Bereavement and Client Diagnosis

Bereavement and Client Diagnosis ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Bereavement and Client Diagnosis Although grief may be painful, for many individuals, it is a temporary journey of sadness. Yet, for others, grief may be a painful, unending road into despair. With grief there is usually a period of bereavement, more commonly known as a mourning period or sadness experienced from death or separation. Bereavement may result in temporary psychological distress or despair, or it may manifest into severe and/or reoccurring psychological disorders, such as depression, posttraumatic stress disorder, and other anxiety disorders. Additionally, the effects of bereavement may complicate client diagnosis, especially for clients that you may already be treating for other disorders. Bereavement and Client Diagnosis For this Discussion, review the attached learning resources as well as any additional current literature to examine how unremitting effects of bereavement may complicate client diagnosis. Select an example from the learning resources where bereavement might present an issue for an existing client. Consider if a psychologist might have to change the original client diagnosis. With these thoughts in mind: Post a brief description the example you selected. Then explain how bereavement might complicate a client’s diagnosis. Finally, post your position on whether a psychologist must change the client’s diagnosis in the example you selected and explain why or why not. Give specific examples and references. Be sure to support your postings and responses with specific references to current literature. 3-4 Paragraphs. APA Format. In-text Citations to Support Literature. Minimum of 2 Peer Reviewed References. attachment_1 attachment_2 attachment_3 attachment_4 DEPRESSION AND ANXIETY 29:425–443 (2012) Review THE BEREAVEMENT EXCLUSION AND DSM-5 Sidney Zisook, M.D.,1,2 ? Emmanuelle Corruble, M.D., Ph.D.,3 Naihua Duan, Ph.D.,4,5 Alana Iglewicz, M.D.,1,2 Elie G Karam, M.D.,6,7 Nicole Lanuoette, M.D.,1,2 Barry Lebowitz, Ph.D.,1,8 Ronald Pies, M.D.,9,10 Charles Reynolds, M.D.,11,12 Kathryn Seay, B.S.,13 M. Katherine Shear, M.D.,14 Naomi Simon, M.D.,15 and Ilanit Tal Young, M.D.1,2 Background: Pre-DSM-III (where DSM is Diagnostic and Statistical Manual), a series of studies demonstrated that major depressive syndromes were common after bereavement and that these syndromes often were transient, not requiring treatment. Largely on the basis of these studies, a decision was made to exclude the diagnosis of a major depressive episode (MDE) if symptoms could be “better accounted for by bereavement than by MDE” unless symptoms were severe and very impairing. Thus, since the publication of DSM-III in 1980, the official position of American Psychiatry has been that recent bereavement may be an exclusion criterion for the diagnosis of an MDE. This review article attempts to answer the question, “Does the best available research favor continuing the ‘bereavement exclusion’ (BE) in DSM-5?” We have previously discussed the proposal by the DSM-5 Mood Disorders Work Group to remove the BE from DSM-5. Methods: Prior reviews have evaluated the validity of the BE based on studies published through 2006. The current review adds research studies published since 2006 and critically examines arguments for and against retaining the BE in DSM-5. Results: The preponderance of data suggests that bereavement-related depression is not different from MDE that presents in any other context; it is equally genetically influenced, most likely to occur in individuals with past personal and family histories of MDE, has similar personality characteristics and patterns 1 Department of Psychiatry, University of California, San Diego, California 2 Veterans Affairs San Diego Healthcare System and Veterans Medical and Research Foundation, La Jolla, California 3 INSERM U669, Department of Psychiatry, Bice?tre University Hospital, Assistance Publique–Ho?pitaux de Paris, France 4 Departments of Biostatistics and Psychiatry, Columbia University, New York, New York 5 Division of Biostatistics and Data Coordination at New York State Psychiatric Institute, New York, New York 6 Department of Psychiatry and Clinical Psychology, St. George Hospital University Medical Center, Balamand University, Beirut Lebanon 7 Faculty of Medicine, Medical Institute for Neuropsychological Disorders (MIND) and Institute for Development, Research, Advocacy & Applied Care (IDRAAC), Beirut Lebanon 8 Departments of Biostatistics and Psychiatry, Columbia University, New York, New York 9 Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York 10 Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts 11 Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania C 2012 Wiley Periodicals, Inc. 12 Department of Community and Behavioral Health Science, University of Pittsburgh Graduate School of Public Health, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania 13 University of California and San Diego State Joint Doctoral Program in Clinical Psychology and Veterans Medical, Education and Research Foundation, La Jolla, California 14 Complicated Grief Treatment Research Program, Columbia University School of Social Work and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York 