Team 5 PresentationWhat was meant by the V code for bereavement? What was the rationale for having such an exemption in relation to MDD? Is there evidence to back this up?

What is the V-code in the DSM

DSM V codes identify conditions other than a disease or injuries. For example, V-codes specify conditions that are not mental disorders but are a focus of attention or treatment. • V-codes can be used when the issue described is the focus of clinical attention. For

example can to report significant factors that may influence present or future care. Factors may include:

• Feeling blue• Lack of desire to socialize• Experiencing insomnia.• Weight loss• However these factors may not to be severe enough to be considered as mental disorder. • DSM V codes are not necessarily a primary diagnosis.• Typically, this V-code category is time limited in terms of treatment.  

What was meant by the V code for bereavement• Bereavement may be retained as a “V” code, not a mental disorder.• In the DSM-IV, bereavement is considered a "V" code: a condition that needs

attention but presents with symptoms characteristic of MDD, such as feelings of sadness, insomnia, or anorexia.

• Bereavement mimics clinical depression but in fact is unlike depression.• For symptoms differentiating bereavement from MDD are provided in the

DSM-IV. Freud wrote nearly 100 years ago that for the person mourning, “it is the world which has become poor and empty” whereas for the person depressed “it is the ego itself.

• The bereaved individual typically regards the depressed mood as "normal”. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode.

Major depressive disorder• Mental disorder• Low mood• Low self esteem• Loss of interest in enjoyable activities• Symptoms must be present for approx. 6 months

https://www.youtube.com/watch?v=lb-TisO17HE

Relationship Between bereavement and Depression • Bereavement is not a mental illness• DSM states that sadness is a "normal" reaction to loss• No "normal" length of bereavement • Major Depressive not given unless symptoms lasted beyond two

months

Difference between MDD & Bereavement

• “In grief, the world looks poor and empty. In depression, the person feels poor and empty”

What is Bereavement exclusion? • Bereavement exclusion is when the clinicians are advised to avoid

diagnosing a patient with MDD during the first two month following the death of a loved one.

Distinguish Bereavement from Major Depression Disorder

Bereavement - Sadness- Insomnia- Poor appetite- Weight loss

Major Depression Disorder- Sadness- Insomnia- Poor appetite- Weight loss

- Person may feel relatively better while in certain situations

- Trigger related

- Symptoms more pervasive- * Exceptions for Atypical

Depression

Exemption in relation to MDD• DSM-IV, clinicians were advised to refrain

from diagnosing major depression in individuals within the first two months following the death of a loved one

• the diagnosis of major depression should not be made, unless:

• (a) are associated with marked functional impairment

• (b) include certain “conditional” features, namely morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Recent Studies • Ongoing study of major depression, remove

the bereavement exclusion from DSM- 5• Removing the bereavement exclusion helps

prevent major depression from being overlooked and facilitates the possibility of appropriate treatment including therapy.

• The new edition characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one.

Bereavement the only stressful life event that is excluded from MDD

• Variety of other serious stressors such as divorce losing a job being a victim of a physical assault major disaster have been found to increase therisk for MDD in vulnerable or sensitive individuals

Normal response Matter is in experience The examples direct effects one’s self

Evidence for Bereavement Exclusion

• Wakefield studied individuals and placed them into categories, those with MDD episodes triggered by either bereavement or other loss, and then further divided the groups into “uncomplicated” and “complicated cases.”

Case Study• Tom visits your office complaining of five weeks of a persistently low

mood, inability to enjoy his usually enjoyable activities, difficulty falling and staying asleep, daytime fatigue, inability to concentrate or make decisions, and poor appetite. He is otherwise in excellent health. Six weeks ago, his wife passed away.

• Andrew visits you with the same complaints and duration as Tom . However, his wife is alive and well. Unfortunately, six weeks ago he lost his job, discovered that his life savings had suddenly been lost, and could not pay his mortgage.

• James visits you with the same symptoms and duration as Tom and Andrew. He has lived a charmed life and cannot understand why he feels so bad when everything else is going so well.

Which of these three patients has major depressive disorder (MDD) or bereavement?

Answers Revealed • In regards to the DSM, Andrew and James would be diagnosed with

MDD. However Tom is Diagnosed with the V Code (that is, not psychiatrically ill) bereavement.