DSM-V and grief

Last week, an interesting discussion went on in the comments section of a post we published two years ago entitled DSM-V: Getting Closer to Pathologizing Everyone? In order to give this exchange more visibility, we decided to publish it as a separate contribution. First the remarks of Ronald Pies, columnist at Psychiatric Times, and then the response from Alan Horwitz, author of the initial post. We would like to thank both authors for taking the time to share their thoughts on h-madness.

First, the original comment:

It is technically not true that “…anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder,” either using DSM-IV or the proposed DSM-5 draft criteria. Those features alone would not meet the full criteria set required for MDD. The person would also need to meet the “C” criterion [in DSM-IV] of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Moreover, simply being “sad” does not satisfy the criterion of having “depressed mood most of the day, nearly every day…” for 2 weeks.

Most recently bereaved individuals will not meet full DSM criteria for MDD; do not have a “disorder”; and do not need clinical treatment. Furthermore, there are profound phenomenological differences between ordinary grief and MDD that the experienced psychiatrist will recognize. For example, the ability to be consoled, as Kay Jamison has observed, is typically present in ordinary grief, but rarely in MDD.

That said, many of us believe that the 2-week minimum duration is too short, in most cases, to make a confident diagnosis after bereavement or any other major loss, such as divorce. However, this is irrelevant to the validity of the bereavement exclusion, (BE) and focusing on the 2-week minimum both misses the real point of the debate, and obfuscates the many underlying problems with the BE; e.g., there are no controlled, clinical studies (as contrasted with community survey data) of bereaved, MDD patients to support the BE.

The 2-week minimum is a separate problem that must be addressed separately, and in no way justifies continuing the BE. Leaving the BE in the DSM-5 will not fix the general problem of the 2-week interval. Indeed, elimination of the BE from DSM-5 would also rid us of the bogus, 2-month limit on the duration of “normal” bereavement, for which there is no scientific or clinical basis. Ordinary grief related to bereavement is quite distinct from MDD, and may go on for months or even years; it is not a disorder, nor does it require treatment, if the grieving person functions adequately in the social, vocational, and interpersonal spheres.

I hope that readers will take a look at my upcoming blog on the Psychcentral website, entitled, “Grief, Bereavement, and the DSM-5: How the Public is Being Misinformed.” Also, I have developed a preliminary screening instrument, called the PBPI, aimed at helping clinicians distinguish, phenomenologically, between ordinary grief and MDD. It may be found on the Psychiatric Times website, after a free registration step, under the title, “After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI, A Potential Assessment Tool.”

Ronald Pies MD

For further reading:

Pies R. The two worlds of grief and depression. http://psychcentral.com/blog/archives/2011/02/23/the-two-worlds-of-grief-and-depression/. Accessed January 27, 2012.

Zisook S, Shear K: Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.

Zisook S, Reynolds CF 3rd, Pies R, et al. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010;71:955-956.

Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the diagnosis of major depression: to be or not to be? Psychiatry (Edgmont). 2010;7:19-25.

Jamison KR. Nothing Was the Same. New York: Vintage Books; 2011.

Then, the response from Alan Horwitz:

Before the DSM-5 Task Force began its deliberations, the idea that normal grief could be a psychiatric disorder would have seemed preposterous. Freud, for example, following thousands of years of psychiatric thought, noted that:
“Although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. We rest assured that after a lapse of time it will be overcome, and we look upon any interference with it as inadvisable or even harmful.”
Indeed, the notion that grief is a natural reaction to the death of an intimate is so deeply commonsensical that the general definition of mental disorder in the DSM itself uses it as the sole example of a condition that should not be considered disordered: “(Mental disorder) must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.”
There are also good empirical reasons for the bereavement exclusion. One of the causes for the original exclusion in the DSM-III was psychiatrist Paula Clayton’s findings that over 40 percent of individuals who had suffered the death of an intimate would meet the MDD criteria in the absence of the bereavement exclusion. Since Clayton used a one-month, rather than the existing two-week, duration that Pies’ suggestion would entail, a majority of the population could likely be diagnosed with major depression using the current diagnostic standards without the exclusion.
A recent study by Ramin Mojtabai uses prospective data from to test the validity of the bereavement exclusion by comparing the prognosis of bereaved and non-bereaved people who have had depressive episodes. Majtabai’s findings show that three years after the initial episode the rate of depression among the bereaved group (8.2%) was comparable to those who were never depressed (7.5%) but significantly lower than the depressed group that was not bereaved (14.7%). Bereaved people are no more likely than people who are not depressed to have subsequent depressive episodes; the prognosis of bereavement is benign compared to other depressed persons; and grieving people, as Freud predicted, are likely to self-heal without treatment. Providing further evidence for the wisdom of maintaining the bereavement exclusion, Majtabai also found that compared to those with other depressive episodes, respondents with bereavement-related episodes were less likely to have impaired role functioning, psychiatric treatment, or comorbid disorders. These findings are likely to understate the differences between the bereaved and others who met MDD criteria because the latter group included people who met these criteria because of other types of losses. Were this group excluded from the MDD group, the differences between the bereaved and non-bereaved group likely would have been even larger.
So, thousands of years of psychiatric history, common sense, and empirical findings all indicate that grief is a natural response to serious loss, not a mental disorder. Why then, does Pies suggest eliminating the current bereavement exclusion? Because the clinical significance criterion of the MDD diagnosis also requires: “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Therefore, according to Pies, only distressed or impaired grieving people will be diagnosed as depressed in the absence of the exclusion. Pies’ rational is odd: obviously grief involves distress. It is part of our nature as humans to feel intense distress after the loss of a loved one. The clinical significance criterion will do nothing to stop the enormous pathologization of grief that abandoning the grief exclusion would entail.
Pies’ eccentric view flies in the face of empirical research, common sense, and thousands of years of psychiatric history, as well as the definition of mental illness in general and depressive disorder in particular, in every previous edition of the DSM. There is no better illustration of the intellectual bankruptcy of current mainstream psychiatric thought than the fact that the DSM-5 is likely to embrace this view. The general public will justifiably be astonished and scornful of the abandonment of the idea that grief is a natural part of life.