15 Center for Anxiety and Traumatic Stress Disorders and Complicated Grief Program, Bereavement and Client Diagnosis Massachusetts General Hospital, Boston, Massachusetts ? Correspondence to: Sidney Zisook, Department of Psychiatry, Uni- versity of California, 9500 Gilman Dr. #9116A, La Jolla, San Diego, CA 92093. E-mail: [email protected] Received for publication 03 October 2011; Revised 24 January 2012; Accepted 28 January 2012 DOI 10.1002/da.21927 Published online in Wiley Online Library ( 426 Zisook et al. of comorbidity, is as likely to be chronic and/or recurrent, and responds to antidepressant medications. Conclusions: We conclude that the BE should not be C 2012 Wiley retained in DSM-5. Depression and Anxiety 29:425–443, 2012. Periodicals, Inc. Key words: bereavement; grief; major depressive disorder; psychiatric diagnosis; nosology; DSM-5 INTRODUCTION BACKGROUND Episodes of major depression often occur in the aftermath of stressful life events, especially those that are associated with loss or humiliation.[1] Thus, it is no surprise that the death of a loved one, one of the most stressful life events of ordinary life,[2] is a robust risk factor for the onset or persistence of a major depressive episode (MDE).[3] Yet, bereavement is the one life event that has been singled out by recent editions of the Diagnostic and Statistical Manual (DSM-III, IV, and IV-TR) to negate the diagnosis of MDE. Thus, since its ?rst appearance in DSM-III in 1980, the syndromal criteria for MDE included a criterion admonishing the clinician not to diagnose MDE if the symptoms “are better accounted for by bereavement,” called the “bereavement exclusion” (BE). However, the empirical validity of this exclusion has not been well established. This unique stature afforded bereavement, compared to all other adverse life events, is rational only if major depressive syndromes following bereavement are substantially different than MDEs occurring spontaneously or following other stressful events. As DSM-5 is now being planned, it is timely to reexamine the BE, particularly in the light of new evidence since the last reviews of this subject.[4, 5] This review assesses studies published after the previously published reports that address similarities and differences between bereavement-related depressive syndromes (BRD) and nonbereavement-related major depressive episodes (NBRD) to answer the question of whether the best available research favors continuing the BE in DSM-5. The BE is not part of the International Diagnostic Classi?cation of diseases (ICD). Nor was it part of DSMI or DSM-II. In the 1960s and early 1970s, Paula Clayton and colleagues completed a series of studies[6–10] on bereaved (mostly) widows and widowers that yielded important data on what to expect in the bereavement period. Her work showed that in the ?rst month of bereavement it is not unusual to experience depressed mood, sleep disturbance, crying, anorexia/weight loss, and dif?culty concentrating/poor memory. By the end of the ?rst year, most somatic symptoms have improved, although insomnia, restlessness, and periodic low mood often persist. They reported that a full depressive syndrome was present in 35–42% of the bereaved at 1 month, decreasing to 16% at 1 year. The 1 year incidence of a full deDepression and Anxiety pressive syndrome was 47% in the bereaved versus 8% in the nonbereaved controls.[11] It was largely on the basis of this work that the DSM-III added the BE. The goal of this exclusion was to prevent “medicalizing” a normal phenomenon, grief, and the subsequent overdiagnosis of MDE in situations where depressive symptoms were common, normal, and perhaps even adaptive.[12, 13] DSM-III AND DSM-III-R In DSM-III, “uncomplicated bereavement” was both a V-Code (clinical condition that is not a mental disorder) and an exclusionary criterion for the diagnosis of MDE. According to DSM-III, “uncomplicated bereavement” “can be used when a focus of attention or treatment is a normal reaction to the death of a loved one (bereavement). A full depressive syndrome is a normal reaction to such a loss, with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. The reaction to the loss may not be immediate, but rarely occurs after the ?rst 2 or 3 months. Bereavement and Client Diagnosis The duration of normal bereavement varies considerably among different subculture groups.[14] To help distinguish “uncomplicated bereavement” from MDE, DSM-III identi?ed several features more characteristic of one than the other: (1) a bereaved individual typically regards the depressed mood as “normal,” although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia; (2) the diagnosis of MDE is generally not given unless the symptoms are still present 2–3 months after the loss; and (3) MDE should be considered in the presence of certain symptoms that are not characteristic of a “normal” grief reaction, such as guilt about things other than actions taken or not taken by the survivor at the time of the death, thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person, morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged and marked functional impairment, and hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person. DSM-IV AND DSM-IV-TR In DSM-IV, “uncomplicated bereavement” was replaced by “bereavement.” The time frame for bereavement was more sharply delineated to be 2 months 427 The Bereavement Exclusion and DSM-5 after the death. Subtle wording changes allowed any one “severe” feature (i.e. marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation) to be suf?cient for a diagnosis of MDE.