Some psychiatrists, however, lambasted the proposed revisions as far too complex and burdensome, arguing that no clinician would ever use the new system. The work group continually revised the proposal, simplifying it as much as possible, and won approval from the DSM-5 Task Force. But the APA Board of Trustees ultimately voted against the proposed changes, according to Andrew Skodol of the University of Arizona College of Medicine, a member of the Personality Disorders Work Group. As a result, the DSM-5 chapter on personality disorders is more or less the same as the DSM-IV chapter. Skodol is not sure why the Board of Trustees rejected the proposal at the 11th hour, but "there was a lot of behind-the-scenes lobbying to keep things the way they were," he says. The work group's proposal has been relegated to a back section of the manual to "encourage further study."

Recognizing that grief can quickly precipitate depression
Symptoms of depression—such as low mood and energy, insomnia, feelings of worthlessness, loss of pleasure and change in weight—must persist for at least two weeks to meet the DSM-IV criteria for a major depressive episode. The DSM-IV stipulates, however, that someone who has recently lost a loved one should not receive a diagnosis of depression unless the relevant symptoms last longer than two months. The idea is that, in these cases, what looks like major depression is probably bereavement—more commonly known as grief—a typical and transient response to loss that does not require medication. The DSM-5 has eliminated this "bereavement exclusion" and replaced it with a few footnotes describing the differences between grief and depression. Now, someone can be diagnosed with depression, and ask their insurance company to cover the costs of antidepressants, as well as talk therapy or other treatment, in the first two months following the death of a loved one.

Richard Friedman of Weill Cornell Medical College and others have criticized this decision, worrying that it will encourage overdiagnosis and overmedication. According to the APA, however, the change reflects the new understanding that bereavement is a severe stressor that can precipitate a major depressive episode relatively quickly.

Some studies have shown, for instance, that symptoms of depression co-occurring with bereavement are similar to depression unrelated to bereavement in their severity and duration, response to antidepressants and long-term outcomes. Therefore, the reasoning goes, people who are grieving and clinically depressed within two months of a loss should have access to treatment. Similarly, some researchers have questioned why, when it comes to identifying depression, the DSM makes an exception of grief following the death of a loved one, but not of any other kinds of loss or psychosocial stress such as divorce, unemployment, financial failure or romantic rejection. The International Classification of Diseases, published by the World Health Organization, makes no such exceptions.

In an article published in Depression and Anxiety in May 2012, Sidney Zisook of the University of California, San Diego, and his co-authors examined the results of several review papers and studies and concluded that the available evidence supports the removal of the bereavement exclusion from DSM-5. "Acknowledging that bereavement can be a severe stressor that may trigger an MDE [major depressive episode] in a vulnerable person does NOT medicalize or pathologize grief!" they wrote (emphasis theirs). "Rather, it prevents MDE from being overlooked or ignored and facilitates the possibility of appropriate treatment. Furthermore, removing the BE [bereavement exclusion] does not imply that grief should end in two months. Indeed, for many individuals, grief lasts for months, years or even a lifetime in its various manifestations, whether or not it is accompanied by MDE."

8 Comments

1. 1. Franklinskid 02:45 PM 1/28/13

   I see nothing here addressing Complex Post Traumatic Stress as a disorder or syndrome or recognizing it at all. Did that not make the cut for this latest manual, or just not for this article?

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2. 2. Geologon 05:18 AM 1/29/13

   I suspect that these manuals tend to disregard many disorders, as insurance companies prefer it that way.

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3. 3. alice w 07:22 AM 1/29/13

   A travesty of scientific evidence
   
   APA does not seem too worried about the serious risk of false positives, which may have dire negative consequences such as unsuitable drugs, professional exclusion, social labelling.
   
   Reads like a conspiracy between insurance companies and mental health professionals, in which mess people with serious and curable syndromes may well be missed.
   

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4. 4. stuball21 08:20 AM 1/29/13

   You didn't discuss the changes in the eating disorder criteria that are also rather controversial.

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5. 5. Diesel67 08:01 PM 1/29/13

   I suspect that this manual will continue to pathologize normal variants of the human personality, and stigmatize those bearing them. While in school, I tended to fidget and look out the window. Now I'm told that that's a symptom of "attention deficit disorder" for which powerful psychoactive drugs are indicated. Never mind that I maintained a 90+ average throughout. Never mind that our ancestors needed a periodic fix on their surroundings if they expected to be the diner and not the dinner. Never mind that our ancestors made their living running for hours on end and killing large animals with primitive weapons. Nothing in biology makes sense except in the light of evoluton, but that doesn't stop fat pigs behind desks from dispensing psychiatric diagnoses to robust healthy rambuntious kids.
   I was never good at matching names with faces or interpreting body language. Now I'm told those are symptoms of Asperger's Syndrome; never mind that I compensate very well with written and spoken language and I do not consider myself sick.
   Hardly a day passes when I do not think of President Kennedy. This does not affect my functioning in the least, except on November 22, the anniversary of his assassination, when I am not in the mood for entertainment or Thanksgiving dinner. Now I'm told I have "complicated grief," but all I experience is natural grief for a political idol the like of whom I do not expect to see again in my lifetime.
   All this is giving me (complicated?) grief, and calls to mind the abuse of psychiatry by the Soviets to quell political dissent. If you have a biochemical, brain imaging or other definitive test for your diagnosis - fine. Otherwise, throw away the cookie cutter and celebrate humanity's pizzazz.

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6. 6. American Muse 03:02 PM 1/30/13

   Geez! Another bestseller for APA. More money folks.

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7. 7. Michael M 12:15 PM 1/31/13

   Unfortunately, commentors are not familiar with the body of work done on DSM, not to mention the study required to become conversant with psychology.
   
   To address only a couple misunderstandings:
   DSM is a large manual, far beyond the 7 extremely short pages of this article.
   
   Unedited internet comments on subjects which take decades of study to develop coherent understanding are particularly inappropriate.
   
   Although I've studied psychology and related disciplines for sometime, I did not do so for therapeutic reasons. That said, almost no comment on the subject on this or other websites takes into account the real empathy which those involved in the therapeutic disciplines and the development of DSM, as well, have for others, ALL others.
   SA is not a panacea site such as MSN Health or any site in which glib curealls are offered for illness or personal difficulties or desires. It is a digest of information which might be used as portal to specific peer-reviewed literature for those who seek knowledge of rigorous research encompassing the lifetimes of hundreds of thousands of dedicated individuals.
   
   I am framing my criticism in terms of a social problem: failure of many in society to respect others, and promoting this disrespect of individuals, groups, and disciplines of professional dedication (ANY discipline, whether within their own culture or outside of it), through using internet comment as aggressive outlet for personal frustration elsewhere.
   
   Commentors might look more insightuflly into their own motivations before attacking others.
   

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8. 8. endo_alley 05:37 PM 5/6/13

   How about G.A.S. ? Guitar Acquisition Syndrome? http://www.steelydan.com/gas.html
   Luckily I've recovered. Sadly many haven't.

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