Grief: Is it a mental disorder?

Some doctors now believe that extreme grief due to the loss of a loved one should be medically classified and treated like any other form of depression. Others argue that grief is a natural (and sometimes, necessary) human emotion and it should not be categorized as an ailment that needs to be corrected by "Happy Pills." I don't know whether grief is a "disorder." I am inclined to say "no." I don't think that our brains, and therefore our lives, are meant to be relentlessly cheerful. I suspect that in the absence of "negative" emotions such as sadness, fear or anger, we would also be lacking in beneficial qualities like empathy and survival skills.  We all cope with life's ups and downs in our own ways. Throughout the world social rites and religious rituals are designed to help survivors deal with suffering due to bereavement. Despite that the loss of a loved one affects different people with vastly different levels of trauma; some come to terms with it requiring no third party intervention while others may need prolonged periods of solace, and even professional counseling. Surely, a grieving person is depressed. The question however is whether such depression requires medication and if so, what carefully considered criteria ought to be in place regarding the duration of the condition and the severity of the debilitation.

Grieving the loss of a friend, family or loved one may soon be considered a form of depression. While many doctors acknowledge that grief is a very normal part of losing someone close to us, they also acknowledge that it’s important to deal with that grief.

Speaking to the New York Times one doctor explains why turning grief into a depression diagnosis could end up hurting those people suffering from some for of grief.

“This would pathologize them for behavior previously thought to be normal.” says one doctor.

Opponents to the diagnosis also say to could lead many people with short term grief receiving drug treatments that would normally be unnecessary outside of depression symptoms.

I asked my co-bloggers to weigh in with their opinions on the matter. Unsurprisingly, their responses fall on both sides of the argument.

Joe:

That is interesting.  I think I like the idea -- grief is a real and sometimes debilitating thing, and recognizing it as a mental health issue could remove stigma from receiving treatment or considering it to be a serious issue (beyond, "sure, you're sad, that's totally normal and good").

Norman:

I agree with Joe on this. Having been close with my father, following my mother's death, I witnessed the toll depression took on him for more than 6 months. It was real. It did not start to abate until, at my insistence, he see his internist to deal with it. Medication did a great deal to reduce the symptoms.

On a less personal note, the matter is one of classification. There are accepted definitions and descriptions of what constitutes a disorder and what constitutes depression. Depression is not made from whole cloth. There are different types of depression, and different degrees of the debilitating effects. There are different causes or triggers, and some of them we understand. There are medications that work - differently for different people, and in varying levels of efficacy. 

Grief is not depression and depression is not grief. However, depression can be triggered by trauma and loss, and for short duration and, in my father's case, more than 6 months before being medicated. 

Last night I happened to watch the movie, A. I. - Artificial Intelligence, a film by Steven Spielberg. The plot direction was established, very early, by showing a mother who is grieving over the loss of her child. The grieving is obsessive and consumes the mother's entire life. An advanced android child is created as a replacement. Interesting movie.

Prasad:

Yikes. I remember once treating grief as a reductio of the idea that terminal cancer patients were clinically depressed something like a quarter of the time and ought to be treated for it. ( I'm D in the comments).

I think this is basically what happens when you combine the idea that the brain is an organ like any other (it is an organ of course, that's fine) with the idea that it's determinative of proper function in any body part to see if the patient/society is happy with it. I think that's a horrible confusion, especially when dealing with mental disorders. Whatever the appropriate proper functioning of a brain looks like, it isn't to make you happy independent of what's going on in your life. The problem is hardly mitigated by stipulating that you'll medicalize only some "small" (but always steadily growing - consider the related case of ADD and ritalin) fraction of cases out in the tail. But what do I know...hook up all grieving relatives to the experience machine.

Anna:

As the article says, at stake is a lot of money. Please consider tying in a related, current topic about a DSM-V definition that moves in the opposite direction-- declinicalizing behavior-- through the narrowed definition of "Autism." Leave aside the cost of medications to treat various symptoms or therapeutic behavioral services such as ABA, speech therapy, occupational therapy. Also at stake is whether an individual will qualify for state funding lifelong developmental services (supported housing, occupational training and supported employment, respite funding for family caregivers) without which the individual and his/her family may be in dire straits, regardless of whether the appropriate diagnosis is "Autism" or "Pervasive Developmental Disorder- NOS." In my ideal world, all treatment or services are simply available to everyone who needs and wants them, regardless of diagnosis, but in all the bureaucracies of the world, from insurance companies to schools to government social services, getting anything depends on being able to submit the right name/code.

The same is true of depression/grief/any other form of mental state. Someone who is not functioning or very unhappy about his or her unhappiness should be able to fall upon the range of treatments available for mood disorders, from talk therapy to medication, regardless of whether the cause is "major depressive disorder" or "dysthymia," or "grief." 