[15] Bereavement remained the only life event that excludes the diagnosis of MDE and MDE is the only psychiatric disorder superseded by bereavement. HYPOTHESES Although the diagnostic conventions described above were based on the best data available when DSM-III was ?rst being crafted, newer data generated over the ensuing 3+ decades allows us to reexamine the validity of maintaining bereavement as an exclusion criterion for the diagnosis of MDE.[4, 5] Although there has not been a de?nitive study to test the validity of the BE, the preponderance of the available data does not support continuing the BE in DSM-5. Two prior reviews critically examined the BE,[4, 5] and found that depressive syndromes occurring in the context of bereavement, BRDs, are similar to NBRDs on almost all MDE validators: demographic features, past personal and family histories of MDE, severity and duration of episodes, biological features, symptomatic patterns, responses to antidepressant medications, and long-term outcome. Subsequently, several newer studies that more directly address the validity of the BE have been published[16–24] and are the focus of this review. As in previous reviews, to answer the question of whether the best available research favors continuing the BE in DSM-5, this review evaluates the relative validity of two competing hypotheses as follows: 1. BRD is fundamentally different than NBRD; and 2. BRD is not fundamentally different than NBRD. To the extent that research supports Hypothesis 1, especially if the differences are in the direction of BRD being less severe, chronic, and treatment-responsive, maintaining the BE in DSM-5 is warranted. To the extent the data support Hypothesis 2, the BE should be dropped from DSM-5. Wherever possible, this review focuses on the subset of individuals who, within 2 months after the loss of a loved one, develop symptoms that technically meet the broad heterogeneous criteria for MDE (i.e. at least 5 of 9 symptoms lasting at least 2 weeks); but who— because of the duration, severity, and impairment features described above—are considered by the DSM-IV to be experiencing “normal bereavement” rather than MDE. also characterize BRD, and especially those instances of BRD that are excluded from the diagnosis of MDE based on the DSM-IV BE. If the predominant weight of the evidence suggests that they do, BRD may be best conceptualized as a form of MDE rather than an extension of “normal” bereavement. Bereavement and Client Diagnosis As described previously,[4, 5] we examined three classes of potential validators with subclasses as follows: (1) antecedent validators (e.g. age, gender, familial aggregation and/or coaggregation, prior history of MDE, and age of onset ?rst MDE); (2) concurrent validators (e.g. severity and duration of depression, speci?c symptoms, patterns of comorbidity, emotional, temperamental and personality correlates, functional and cognitive impairment, and associated clinical features); and (3) predictive validators (e.g. response to treatment and course of illness). The previous reviews included only studies published through 2006; therefore, this report comprises studies published since then, each of which focuses more directly on examining the validity of the BE than most previous studies. In addition, this review provides a more explicit discussion of the main arguments for and against the removal of the BE in DSM-5. Only English language articles were located with Medline searches from January 2007 through November 2011. Exploded searches, using “grief or bereavement” and “depression” in the title or abstract or as key words, were employed. Bibliographies of located articles were searched for additional studies. Publications were selected for inclusion if they contained original data; included adults with a recent bereavement who were diagnosed with syndromal depression or threshold levels for clinically signi?cant depression based on validated depression interviews or scales; and included one or more nonbereaved comparison groups. The literature search was conducted by the ?rst author (SZ) and other authors were invited to add relevant studies that might have been missed. Although it would have been ideal to conduct a formal meta-analysis of the literature, this was not feasible as very few primary reports provided con?dence intervals (or standard errors) of the estimates or primary data (i.e. contingency or correlations; Fig. 1). Each validator was scored in terms of whether it provided more support for Hypothesis 1 (BRD does not resemble NBRD and continuing the BE in DSM-5 is warranted) or for Hypothesis 2 (BRD resembles NBRD and continuing the BE in DSM-5 is not warranted). The initial judgment was made by the ?rst author (SZ) subject to discussion and a consensus decision if any of the coauthors disagreed. If BRD was statistically and clinically similar to NBRD, it was scored as H.2. (favoring Hypothesis 2) for the corresponding validator. If the