Shades of Grief: When Does Mourning Become a Mental Illness?

The new edition of a psychiatric manual called DSM-5 tackles what to do when mourning becomes complicated or leads to depression

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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.

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