There are many forces, or at least, the one, very powerful force of the pharmaceutical industry, which pushes in the direction of over-treatment, or at least over-medication and too little coverage for non-pharmaceutical treatments. But there are also many barriers to treatment, and if a condition name is what it requires for a very unhappy person to get the help he wants or needs after a profound personal loss, then give him the name grief.

Norman:

Anna hit the nail on its many heads. The issue of depression associated with grieving is more than a matter of classification and definition. I wish it were simply a matter of definition. At the core of the matter is, in significant part, a pharmaceutical industry that maximizes production and profit, without sufficient monitoring, moderation, and modification of dose. Beyond that, there is a name game being played in order to obtain treatment. For example, insurance does not cover PTSD, for the most part. However, to look at the diagnostic codes for reimbursement, one would conclude that everybody in the country who seeks therapy suffers from generalized anxiety disorder and nothing else. This might not reflect, accurately, the frequency and distribution of various disorders, but it enables more people to find treatment and other services.

Getting back to the narrow issue of definition and classification, few of the public understand that one of the primary functions of the DSM is research. One cannot conduct research and publish findings unless there is an agreement on the definition of variables, states, and standards. Electrical engineering, metallurgy, biochemistry, and particle physics have these worked out reasonably well - psycho-pharmacology, psychiatry, psychology, and psychotherapy not so much. However, the current DSM-IV TR is a vast improvement over the earlier collections of 'mushy' generalities.

It's difficult (though not impossible) to have a productive debate in a public forum on the issues in all their complexities. Say the words 'mental disorders,' and you get reactions that range from great compassion to great denial - "There was no such thing as PTSD when I was in the Army 50 years ago." Say the word 'drugs' and powerful emotional reactions come to the surface and find vocal expressions like 'miracle drug', 'saved my life', 'nearly killed me', 'big pharma conspiracies', 'get the country hooked', 'my child will die without it', 'over medicated', and on and on.

I've resisted conspiracy theories for most of my life. The recent decline in breast cancers, resulting from the sharp curtailing of hormone replacement therapies, has changed my mind. The decades long research and writings of Barbara Seaman, and others, exposed the complicity of Big Pharma and the AMA.

Dean:

I experience grief not so much as a medical condition, but as a phase of life involving among other things the acknowledgment of absolute loss, so it's hard for me to imagine viewing grief per se as a disorder. Obviously, phases of life can trigger disorders, too.

Sujatha:

Earlier, I used to think that it wouldn't have been such a big deal to use anti-depressants as a crutch, but after reading Robert Whitaker's 'Anatomy of an Epidemic', and reading about irreversible alterations in brain chemistry as one begins to use such drugs, I'm not so sure about even seemingly benign and short term use.

 

Comments

[Zachary Latif]

I think everyone has their own path but (and I could be completely wrong on this) but grief (like any other emotion) has to be worked through and reconciled to the inner psyche.

I do agree with Ruchira that our lives are not meant to be constantly happy otherwise they would lose meaning.

Also I do not think that emotional states are necessarily the point of our life. Incidentally I just mentioned to a friend about the constant quest of the "self-actualised" individuals of our generation who are still trying to find themselves in their 20s and even through to their 30s.

[Norman Costa]

CRITERIA FOR LABELING ABNORMAL BEHAVIOR

The following is taken from "Psychology in Action," 8th edition, 2007, by Karen Huffman, John Wiley and Sons.

(Rare) <<----->> (Common)
1. Statistical Infrequency
(e.g., believing others are plotting against you)

(Low) <<----->> (High)
2. Disability or Dysfunction 
(e.g., being unable to go to work due to alcohol abuse)

(Low) <<----->> (High)
3. Personal Distress 
(e.g., having thoughts of suicide)

(Rare) <<----->> (Common)
4. Violation of Norms 
(e.g., shouting at strangers)

"[T]raits like intelligence or creativity, and ... abnormal behaviors, lie along a continuum. Most of the population falls somewhere between the two extreme end points.

"Recognizing this continuum, how do we decide when behavior becomes abnormal? Let's begin with one of the most widely accepted definitions of abnormal behavior-patterns of emotion, thought, and action considered pathological (diseased or disordered) for one or more of the following reasons: statistical infrequency, disability or dysfunction, personal distress, or violation of norms (Davison, Neale, & Kring, 2004

"As you can see [above]..., for each of these four criteria abnormal behavior falls along a continuum.... Keep in mind that each criterion has its merit and limits and that no single criterion is adequate for identifying all forms of abnormal behavior. Psychologists and other mental health professionals recognize this. They seldom label behavior as abnormal unless it meets several of these standards.

