine being told that the anguish you are feeling over the loss of your partner means that you are mentally ill. Is there any way that this could be helpful, or would it just serve to make you feel much more lost and hopeless? What would it be like if a doctor suggested you take medication? Imagine being told to take a pill to get over the death of a loved one. Should you find yourself in a therapist’s office grieving the loss of a loved one and your therapist suggests a diagnosis of MDD, don’t be so quick to accept the label—it is entirely possible that you are simply, and appropriately, grieving.
© Copyright 2013 by Sarah Noel, MS, LMHC, therapist in Brooklyn, NY. All Rights Reserved.
JillFebruary 5th, 2013 at 3:43 AM
Sure, lose your spouse or child, be sad about it for months on end, and have a provider tell you that you are mentally ill.
Yeah those are the exact words that I need to help get me back on my feet again
Kalila BorghiniFebruary 5th, 2013 at 4:16 AM
As a mental health professional who has treated many people grieving and presenting symptoms of what is known as complicated grief, I had mixed feelings about your article. Yes, it is unfortunate that grief will be pathologized but if insurance companies will pay/reimburse for counseling, I’m all for it. If it means that the public will take grief and its symptoms seriously and get help for themselves and others, I’m all for that. I even have a reaction to the existing criterion in the DSM of “more than two months” because coming to terms with a devastating loss can take far longer than that (with the symptoms described). If you can think of the DSM as not only a guide (and not necessarily a great one) for diagnosis, it may also help to think of it as a guide to helping our patients get their insurance companies to pay at least part of the mental health care they (our patients)deserve.
RWFebruary 5th, 2013 at 3:14 PM
Didn’t know much about DSM until I read about it in this article and did a little reading online.
At first I was shocked to see even grieving can be labelled as a mental illness. But having read on DSM now, and from the example you have given about how it treated homosexuality in the past, it seems like this ‘manual’ only deserves a place in the museum under the bizarre section. sad that we are using this as the gold standard when it comes to mental health treatment
Danya EspinosaFebruary 5th, 2013 at 4:41 PM
I agree with Kalila. As a counselor, it is difficult to diagnosis and the DSM is meant to be a guide for that diagnosis. Unfortunately, insurance companies insist upon a diagnosis in order for us counselors to bill our sessions. If anything, this change will help clients maintain coverage from their insurance companies so they can continue with counseling as needed.
HeatherFebruary 5th, 2013 at 6:20 PM
Here in Australia, we therapists do not require diagnosis as we don’t need insurance companies to assist us. It may well be that insurance companies need to change in order for more real and accurate DSM’s manuals.
MiltonFebruary 5th, 2013 at 10:55 PM
Enabling insurance claims may be the only positive thing out of this.But what about the label?Is money so big that one should be ready to accept a label even though he or she clearly is not mentally ill?If anything this just shows how much of a grip the insurance conditions have on our healthcare.Its time the control rests in our own hands and not in the hands of the insurance companies!
AlketaFebruary 6th, 2013 at 1:41 AM
So we have to be mentally ill in order to have the support of the insurance companies? We have to change the definition of what we have, change our self-perception? Change a world guide book as DSM only for insurance?
JacquelyneFebruary 6th, 2013 at 3:59 AM
It is unfortunate that to get help for people struggling with grief that often accompanies the changes in life, they have to be labeled with a pathology. However, therapists must give a diagnosis to those wishing to use their insurance. Insurance companies require that we ‘label’ our clients’ pathologies in order for them to get the help needed. If we didn’t have to give it a label, many therapists would probably get rid of all diagnoses.
Danya EspinosaFebruary 6th, 2013 at 1:51 PM
As a counselor, I would prefer not to label my clients with a diagnosis. It would be great to simply bill without explanation, but that’s not the case. Programs such as employee assistance (EAP) do not necessarily require a diagnosis for treatment, but these programs usually only cover 3 sessions are so. If insurance companies don’t pay, it would be very difficult to get treatment due to high costs. Until there are more restrictions and legislation for mental health advocacy, we appear to be stuck with the way things work right now.
