Sooner or later most of us suffer deep grief over the death of someone we love. The experience often causes people to question their sanity—as when they momentarily think they have caught sight of their loved one on a crowded street. Many mourners ponder, even if only abstractedly, their reason for living. But when are these disturbing thoughts and emotions normal—that is to say, they become less consuming and intense with the passage of time—and when do they cross the line to pathology, requiring ongoing treatment with powerful antidepressants or psychotherapy, or both?

Two proposed changes in the “bible” of psychiatric disorders—­the Diagnostic and Statistical Manual of Mental Disorders (DSM)—­aim to answer that question when the book’s fifth edition comes out in 2013. One change expected to appear in the DSM-5 reflects a growing consensus in the mental health field; the other has provoked great controversy.

In the less controversial change, the manual would add a new category: Complicated Grief Disorder, also known as traumatic or prolonged grief. The new diagnosis refers to a situation in which many of grief’s common symptoms—such as powerful pining for the deceased, great difficulty moving on, a sense that life is meaningless, and bitterness or anger about the loss—­last longer than six months. The controversial change focuses on the other end of the time spectrum: it allows medical treatment for depression in the first few weeks after a death. Currently the DSM specifically bars a bereaved person from being diagnosed with full-blown depression until at least two months have elapsed from the start of mourning.

Those changes matter to patients and mental health professionals because the manual’s definitions of mental illness determine how people are treated and, in many cases, whether the therapy is paid for by insurance. The logic behind the proposed revisions, therefore, merits a further look.

Abnormal Grief
The concept of pathological mourning has been around since Sigmund Freud, but it began receiving formal attention more recently. In several studies of widows with severe, long-lasting grief in the 1980s and 1990s, researchers noticed that antidepressant medications relieved such depressive feelings as sadness and worthlessness but did nothing for other aspects of grief, such as pining and intrusive thoughts about the deceased. The finding suggested that complicated grief and depression arise from different circuits in the brain, but the work was not far enough along to make it into the current, fourth edition of the DSM, published in 1994. In the 886-page book, bereavement is relegated to just one paragraph and is described as a symptom that “may be a focus of clinical attention.” Complicated grief is not mentioned.

Over the next few years other studies revealed that persistent, consuming grief may, in and of itself, increase the risk of other illnesses, such as heart problems, high blood pressure and cancer. Holly G. Prigerson, one of the pioneers of grief research, organized a meeting of loss experts in Pittsburgh in 1997 to hash out preliminary criteria for what she and her colleagues saw as an emerging condition, which they termed traumatic grief. Their view of its defining features: an intense daily yearning and preoccupation with the deceased. In essence, it is the inability to adjust to life without that person, notes Mardi J. Horowitz, professor of psychiatry at the University of California, San Francisco, and another early researcher of the condition. Prigerson, then an assistant professor at the Western Psychiatric Institute and Clinic in Pittsburgh, hoped the meeting would begin the process of finding enough evidence to support changing the DSM. “We knew that grief predicted a lot of bad outcomes—over and above depression and anxiety—and thought it was worthy of clinical attention in its own right,” says Prigerson, now a professor of psychiatry at Harvard Medical School.

4 Comments

1. 1. Howboy 01:09 PM 6/8/11

   I had my "Roberta Flack Moment" when I turned to page 34 (Shades of Grief) in your June 2011 edition and the article "was telling my whole life" there, in public. But I don't feel like it was 'killing me softly' with words - this was enlightenment.
   
   Since the sudden and shocking loss of my wife in April 2004 I've had trouble readjusting, and reading that others have already been where I am, and learned from it, has been a source of strength.
   
   The definining of 'complex grief disorder' is a good beginning. I hope that future consoulers are able to use this to shorten other people's losses.
   
   I had suffered three previous periods of depression in my life, and thought I had some understanding of it. One key thing was knowing it would end; yet I could not understand why my depression over the loss of my wife seemed to pass - and then quickly return, over and over. The concept of complex grief fits. I could have written the criteria without looking.
   
   Also, the nature of the way I found my wife, dying of brain anurysm, added a bit of traumatic shock to my particular case; throw in a three hurricanes and I had a few difficult years. Like any illness, I deal with the scars (for a while, strong winds put a chill down the spine, for instance).
   
   If you haven't listened to Roberta Flack's "Killing Me Softly With His Song" for a while, do. It is the best way to describe how I felt when I first read this article - jaw open, reading, glancing back and forth at the author's face "Does she know ME?"

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2. 2. Squeedle 06:15 PM 6/8/11

   I hope that it is not assumed that only those who lose a human being, or only those who lose someone through death are subject to this sort of grief. I've experienced this myself from the breakup of a relationship and I've seen other people have a very difficult time adjusting to their lives after such a loss, even of a beloved pet. Fortunately I was aware enough to obtain help and now I'm fine, but other people may be unaware that they are not going through a healthy progression of emotional states.

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3. 3. Asclepius 05:10 AM 6/9/11

   The special addition addressing traumatic grief has direct application to returning veterans. Additionally, if the practitioner also couples that diagnostic advice with DSM advice about guilt there could be a significant breakthrough in the treatment of what we class as PTSD.
   
   It is critical however, that the DSM be regarded and utilized as a supportive guide not as a diagnostic and treatment protocol.

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4. 4. verdai 07:49 PM 6/23/11

   Remember.
   It would be insane to forget.
   Live With It.

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