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

Jerome C. Wakefield

    Research output: Contribution to journalReview article

    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.

    Original languageEnglish (US)
    Pages (from-to)825-845
    Number of pages21
    JournalClinical Psychology Review
    Volume33
    Issue number7
    DOIs
    StatePublished - Nov 1 2013

    Fingerprint

    Bereavement
    Mental Disorders
    Depression
    Social Justice
    Psychology
    Research

    Keywords

    • Bereavement exclusion
    • Depression
    • DSM-5
    • Empirical supported treatment
    • Harmful dysfunction
    • Validity of diagnosis

    ASJC Scopus subject areas

    • Clinical Psychology
    • Psychiatry and Mental health

    Cite this

    The DSM-5 debate over the bereavement exclusion : Psychiatric diagnosis and the future of empirically supported treatment. / Wakefield, Jerome C.

    In: Clinical Psychology Review, Vol. 33, No. 7, 01.11.2013, p. 825-845.

    Research output: Contribution to journalReview article

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