Sarah Noel, MS, LMHCFebruary 11th, 2013 at 7:15 PM
Thanks for all of the comments and the lively conversation. @Kalila and @Danya, insurance reimbursements are about the only positive thing I see coming from this and I do hope that in that way, so people who are suffering are able to benefit from this change. That said, I’m not sure that justifies the change. It seems an incredibly slippery slope to pathologize perfectly normal behaviors in order to get insurance to cover it. @Milton, I agree with where I think you are going with your comments – it seems a better, though admittedly longer and much more complicated, course of action is working to reform health care and the insurance industry. @Heather, Australia sounds like a wonderful place to practice!
Steve FreedkinMarch 16th, 2013 at 2:20 PM
There are various good reasons to include bereavement-related depression in the DSM-5. One is that research shows that depression following a loss is similar to, and responds to the same treatments as, depression from many other causes that have long been accepted in the DSM, as I learned in the DSM-5 Pre-Publication Overview online course at psyte-online.com (psyte-online.com/online-courses.html). Sadly but perhaps most importantly to those seeking help, most insurance companies in the U.S. require a DSM-approved diagnosis in order to cover therapy, so including bereavement will enable many more people to get help at a time of great trauma. The “pathologizing” of a natural reaction to loss is a price we must pay for having a private profit-driven health-delivery system, alas.
AnnApril 28th, 2013 at 3:04 PM
The underlying assumption taken and ACCEPTED by everyone who is reacting to this post is interesting; that having a diagnosis of “mental illness” is negative and implies there is something very wrong with you as a human being. The stigma associated with “mental illness” is sounding through in each of the above responses. Perhaps part of this equation is also taking a look at the pathologizing of individuals. PTSD diagnosis as well as Borderline Personality Disorder, … often are a result of a client’s history with very painful and horrible events. In my view, giving a label in those cases is as unacceptable as giving a MDD diagnosis to someone who is grieving. As with grieving, which is an adaptive response, many of the behaviors that have come from past events and learned were adaptive. Isn’t it time we looked at the overall issue of pathologizing and of stigma?
Ronald Pies MDMay 28th, 2013 at 3:11 PM
Contrary to much misinformation and fear-mongering in the press, the DSM-5 doesn’t label ordinary grief as major depression shortly after the death of a loved one. It merely says that the diagnosis of major depression will not be withheld when a person meets the full symptom, severity, duration and impairment criteria for major depression shortly after the death of a loved one (bereavement).
It is true that major depression may be diagnosed within as few as two weeks after the death, but in DSM-5, this is true of any episode of major depression– whether due to bereavement, loss of house and home or no loss at all.
The two-week period may indeed be too short, but the clinician is under no obligation to diagnose major depression in a grieving patient within two weeks after the death of a loved one. Very often a few more weeks of careful assessment are needed, taking into consideration the patient’s past depression history, family history and the cultural or religious factors that may influence the patient’s manner of grieving. Grief is not a disorder, and the DSM-5 doesn’t “medicalize” normal grief. However,we must also avoid normalizing major depression—a potentially lethal but highly treatable condition.
Ronald Pies, M.D.
Linda TiceJuly 9th, 2013 at 7:16 PM
I meet every single one of those. My loss was 11 months ago when my beautiful 26 yr old son got in an argument with my husband and then shot himself in the head with his shotgun. My son was an addict. You well meaning professionals kept calling us enablers and preached tough love. The day we tried it, he was gone. So I don’t think too much of therapeutic methods to begin with. I am deep in grief and between my husband and i we barely get through the basics or life. We don’t eat good, we don’t sleep good, we are preoccupied with our loss, we can’t concentrate, we are deeply sad…what we are is grief stricken not mentally ill. what we know from the people we trust, those who have walked this path is that the only thing that will fix this is time. Every small victory, like going out of town a few weeks ago, or getting through a day without breaking down, laughing at a memory, all those with time will let us move forward but we will never heal the hole in our soul that Billy’s death left and medicine or talk therapy will not either.
KimberleeOctober 24th, 2013 at 3:00 PM
Prayers and hope for you and your family, Linda. There is often more to the story than some professionals and other “helpers” realize and timing can be everything but you had no way of knowing. I hope that there is someone helping you guys…a support group or religious person, someone. We all deserve support and it sounds like you had done all you could think of.
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