BRD was unlike NBRD on a given validator, it was generally scored as H.1. (favoring Hypothesis 1). However, in those instances when BRD was different than NBMR but the difference was in the direction of being consistent with well-known characteristics of MDE, such as having more previous episodes of depression than the NBRD control group, the validator was scored as H.1./H.2. (not favoring either Hypothesis). H.1./H.2. was also used for results that were equivocal or not clearly favoring either hypothesis, such as when “uncomplicated” BRD resembled “uncomplicated” NBRD, but neither resembled “complicated” depressive syndromes[16] . To conserve space, studies that were previously reported in comprehensive reviews of the BE[4, 5] are not included in this report. METHODS RESULTS This review focuses on studies published from January 2007 through November 2011. Using diagnostic validators as originally proposed by Robins and Guze[25] and expanded by Kendler,[26] this review evaluates whether key characteristics that de?ne and characterize MDE Nine informative studies from four countries published since the last comprehensive reviews on the validity of the BE are reviewed: ?ve large populationbased studies[16–18,23, 24] and four studies of clinical Depression and Anxiety 428 Zisook et al. Figure 1. Selection of studies for review. populations[19–22] . The text below brie?y summarizes results from each of the nine studies. Bereavement and Client Diagnosis Table 1 provides a detailed summary of each key study and Tables 2–4 tabulate results related to each validator. The last three columns in Tables 2–4 provide summary judgments of whether the data best supports Hypothesis 1 (noted as H.1), Hypothesis 2 (noted as H.2.), or is too close to call (H.1./H.2.). In the ?rst of these studies, Wake?eld et al.[16] provided a secondary analysis from the National Comorbidity Survey of 8,089 persons representative of the United States population and identi?ed 157 individuals whose major depressive syndromes were triggered by bereavement (BRD) and 710 triggered by other losses (NBRD). They further divided the sample into uncomplicated and complicated cases based on an approximation of Depression and Anxiety the DSM-IIIR duration, severity, and impairment criteria for the BE. Wake?eld et al. de?ned a “complicated case” as a depressive syndrome that satis?es at least two of the following features: morbid feelings of worthlessness, psychomotor retardation, suicidal ideation, suicide attempts, marked functional impairment, and duration >12 weeks. The use of this terminology is unfortunate as it invites confusion with the term “complicated grief,” which is a bereavement-related syndrome distinct from MDE.[27] However, using this terminology, Wake?eld et al. identi?ed four groups as follows: (1) uncomplicated BRD (n = 56), (2) complicated BRD (n = 101), (3) uncomplicated NBRD (n = 174), and (4) complicated NBRD (n = 536). The main ?ndings were that uncomplicated BRD resembled uncomplicated NBRD on almost all features measured (e.g. age, gender, race, Comparison group Type of comparison Kessing et al.[20] BRD versus NBRD 167 (1.8%) with NBRD 83 (1%) with BRD related to other stressful 23/82 (28%) with BRD were life events excluded by DSM BE 55/167 (25%) also had criteria (duration <2 episodes lasting <2 months, no psychomotor months. and no retardation, suicidal psychomotor retardation, ideation, or severe suicidal ideation, or severe functional impairment. mood impairment. (uncomplicated BRD group) (uncomplicated NBRD group) Clinical sample: 301 ?rst BRD versus NBRD 26 (8.6%) with BRD 275 (91.4%) with NBRD episode MDE (ICD-10) 163/275 (54.2%) experienced inpatients or outpatients in other stressful life events East Denmark within 6 months prior to the onset MDE 112/275 (37.2%)—no bereavement or other stressful life event within 6 months onset of NBRD Community-based epidemiologic study of twins from the VATS PSUD involving 266,409 person–months of data from 9,242 individuals Kendler et al.[17] BRD versus NBRD 710 (8.8%) with NBRD 157 (1.9%) with BRD triggered by other loss 56/157 “uncomplicated” BRD (<12 weeks and not 174/710 “uncomplicated” other loss-related depression impaired AND <2 of the (>12 weeks and not following symptoms: impaired AND <2 of the worthlessness, following symptoms: psychomotor retardation, suicidal ideation, or suicide worthlessness, psychomotor retardation, attempt) suicidal ideation, or suicide 101/157 “complicated” BRD attempt) (>12 weeks or impaired 536/710 “complicated” other OR ?2 of the following loss-related depression (>12 symptoms: worthlessness, weeks OR impaired OR psychomotor retardation, suicidal ideation or suicidal ?2 of the following symptoms: worthlessness, attempt) psychomotor retardation, suicidal ideation, or suicidal attempt) Sample Community-based epidemiologic study from the NCS involving 8,098 persons ages 15–54 Type of study Wake?eld et al.[16] Author TABLE 1. Overview of studies published 2007–2011 Life events assessment SCAN SCID <3 months and >3 months Time since death IRLE <6 months <2 months At each interview (four and 2–12 times over 10 years) months participants provided information on li … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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