“Pain is inevitable; suffering is optional”– Buddhist proverb
I’ve been reading about the ongoing and sometimes rancorous debate about whether or not to eliminate the bereavement exclusion (BE) from the diagnostic criteria for Major Depressive Disorder (MDD).The participants are very learned, very passionate about their positions, and often marshal very complex arguments in favor of them. I find it a little difficult to follow at times.To diagnose grief or not to diagnose grief…is this the question?
I like to keep this simple whenever I can. If I organized this post to give everyone a thorough hearing, it would be rough-going. So this is going to have a collage feel to it. Let’s start with a bare bones outline of the arguments for and against removing the BE as succinctly put by the Editor in Chief of Psychiatric Times:
The Bereavement Exclusion (BE) Debate:
BE should stay:
Loss of BE pathologizes normal grief
- Loss of BE risks blurred boundaries between grief and MDD
- We’ve had 30+ years of BE–“if it ain’t broke, don’t ‘fix’ it”
- But for BE, a significant proportion of normally grieving individuals would meet MDD criteria during the first 2 months after the loss
BE should go:
- No study has demonstrated that patients with normal grief are mistakenly “overdiagnosed” with MDD
- No evidence to support separation of loss of loved one from other stressors
- Keeping BE interferes with diagnosis and treatment of potentially serious depression
- No compelling clinical evidence that BE criteria represent a “clarifying” or clinically useful construct 
And probably one of the best articles to read for background on the subject is by Lamb and colleagues (including Dr. Ronald Pies, MD) . See the web link to read the paper, including the arguments for removing the BE exclusion, The Bereavement Exclusion for the Diagnosis of Major Depression. I really loved Dr. Ronald Pies’ most recent blogs in Psychiatric Times on the conflict. In the most recent one he called for an independent “blue ribbon” scientific panel review of the BE exclusion issue . I doubt he meant the Scientific Advisory Committee of the Association for Death Education and Counseling (ADEC), but they did review the question in a 2011 issue of Omega . Balk and colleagues eventually came down on the side of keeping the BE exclusion (Dr. Pies favors getting rid of the BE exclusion), but I was more intrigued by the opinions of the clinicians they surveyed:
“Normal grief hurts, but it does not make us ill.”
“To me the question is not ‘is emotional pain necessary?’ Emotion is necessary. And sometimes the emotion is painful. Emotion has survived the evolutionary process because it serves a purpose–it focuses our attention and directs our activity…”The question is not whether we need to feel pain, but what point the pain is destructive, ruminative–in other words, when it makes us ill.”
“Recognizing that a person has symptoms that are beyond normal grief doesn’t have to mean that we give everyone with these symptoms medication.”
“…as a clinician, I am interested in diagnostic categories only insofar as they help me a) understand the client in front of me and b) help me know what to do to help that client deal with their problems….As such, I tend to think much more in terms of symptoms, and ‘solutions’ for those symptoms that people are experiencing, rather than diagnostic categories as reified, real entities.”
“To paraphrase someone whose name I cannot recall, I am as or more interested in the person who has the diagnosis as I am in the diagnosis the person has, and diagnostic categories are, in my view, only a tool that helps me better understand that person. I think most experienced clinicians function this way in the ‘real’ world, and so the question of whether to change the DSM exclusionary criteria around depression and bereavement will not meaningfully change how I practice.”
There is a major push to help clinicians, whether they’re mental health specialists for primary care clinicians, to learn the difference between MDD, normal bereavement, and an entity that is variously referred to as “complicated grief” and prolonged pathologic grief–but I had to look long and hard for clear diagnostic criteria for the latter:
Proposed Criteria for Complicated Grief:
A. The person has been bereaved, i.e. experienced the death of a loved
one, for at least 6 months
B. At least one of the following symptoms of persistent intense acute
grief has been present for a period longer than is expected by
others in the person’s social or cultural environment
1. Persistent intense yearning or longing for the person who died
2. Frequent intense feelings of loneliness or like life is empty or
meaningless without the person who died
3. Recurrent thoughts that it is unfair, meaningless, or unbearable
to have to live when a loved one has died, or a recurrent urge to die
in order to find or to join the deceased
4. Frequent preoccupying thoughts about the person who died, e.g.
thoughts or images of the person intrude on usual activities or
interfere with functioning
C. At least two of the following symptoms are present for at least a
1. Frequent troubling rumination about circumstances or
consequences of the death, e.g. concerns about how or why the
person died, or about not being able to manage without their loved
one, thoughts of having let the deceased person down, etc.
2. Recurrent feeling of disbelief or inability to accept the death, like
the person cannot believe or accept that their loved one is really
3. Persistent feeling of being shocked, stunned, dazed or
emotionally numb since the death
4. Recurrent feelings of anger or bitterness related to the death
5. Persistent difficulty trusting or caring about other people or
feeling intensely envious of others who have not experienced a
6. Frequently experiencing pain or other symptoms that the
deceased person had, or hearing the voice or seeing the deceased
7. Experiencing intense emotional or physiological reactivity to
memories of the person who died or to reminders of the loss
8. Change in behavior due to excessive avoidance or the opposite,
excessive proximity seeking, e.g. refraining from going places,
doing things, or having contact with things that are reminders of
the loss, or feeling drawn to reminders of the person, such as
wanting to see, touch, hear or smell things to feel close to the
person who died. (Note: sometimes people experience both of
these seemingly contradictory symptoms.)