Talk and Exhibition: Shakespeare and the Four Humors (Bethesda, Maryland)

History of Medicine Division Lecture
Tuesday, February 28, 2012, 2:00 – 3:30 p.m.
Lister Hill Auditorium
NLM Building 38A
Bethesda, MD

Dear NLM Colleagues,

You are cordially invited to the next History of Medicine lecture, to be
held Tuesday, February 28, 2012, from 2:00 to 3:30 p.m., in Lister Hill

“Shrew Taming and Other Tales of the Four Humors”

Dr. Gail Kern Paster,
Folger Shakespeare Library

William Shakespeare is widely praised for creating the most recognizable
characters in all of literature, yet he understood human behavior in the
terms available to his age–the classical theory of the four humors of
blood, phlegm, choler, and melancholy. These humors accounted for the
health and actions of male and female, young and old, rich man and poor
man. It was the darker emotions of anger and melancholy that preoccupied
Shakespeare, especially as they appeared in the madness of Ophelia and the
shrewish resistance of Katharine Minola to her female destiny of wifely

This lecture is being held in conjunction with NLM’s newest exhibit, “‘And
there’s the humor of it’ – Shakespeare and the four humors,” a display,
online exhibition, and traveling banner exhibition featuring treasures
from NLM and the Folger Shakespeare Library

All are welcome.

Sign language interpretation is provided. Individuals with disabilities
who need reasonable accommodation to participate may contact Stephen
Greenberg at 301-435-4995, e-mail greenbes@mail.nih.gov, or the Federal
Relay (1-800-877-8339).

Sponsored by
NLM’s History of Medicine Division
Jeffrey S. Reznick, PhD, Chief

Event contact:
Stephen J. Greenberg, MSLS, PhD
Coordinator of Public Services
History of Medicine Division
National Library of Medicine, NIH

Meet the historian: Sally Alexander

MEET THE HISTORIAN: Sally Alexander, 6pm, 22 Feb 2012, Room 104, South Block, Senate House, London WC1E 7HU
History Lab’s ‘Meet the Historian’ events are an opportunity to hear at first hand from noted historians how and why they became historians in the first place, their thoughts on research and the discipline generally, and about their latest work. There will be the chance to ask questions and enter into discussion, and to join the speaker for drinks after the talk.
Sally Alexander is Professor of Modern History at Goldsmiths, University of London. She has been an editor of History Workshop Journal since its foundation in 1976 and her research interests lie in the history of social movements, feminism in particular, London history, the history of psychoanalysis, oral history and subjectivity. Co-convenor of the Modern British History seminar and Psychoanalysis and History at the IHR, she is currently editing, with Professor Barbara Taylor, a volume on Psychoanalysis and History for Palgrave, 2012.

Grief Exclusion and DSM V

A recent report in the popular press cites Kenneth Kendler and Arthur Kleinman on the pathologization of grief.

