Wednesday, May 19, 2010
The Diagnostic and Statistical Manual of Mental Disorders has probably been the most widely used classification in clinical practice since the publication of DSM-III in 1980. The manual is now in its fourth edition (DSM-IV-TR) and work is underway to create the next edition, DSM-V. A major change is proposed to the diagnosis of Major Depressive Disorder. According to the current criteria, the occurrence of one or more major depressive episodes (MDE) is the main feature of Major Depressive Disorder, and one of the exclusion criteria for MDE is bereavement. In other words, the diagnosis should not be made if the syndrome follows the death of a loved one - unless the symptoms are too extreme or too persistent to represent bereavement. The proposal for DSM-V involves removing this bereavement criterion. This proposal, if it is accepted, has the advantage of making the criteria more free from judgment - ie. more purely empirical, which may increase their utility for research. However, it also represents a broadening of the diagnostic criteria. This will mean that episodes previously regarded as grief-reactions will now qualify for a diagnosis of a mood disorder. Whether such episodes should be treated 'as if' they were the same as other mood disorders is a different question - one suspects that they should not be. An argument has been put forward that in some respects the exclusion for bereavement is arbitrary - other losses (employment, relationship, health-related) are not treated as exclusions in DSM. On the other hand, depressive symptoms following losses may represent an adaptive response of some type - and certainly it seems to be a 'natural' response to many people. A general principle seems to hold true: that as diagnostic categories widen they become more heterogeneous which probably means that the clinical response to them should be more flexible.