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Loss of Grief: A Brief History of the DSM 5

The Diagnostic and Statistical Manual of Mental Disorders is a reference book that contains standard criteria for the classification and diagnosis of mental disorders. It is considered an authoritative source of information for psychiatrists,psychologists, policy makers, health insurance companies, pharmaceutical companies,and other health care professionals. Published by the American Psychiatric Association, the DSM evolved out of systems used for collecting census and psychiatric hospital statistics, and from a US army manual that was used at the turn of the 19th century. Once an obscure and arcane collection of psychiatric diagnoses, the DSM is now a recognized and authoritative source on psychiatric pathology.

The DSM I was published in 1952, and has undergone three subsequent revisions. Each new edition reflects the complex and evolving interpretation of psychiatric illness in America. The classification and diagnosis of mental illness involves a measure of subjectivity by the examiner and is framed by the larger culture in which these diagnoses are imbedded. The history and publication of each DSM has, therefore, been mired in controversy, at least to some extent.

Labeling of human behavior and patterns of thought as deviant or abnormal continues to be fraught with controversy, as no litmus tests exist to precisely define conditions that are rendered by modern psychiatry. Malignant tumors can be visualized by high tech diagnostics; abnormal glucose levels can be evidenced by laboratory tests. Strokes and heart attacks are readily diagnosed. Those who suffer from schizophrenia, major depression, and anxiety disorders, however, are diagnosed without the benefit of such objective standards. Ultimately, diagnosticians evaluate and determine an individual’s mental illness by what he or she is not. The depressed patient is not able to free himself from pervasive thoughts of suicide. The schizophrenic is not able to think without intrusive auditory hallucinations. Diagnosis of psychiatric illness requires the constant comparison of the abnormal individual to a vague but constant normalcy, to the generic vision of a pathos-free individual.

The history of the DSM is based on many such comparisons. Over the years controversial diagnoses have been eliminated or subsumed under broader categories. In 2012, the Board of Trustees of the American Psychiatric Association approved an updated version of the psychiatry bible, which was published in 2013. Like many earlier editions, this one is mired in controversy. One of its biggest critics is Dr. Allen Frances, the former chair of the DSM-IV task force, and professor emeritus at Duke University. Dr. Frances’ backlash is a stunning and courageous outcry against what he considers to be a distortion of normal human behavior, now officially enshrined in the DSM 5. His article, DSM 5 is Guide Not Bible-Ignore its Ten Worst Changes, has been big news in psychiatry and medical circles since it was published in December, 2012.

Although Dr. Frances lists ten of the most egregious changes to the latest DSM, he reserves particular ire for the elimination of the “bereavement exclusion”. This exempts grieving individuals, even those who exhibit signs of clinical depression, from the psychiatric disorder of depression. Dr. Frances opines that:

Normal grief will become Major Depressive Disorder, thus medicalization and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

Perhaps the “medicalization” of normal grief is just another misguided attempt on the part of American psychiatry to soothe the individual psyche, free it of one more painful and disabling symptom of grief.

Dr. Frances, however, attributes the grief exclusion to a far less benign process:

The American Psychiatric Association’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as bestseller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only-so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

Other experts acknowledge Dr. Frances’ deep concerns about the erosion of the APA’s credibility. In DSM 5: Science or Dogma, Dr. Bruce E. Levine, clinical psychologist, boldly echoes Dr. Frances’ claims:

Psychiatry’s official diagnostic battle is over. Mental illness gatekeepers such as Frances who are concerned about further undermining the credibility of the APA have lost, and mental illness expansionists-psychiatry’s “neocons”-have won.

Sometimes malevolent intentions ironically lead to a tolerable conclusion, an end that can be lived with. For Drs. Frances and Levine, and many others, the blatant disregard for psychiatric integrity, for the boundaries of a purist ideology have been, quite simply, trashed.

Perhaps they are right. Tinkering with the definition of grief is profane, a debasement of something fundamentally human. It does not enhance the healing science of psychiatry. In fact, the tidy sanitization of grief into a pat diagnostic category creates a cataclysmic shift away from reconciliation. Ultimately, grief transformed to pathos brings another loss, one that is deeply unnatural, an essential dehumanization of the human spirit.