Abstract
The controversial debate on whether to remove the bereavement exclusion from the DSM’s depression criteria has mostly focused on whether depression and grief related distress are in fact distinct. Those who argue for the removal provided scientific evidence for the truth of this claim, while those argue against it suggested that the cited evidence base is slim. Despite heated controversy, the change took place. In this article, I use a different argument to address the problems with this change in the DSM-5. Even if we assume that there is no meaningful difference between the properties of grief-related distress and depression symptoms, diagnosing the grieving individual with depression is not the best therapeutic approach to address their needs.
“There is nothing more terrible, I learned, than having to face the objects of a dead man. Things are inert: they have meaning only in function of the life that makes use of them. When that life ends, the things change, even though they remain the same. They are there and yet not there: tangible ghosts, condemned to survive in a world they no longer belong to. What is one to think, for example, of a closetful of clothes waiting silently to be worn again by a man who will not be coming back to open the door?…Or a dozen empty tubes of hair coloring hidden away in a leather traveling case? – suddenly revealing things one has no desire to see, no desire to know. There is poignancy to it, and also a kind of horror. In themselves the things mean nothing, like the cooking utensils of some vanished civilization. And yet, they say something to us, standing there not as objects but as remnants of thought, of consciousness, emblems of solitude in which a man comes to make decisions about himself: whether to color his hair, whether to wear this or that shirt, whether to live, whether to die. And the futility of it all once there is death.”
(Paul Auster 1982, pp. 10–11)
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- 1.
I use the word “erosion” because the DSM’s removal of the bereavement exclusion criterion from the depression category has been an extended process, starting with the publication of the DSM-III (1980) and ending with the APA (2013). In other words, the “erosion problem” existed long before the DSM-5 was published. Section “DSM Hyponarrativity and Grief Erosion” summarizes this process. Inspiration for this concept comes from Alan Horwitz and Jerome Wakefield’s Loss of Sadness (2007).
- 2.
In a National Public Radio interview, Sidney Zisook said: “I’d rather make the mistake of calling someone depressed who may not be depressed, than missing the diagnosis of depression, not treating it, and having that person kill themselves” (Zisook 2010).
- 3.
I do not claim that all those in grief must be clinically treated. Rather, my focus is on those who have difficulty coping with their loss on their own, and who need clinical assistance. This is known as complicated grief in the medical literature, including the DSM-5. Throughout the essay, whenever I indicate “grief related distress” I refer to complicated grief.
- 4.
Grief generating loss includes the death of a loved one, loss of home, property, employment, as well as losses due to a natural disaster. In this article, I limit my discussion to bereavement.
- 5.
The symptom-based approach is also known as “atheoretical” or “purely descriptive.”
- 6.
See also Tsou’s chapter in this volume for a detailed discussion about the theoretical and descriptive views of psychiatry.
- 7.
This move was influenced by the rise of logical positivism and the development of computer assisted diagnosis, i.e., DIAGNO by Robert Spitzer and Jean Endicott (1968).
- 8.
Among the examples for psychological symptoms comes depression as mood related; obsessive thoughts as thought related; memory problems as related to cognitive functioning. Symptoms of anxiety (e.g., palpitation) and disturbances of vegetative functions (e.g. appetite loss, weight gain) are included among physical symptoms (APA 1994; Fulford et al. 2006;).
- 9.
Another argument for a symptom-based approach is to model mental disorders following physical diseases. For instance, from a nosological point of view it does not matter if someone has lung cancer because he smokes too much, or because he lives in a polluted city, or because he is unlucky. Whatever the cause, his disease is lung cancer. A similar reasoning is at play with depression and the DSM-5: the cause of the symptoms does not matter; a disease is not defined by its cause, but by its symptoms and signs. Context does not dissolve disorder, even if it seems to explain it. In fact, to further research into the genetic and neural underpinnings of mental disorders, it might be necessary to isolate the content from the context, and focus exclusively on the observable properties of mental disorders. I thank Steeves Demazeux and Patrick Singy for their helpful input on this point.
