Grief, the DSM-5, and Avoiding Checklist Psychiatry

Jeffrey A. Lieberman, MD


June 08, 2012

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Hello. This is Dr. Jeffery Lieberman of Columbia University, speaking to you today for Medscape. As you know, the American Psychiatric Association (APA) is in the process of revising the Diagnostic and Statistical Manual of Mental Disorders into its fifth edition (DSM-5).

There has been a great deal of commentary about the process, both in terms of reports about the progress of DSM-5 development from the APA and commentary from people in the field, including critics and concerned clinicians and academicians. Many have thought that this was a critical, acrimonious debate, but I see it as a dynamic process in which a group of selected experts is working to develop a nosologic system that will guide clinicians to identify and treat people with mental disorders, and is receiving input on the process from observers and interested members of the field and also from the advocacy and consumer communities. Ultimately, this will result in something that is not just a scientifically focused and rigorously developed document, but also one that takes into account various perspectives from all the stakeholders in the area of mental healthcare.

During the past week, the New England Journal of Medicine featured 2 commentaries on the DSM.[1,2] One was by Richard Friedman,[1] who focused on the issue of grief and depression in DSM-5. Dr. Friedman commented that the exclusion of bereavement in the major depression diagnosis should not be eliminated, as is being considered by the DSM-5 depression work group, because it could medicalize what is a normal occurrence in people's lives when they lose a loved one -- something that is part of the mourning or bereavement process. His admonition is to normalize, not medicalize, grief.

This is a valid point of view and one that I am sure the work group will take into account when finalizing their proposed criteria and submitting them for final vetting and approval. This illustrates the give-and-take of the process that I was alluding to: a dynamic method in which criteria are reviewed, revised, vetted, refined, and ultimately finalized before the DSM-5 is rolled out. These comments presumably will be taken into serious consideration.

The second commentary was by Dr. Paul McHugh and Dr. Phillip Slavney[2] of Johns Hopkins University. This was a very thoughtful commentary that reviewed the history of the development of the DSM and tried to put it into a broader context of the current status of psychiatric nosology and, ultimately, the purpose it needs to serve, or the final goals to which any nosologic system aspires.

These authors remind us that the DSM initially emerged as a volume for psychiatric physicians who were interested in describing and understanding the frequency with which mental illnesses developed in our society, as a companion in that respect to the International Classification of Diseases (ICD), which is used internationally in all disciplines of medicine. In 1980, under the leadership of Robert Spitzer, the DSM-III reconceptualized and revolutionized the paradigm of psychiatric diagnosis and moved from a descriptive or conceptual approach to an operationalized, criteria-defining approach, which essentially enabled clinicians to prescribe diagnoses on the basis of whether a patient's symptoms matched the diagnostic criteria.

McHugh and Slavney point out that the primary motivation for this was to establish a higher degree of consistency or reliability within the psychiatric community, which DSM-III very successfully achieved; it improved the consistency and reliability of psychiatric diagnoses across clinicians. The manual did this in a very specific way, which enhanced reliability but deemphasized the issue of trying to understand the conceptual basis of the diagnosis and its underlining etiologic causes.

When DSM-III was first instituted, the expectation was that research would identify the underlying etiologies and pathophysiologic bases of these disorders, which would allow greater refinement of the criteria and ultimately their validation by these biological measures and etiologies. In the DSM-IV and, now, DSM-5, the progress of research has not led to the definitive identification of etiologies or the validation of proven biological measures to define the disorders. We are still using these operational criteria, which elevate the importance of consistency and reliability of diagnoses but do not necessarily advance our understanding of the causes of the disorders.

One of the consequences of this is that there is a risk of combining individuals who have manifestations of any given psychiatric disorder, whether it is depression, anxiety, or an attentional disorder, but who have these symptoms arise from different causes. The example that Drs. McHugh and Slavney give is of an individual who is given a diagnosis of major depression because they have the symptoms fitting the criteria -- but this depression could be a classic form of melancholia, or some type of prolonged bereavement associated with the loss of a loved one, or they may have faced adverse life events that have caused their spirits to plummet for some period of time. The symptoms look the same, but the underlying causes may be different. The authors suggest that this may be why the response rates to antidepressant drugs or any form of treatment for depression in clinical trials may have diminished over time: because of aggregating individuals who have the same symptoms, but from different causes.

What McHugh and Slavney encourage the field to do is to think of ways in which the underlying causal basis of disorders can be considered while diagnosing psychiatric disorders, in the practical and reliable way that they currently are considered according to the DSM methodology. They suggest that when we approach the diagnostic evaluation of patients, not to simply evaluate current symptoms and recent history on the basis of whether they meet criteria or not, but rather to conduct comprehensive life histories of patients, including a developmental history, onset of present illness, course of illness treatment response, family history, and a rigorous evaluation of current mental status -- and in this way, to develop inferences about causal factors at the same time as we establish diagnoses to formulate treatment plans for the current episode.

They outline a couple of ways of organizing diagnoses by different categories that may allow for inferences about causes. They suggest that the 4 categories could be brain diseases (eg, delirium, dementia, schizophrenia); personality disorders (eg, obsessive-compulsive personality or borderline personality); motivational behaviors (eg, eating disorders, such as anorexia or bulimia, or substance abuse, such as alcohol dependence or use); and, finally, life encounters (eg, the experiential events that occasion symptoms that are diagnosable as a mental disorder, such as adjustment disorder or posttraumatic stress injury or disorder).

I recommend to you this very thoughtful article by Drs. McHugh and Slavney in the context of the ongoing process of the development of the DSM-5 and the debate associated with it.

This is a process we will follow through the completion of DSM and its introduction in the next year. This will have an important impact and, hopefully, enhance the ability of the field to address and treat the mental health needs of the patient populations that we serve.

I thank you for tuning in today. This is Dr. Jeffery Lieberman, of Columbia University.


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