D. The duration of symptoms and impairment is at least 1 month
E. The symptoms cause clinically significant distress or impairment
in social, occupational or other important areas of functioning,
where impairment is not better explained as a culturally
appropriate response 
And there are a number of rating scales available for measuring grief, although I don’t have any idea how often clinicians use them. One of the better validated is the Inventory of Complicated Grief . Dr. Pies and other colleagues are working on a scale called the Post-Bereavement Phenomenology Inventory (PBPI) .
What do patients think about the issue? Again, I have Dr. Pies to thank for the referral to a blog, http://prozacmonologues.blogspot.com/2012/02/griefdepression-iii-telling-difference.html, a quote from which is telling:
“The Difference Between Grief and Depression
There is the difference between grief and Big-D Depression. It’s just not in the DSM. The proximate cause of the symptoms is not sufficient to tell the difference. Neither is two weeks. Neither is two months.
The point is, it is perfectly possible to have both. People who have life-threatening depression can lose a loved one, just as easily as people who do not have a life-threatening depression. Bereavement is not a protective factor. In fact, it is a risk factor. People who have Big D- depression need treatment, regardless of whether their depressed mood makes sense in their context.”
A collage really doesn’t have a beginning, middle, and end. So how do I wrap up a collage? Clinicians, patients, and families will just have to talk together about what loss means and decide what, if anything, needs to be done to help healing take place. I hope common sense will be our guide, though I’m painfully aware that common sense is not applied commonly. I’m sure that when all is said and done…someone will go right on talking.
1. Knoll, J. L., IV, MD (2012) Sinking Into Grief. Psychiatric Times 22.
2. Lamb, K., R. Pies, et al. (2010). “The Bereavement Exclusion for the Diagnosis of Major Depression: To be, or not to be.” Psychiatry (Edgmont) 7(7): 19-25.
This paper reviews studies bearing on the validity of the bereavement exclusion for the diagnosis of major depression. It concludes that the exclusion is not supported by the best available data, and the authors propose revisions for Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition.
3. Pies, R. W., MD (2012) DSM-5’s Bereavement Bind: Time for an Independent Review. Psychiatric Times 22.
4. Balk, D. E., I. Noppe, et al. (2011). “Bereavement and depression: possible changes to the diagnostic and statistical manual of mental disorders: a report from the Scientific Advisory Committee of the Association for Death Education and Counseling.” Omega 63(3): 199-220.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is being revised. A proposed revision hotly debated is to remove what is known as the exclusionary criterion and allow clinicians to diagnose a person with a major depressive episode within the early days and weeks following a death. The Executive Committee of the Association for Death Education and Counseling (ADEC) commissioned its Scientific Advisory Committee (SAC) to examine the debate over removing the exclusionary criterion and provide a written report. The DSM-IV-TR classifies bereavement as a clinical condition that is not a mental disorder. The exclusionary criterion states that within the first 2 months of the onset of bereavement a person should not be diagnosed as having major depression unless certain symptoms not characteristic of a normal grief reaction are present. We note these symptoms when discussing the exclusionary criterion. In the report we identify the features that comprise the exclusionary criterion, examine reasons (including research conclusions and clinical concerns) given for retaining and for eliminating the exclusionary criterion, offer extensive comments from experienced licensed clinicians about the issues involved, discuss diagnostic and treatment implications, and offer specific recommendations for ADEC to implement.
5. Shear, M. K., N. Simon, et al. (2011). “Complicated grief and related bereavement issues for DSM-5.” Depression and Anxiety 28(2): 103-117.
Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders. Depression and Anxiety, 2011. © 2011 Wiley-Liss, Inc.
6. Prigerson, H. G., P. K. Maciejewski, et al. (1995). “Inventory of complicated grief: A scale to measure maladaptive symptoms of loss.” Psychiatry Research 59(1–2): 65-79.
Certain symptoms of grief have been shown 1. (a) to be distinct from bereavement-related depression and anxiety, and 2. (b) to predict long-term functional impairments. We termed these symptoms of “complicated grief” and developed the Inventory of Complicated Grief (ICG) to assess them. Data were derived from 97 conjugally bereaved elders who completed the ICG, along with other self-report scales measuring grief, depression, and background characteristics. Exploratory factor analyses indicated that the ICG measured a single underlying construct of complicated grief. High internal consistency and test-retest reliabilities were evidence of the ICG’s reliability. The ICG total score’s association with severity of depressive symptoms and a general measure of grief suggested a valid, yet distinct, assessment of emotional distress. Respondents with ICG scores >25 were significantly more impaired in social, general, mental, and physical health functioning and in bodily pain than those with ICG scores ≤25. Thus, the ICG, a scale with demonstrated internal consistency, and convergent and criterion validity, provides an easily administered assessment for symptoms of complicated grief.
7. Pies, R. W., MD (2012) After Bereavement, Is It “Normal Grief” or Major Depression?
The PBPI: A Potential Assessment Tool Psychiatric Times 22,