Elsevier

Clinical Psychology Review

Volume 33, Issue 7, November 2013, Pages 825-845
Clinical Psychology Review

The DSM-5 debate over the bereavement exclusion: Psychiatric diagnosis and the future of empirically supported treatment

https://doi.org/10.1016/j.cpr.2013.03.007Get rights and content

Highlights

  • Fruitful treatment research requires valid, generalizable diagnostic categories.

  • Construct validity eludes us; focus on conceptual validity (normal vs. disordered).

  • Bereavement-excluded major depression lacks elevated recurrence and other validators.

  • The exclusion extended to other stressors has concurrent and predictive validity.

  • DSM-5's elimination of the bereavement exclusion undermined conceptual validity.

Abstract

Valid diagnostic criteria support generalizations about treatment effectiveness, allowing progress in developing empirically supported treatments. The DSM-5 revision provides an opportunity to consider whether diagnostic changes are increasing validity. In this paper, I first offer broad suggestions for conceptually advancing diagnostic validity while awaiting greater etiological understanding. These include, for example, improving “conceptual validity” (disorder/nondisorder differentiation); extending diagnosis beyond disorders to include mismatches between normal variation and social demands (“psychological justice”); placing disorder etiology in evolutionary context as harmful failure of biologically designed functioning (“harmful dysfunction”); and taking an integrative theoretical approach to human meaning systems. The paper then examines the DSM-5's controversial decision to eliminate the major depression bereavement exclusion (BE), detailing the evidence and attendant debate. Elimination was defended by citing several hypotheses (e.g., excluded cases are similar to other MDD; exclusions risk missing suicidal cases; medication works with excluded cases), all of which were either empirically falsified or based on faulty arguments. Most dramatically, excluded cases were empirically demonstrated to have no more depression on follow-up than those who never had MDD. I conclude that BE elimination undermined rather than increased conceptual validity and usefulness for treatment research. Finally, I draw some general lessons from the DSM-5 BE debacle.

Introduction

Categories are useful in science to the degree that they form components of successful theories and laws. Thus, to say what diagnostic concepts might help to accelerate progress in evidence-based practice is in effect to place a bet on what categories will form the components of the successful theories of practice of the future. That is a form of crystal ball gazing that I prefer to resist. Given how limited our therapeutic powers are at present, whatever the successful empirically grounded theories of the future may turn out to be, they will probably surprise us and are not easily projectable from our current practices, as in any other area of science. Instead, I will first offer some general conceptual suggestions as to how at this juncture we might aim to improve the validity of diagnostic categories and place our diagnostic house in a little better order to serve the progress of empirically supported treatment. I will then explore in detail one example of diagnostic revision — the DSM-5's elimination of the bereavement exclusion (BE) for major depressive disorder (MDD) — to illustrate what I think represents much that is problematic for the future of scientific psychology in the way we now approach the revision of diagnostic criteria. I will end by placing the BE debate into the context of the framework of points suggested at the beginning, and considering where the debate went right and wrong.

Section snippets

Conceptual validity versus construct validity

Most DSM diagnostic categories do not have construct validity, that is, they do not “carve nature at the joints” by picking out just one kind of condition with a distinctive etiology. Rather, current categories are syndromes that encompass many different etiologies. In the long run, the goal of diagnostic research is construct validity because that yields the most insight and the most chance for developing novel and carefully targeted empirically supported treatments.

While awaiting etiological

The DSM-5 bereavement exclusion debate

The DSM-5 has eliminated the major depression bereavement exclusion (BE) that was included in all previous editions starting with DSM-III. This was the most controversial of the DSM-5's decisions, and surely the most bewildering. The reasons provided for this change varied over time, and ranged from fear of missing genuine cases of depression and fear of missing suicidal cases to the effectiveness of medication with the excluded group and the fear that clinicians would misapply the exclusion.

Discussion

The BE debate offers an opportunity to assess the ideas noted earlier: conceptual validity distinguished from construct validity, the evolutionary perspective on normality, dysfunction essentialism about disorder, distinguishing the mental health professions' medical mission from its broader mission that goes beyond disorder, moving beyond syndromal reification, splitting categories to achieve greater homogeneity, and so on. Such an assessment can hopefully yield insight into why some of our

Acknowledgments

I thank Brandon Gaudiano for very helpful comments on earlier drafts of this paper.

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    Disclosure: The author has no competing interests.

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