Diagnosis: Grief? (Part II)
Last month in “Diagnosis: Grief?” I wrote about the DSM-V proposal to remove the bereavement exclusion in Major Depressive Disorder (MDD) and create a new disorder called “Complicated Grief.” The current edition of the DSM, the DSM-IV, only mentions grief as an exclusion within MDD. It excludes those who are depressed as a result of bereavement, since their depression likely stems from a reaction to the loss of a loved one, is situational, and could most definitely last longer than two weeks (the threshhold at which a diagnosis of MDD can be made in someone who is depressed). The bereavement exclusion helps to guide clinicians in their diagnosis of a patient, which in turn, helps them work with the patient to determine the best course of treatment.
On the other hand, there were those who pointed out that other diagnostic tools such as the International Classification of Diseases contained no exclusion for grief at all, and since grief can be a precursor to MDD, a bereavement exclusion wasn’t necessary. This is a valid point to consider, since people do slide into MDD or develop generalized anxiety or suffer from post-traumatic stress as the result of a loved one’s death. The main issue, though, wasn’t with removal of the exclusion (although some people were unhappy with the idea that the exclusion was slated for removal). I’m not sure it needs to be included, either, but it should naturally be considered when treating a patient. The main issue was that they wanted to turn grief, which is a natural reaction to loss of any kind, into a disorder.
The original proposal for Complicated Grief garnered a lot of criticism, most of it against creating a disorder for a normal human reaction, especially the fact that one of the primary criteria in diagnosing Complicated Grief was thethe first portion of the criteria: whether or not the patient was having issues after 12 months (6 months for a child). I discussed in the previous article my own experience of putting on a brave face and going numb for the first twelve months and not grieving until after that time, which my therapist said was not uncommon, especially in those who still have caretaking duties for children or others.
Those that have suffered losses, especially the loss of a child, can tell those that haven’t that there isn’t any timetable. Truly, you never stop grieving your child. You might finally come out from underneath the covers, return to work, spend less time crying than you did before, but that loss is still there—the ache never goes away. Since this is the experience of most bereaved parents, including those in the mental health community, there was vocal opposition to medicalizing grief via a disorder in the DSM-V (which would ultimately become a diagnosis code for insurance companies). There were worries of medicating people who needed time rather than pills. There were concerns that this was merely another way for pharmaceutical companies to make even more money than they already do. These concerns drove people to speak up.
In response to the overwhelming amount of feedback, the DSM-V work group responded with a new proposal for a reworded bereavement exclusion in MDD. You can read it here.
The proposal for Complicated Grief has also been slightly altered. It is now called “Persistent Complex Bereavement-Related Disorder” and is now slated for inclusion in section III of the DSM-V, which indicates it as an area for further study as a possible future diagnosis.
I still have some concern about ever considering grief in any degree to be a disorder. Stigmatizing grief further in our feel-happy-all-the-time culture isn’t beneficial to anyone, I don’t think. I think that most people whose mighty struggles with grief transform into some degree of a mental disorder could easily be diagnosed and treated using the guidelines for those particular disorders, and should be treated in such a manner, rather than treating the grief as the disorder. I see grief as a trigger, rather than a disorder itself. Grief is normal, natural and necessary. In my experience, it only becomes a problem when it causes other problems. Ultimately, if nothing else, the controversies surrounding the DSM and grief are forcing real discussion of grief and bringing something that is so often swept under the carpet—especially in the Western world—out into the light of day.