CfP – Pain and Old Age


Public Conference: 27 October 2012

The Birkbeck Pain Project and the Birkbeck Institute for the Humanities

Birkbeck, University of London

Organised by Visiting Fellow to the Birkbeck Pain Project, Prof. Lynn Botelho (Department of History, Indiana University of Pennsylvania)

According to the British Pain Society, ‘pain is not a normal part of ageing’ (2008). Yet for generations of older people, pain was something that was intimately tied to the ageing process. For many, it was the body in pain that signalled their entry into old age. Furthermore, the elderly have not wanted to be a ‘burden’ to their families, friends, and support systems, and consequently they often endured pain with a quiet acceptance. When did this relationship between pain and old age undergo such a profound and fundamental shift? Or, did it? Were the elderly in the past always quietly accepting of the aches and pains of a physically declining body? Or did they fight against pain and the very real physical, emotional, and familial restrictions that chronic pain can impose?

This one-day conference explores the nature of pain in old age between the 18th and the 20th centuries. It explicitly does so through the lens of the humanities, rather than hard sciences. The conference strives to be wide-ranging in terms of disciplines, methodologies, and approaches. In doing so, it seeks to engage both panellists and audience in discussion, dialogue, and debate. Our aim is to facilitate new ways of thinking about both the nature of pain and what it meant to be old.

Possible paper topics might include, but are not limited to

  • Pain, old age and social relationships (partner, children, friends, neighbours)
  • Pain and sexual relations
  • The philosophy of pain
  • Pain and the ageing self
  • Pain as a marker of old age
  • Pain, piety, and religion
  • Representations of pain and old age in literature, art, and autobiography
  • Pain as a mechanism of self-fashioning
  • Pain clustering and the loci of pain, including physical, emotional, and spiritual pain
  • The elderly’s engagement with medicine and medical practitioners
  • The medical community’s response to pain in the old

Please send a 300-500 word abstract and a short C.V. by email to Lynn Botelho (Botelho@iup.edu) by 1 June 2012.

More information regarding the The Birkbeck Pain Project is available here.

Call for Papers: Second International Health Humanities Conference on Music, Health, and Humanity


Music, Health, and Humanity
The Colleges of the Arts and of the Humanities and Social Sciences at Montclair State University, New Jersey, USA, are hosting the Second International Health Humanities Conference from Thursday-Saturday, 9, 10, 11 August, 2012.


In accordance with the interdisciplinary nature of the Health Humanities, we invite the participation of colleagues from music, other arts disciplines, the humanities, and clinical health backgrounds who wish to participate in an exploration concerning the various relationships among music, health, and humanity. We encourage individual and group (colloquium) presentations addressing theory, practice, and/or research (in progress or
completed), addressing questions and issues pertinent to the conference theme. Example include (but are not limited to):
– How do the critical intersections of music and health manifest across other arts
modalities (visual art, dance, drama, etc.), and across the various humanities disciplines
(history, philosophy, literature, languages, law, etc.)? How do each of these
manifestations inform us about the role of music in expressing, communicating, and
promoting human health (physical, mental/emotional, social, etc.)?
– What is the role of music in the well being of communities, culture, and humanity?
– How do musical works and discourses about music raise and/or address issues
concerning gender, sexuality, ethnicity, age, economics, and power?
– In what ways does music represent “social capital,” and what are the implications for
one’s socioeconomic health?
– What are the manifestations and roles of music in fictional and non-fictional literature
conveying narratives relevant to health?
– What are some of the ways in which the field of music therapy can be understood from a
health humanities perspective? Is there social legitimacy and economic viability in such a perspective? How can this perspective be differentiated from, yet play a complementary role with, a health science perspective?
Please Note: We also invite proposals for at least one broad-based colloquium addressing
more general relationships among the arts, humanities, and health (not necessarily centered
upon music).
We foresee the publication of papers (expanded, revised and submitted to a peer-review
process) in one or more volumes post-conference, according to principles of intellectual and
theoretical coherence that will give such publications editorial consistency.


Deadline is 1st April 2012.

For more information, see http://www.montclair.edu/health-humanities-conference/index.php

For the online application, see https://surveys.montclair.edu/survey/entry.jsp?id=1320899564175

Call for Papers: “Theatre, Performance, Madness, and Psychiatry”

Below you will find a call for papers for an international conference on the subject of Theatre, Performance, Madness, and Psychiatry. This interdisciplinary conference is part of an AHRC funded project to investigate the history of performance in, and about, psychiatric asylums and hospitals since the 19th century. The conference will take place on 17th an 18th of September 2012 at Corpus Christi College, Cambridge and we welcome abstracts from across all disciplines. It is anticipated that selected papers from the conference will be included in the publication that is being produced as part of the grant. Please follow this link for further details on the project.

If you require any further info, please do not hesitate to get in touch. All details are included in the e-flyer.

Best Wishes,
Dr Anna Harpin

Lecturer in Drama
Co Artistic Director of Idiot Child
Trustee of Stepping Out Theatre Company

University of Exeter
Department of Drama
College of Humanities
New North Road

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