- 10.
The “evidence” is one review paper (Zisook and Kendler 2007) which purports to show that bereavement-related experiences are generally similar to the symptoms of standard depression; including extreme sadness, disturbed sleep, disturbed appetite and energy, agitation, difficulty concentrating, etc. Some have taken issue with the vagueness of the notion of “similarity” and the slim evidence provided, but their concerns have not affected the DSM outcome (First and Wakefield 2012).
- 11.
It is beyond the scope of this paper to discuss whether re-appraising the self-related aspects of encounter with mental disorder is even possible within the framework of the DSM project.
- 12.
The limitations of the symptom-based approach are acknowledged in the introduction to DSM-5, which emphasizes that a categorical approach to classifications works best when all members of a class are homogeneous, when there are clear boundaries, and when the different classes are mutually exclusive. It acknowledges that this is not the case in mental disorders. Patients, even if they share a diagnosis, form heterogeneous classes, as each has a unique encounter with mental disorder, due to the contingencies of her own life. Further, using the categorical system does not assume clear boundaries between different mental disorders (APA 2013, 19–20). Despite these shortcomings, the DSM is considered able “to assist trained clinicians in the diagnosis of their patients’ mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual” (APA 2013, 20).
- 13.
I am not suggesting that a symptom-based approach to mental disorder is completely wrong, I am suggesting that it is incomplete, i.e., it only captures some aspects of a mental disorder, and leaves out the subjective aspects. This may have some advantages, but when it comes to individual’s reflection on her condition, a symptom-oriented approach, as opposed to a more integrated one, has negative implications.
- 14.
The “self” is introduced in the DSM for the first time via the general definition of personality disorders in the DSM-5 (APA 2013). My focus here is on mood related disorders.
- 15.
Research in psychology indicates the positive influence of a detailed language of emotion on subjects’ responses to traumatic life experiences. For instance, in a study conducted among families with preadolescent children, Robyn Fivush et al. found that family narratives in which specific emotions were expressed and explained in a collaborative fashion, while acknowledging especially the negative emotions, were positively related to preadolescents’ reported competencies and self-esteem. However, family narratives expressing very general positive emotions and neglecting negative emotions were negatively related to preadolescents’ competencies (Marin et al. 2008). These studies support the idea that a detailed understanding of subjective experience of mood disorders has a significant influence on an individual’s ability to cope with her mood disorder.
- 16.
Pennebaker et al. write: “When individuals write or talk about personally upsetting experiences in the laboratory, consistent and significant health improvements are found. The effects are found in both subjective and objective markers of health and well-being. The disclosure phenomenon appears to generalize across settings, most individual differences, and many western cultures, and is independent of social feedback” (Pennebaker et al. 1997, 164).
- 17.
Pennebaker et al.’s analysis of data from six writing studies found three linguistic factors reliably improved physical health. First, the more that individuals use positive emotion words, the better their subsequent health. Second, a moderate number of negative emotion words predicted health. Both very high and very low levels of negative emotion words correlated with poor health. Third, an increase in both causal and insight words over the course of writing was strongly associated with improved health (Pennebaker et al. 1997, 165).
- 18.
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Acknowledgments
I would like to thank Patrick Singy, Steeves Demazeux, George Graham, Hanna Pickard, Owen Flanagan, and Jennifer Radden for their helpful comments on this article. The paper was presented at the University of Western Michigan Medical Humanities conference in September 2013; I also thank the audience for their comments.
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Tekin, Ş. (2015). Against Hyponarrating Grief: Incompatible Research and Treatment Interests in the DSM-5. In: Demazeux, S., Singy, P. (eds) The DSM-5 in Perspective. History, Philosophy and Theory of the Life Sciences, vol 10. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-9765-8_11
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