"1. Statistical infrequency. (How rare is the behavior?) 
A behavior may be judged abnor­mal ifit occurs infrequently in a given population. For example, believing that oth­ers are plotting against you is statistically abnormal. And it might be a sign of a serious problem called delusions ofpersecution. However, having great intelligence (Albert Einstein), exceptional athletic ability (Lance Armstrong), or an unusual artistic skill (Frida Kahlo) is not classified as abnormal by the public (or by psy­chologists). Therefore, we cannot use statistical infrequency as the sole criterion for determining what is normal versus abnormal.

"2. Disability or dysfunction. (Is there a loss of normal functioning?) 
People who suffer from psychological disorders may be unable to get along with others, hold a job, eat properly, or clean themselves. Their ability to think clearly and make rational decisions also may be impaired. Therefore, when people's use of alcohol (or other drugs) is so extreme that it interferes with their normal social or occupational func­tioning, they may be diagnosed as having a substance-related disorder.

"3. Personal distress. (Is the person unhappy?) The personal distress criterion focuses on the individual's own judgment of his or her level of functioning. For example, someone who drinks heavily every day may realize it is unhealthy and wish to stop. Unfortunately, many people with true alcohol-dependence dis01'ders deny they have a problem. Also, some serious psychological disorders cause little or no emotional discomfort. A serial killer, for instance, can torture someone without feeling remorse or guilt. The personal distress criterion by itself, then, is not sufficient for identifying all forms of abnormal behavior,

"4. Violation of norms. (Is the behavior culturally abnormal?) The fourth approach to identifying abnormal behavior is violation of, or nonconformance to, social norms, which are cultural rules that guide behavior in particular situations. Being in such a highly excited state that you forget to pay the rent but pass out $20 bills to strangers is a violation of norms. This type of behavior is common among individ­uals who are diagnosed with bipolar disorder.

"A major problem with this criterion, however, is that cultural diversity can affect what people consider a violation of norms (Lopez & Guarnaccia, 2000). Abnormal behavior is often culturally relative-understandable only in terms of the culture in which it occurs. For example, believing in possession by spirits is com­mon in some cultures. And it should probably not be taken as a sign that the believer in those cultures is mentally ill. In addition, there are also culture-bound disorders that are unique and found only in particular cultures, as well as culture­general symptoms that are found in all cultures (Flaskerud, 2000; Green, 1999; Lopez & Guarnaccia, 2000). These terms are fully discussed later in this section.

"What about the term insanity? Where does it fit in? Insanity is a legal term indi­cating that a person cannot be held responsible for his or her actions, or is judged incompetent to manage his or her own affairs, because of mental illness. In the law, the definition of mental illness rests primarily on a person's inability to tell right from wrong. Some critics have argued that insanity is misused as a type of "get out of jail free" card. However, the insanity plea is used in less than 1 percent of all cases that reach trial. Furthermore, when used, it is rarely successful (Kirschner, Litwack, & Galperin, 2004; Steadman, 1993).

"For our purposes, it's important to keep in mind that insanity is a legal term. It is not the same as abnormal behavior. Consider the case of Andrea Yates, the mother who killed her five small children. Both the defense and prosecu­tion agreed that Yates was mentally ill at the time of the murder, yet the jury still found her guilty and sentenced her to life in prison. How could the jury not find her insane? Her behavior was statistically infrequent, she was clearly dysfunctional and personally distressed (diagnosed by her doctor as suffering from psychotic postpartum depression), and her behavior was considered abnormal by almost everyone in our culture. Due to a legal technicality, Andrea Yates' conviction was later overturned, but she remains in prison under medical supervision.

"Insanity - Legal term applied when people cannot be held responsible for their actions, or are judged incompetent to manage their human affairs, because of mental illness.

"The insanity plea. Andrea Yates admitted drowning her five children and was sentenced to life imprisonment despite a vigorous defense failed a plea ofinsanity. An appellate court overrulled her conviction in 2005, primarily because ofa mistake by the prosecution's star witness. He insisted Yates was copying a law and order episode from television, in which the woman was acquitted on an insanity plea. The problem? There was no such episode! (Note: Keep in mind that an insanity verdict normally results in tbe defendant being committed to a mental institlltion indefinitely - sometimes longer tban a prison term for a similar crime.)"

[Rekha Shorey]

It sure is an emotion to be experienced,dealt with,expressed fully so it works as a catharsis and one is released of all the pent up anger and helplessness and the constantly nagging 'why?' And the entire process eventually drains and empties you to a point when you can't cry any more.And then you start to feel other emotions like fond retrospection,reliving fun and warm moments.........and the emotional roller coaster starts to come to a slow halt and thus begins reconciliation with the irreversible.
Drugs do help tide over the initial stage of shock and denial but certainly need to be closely monitored and tapered down as one gets emotionally ready to deal with the aftermath.

[Elatia Harris]

If grief=depression, then love=mania. To all of us, more wonderful things than we can possibly have arranged for and more awful things than we can remotely have deserved, happen. Shouldn't there be some extremes of the human condition that are natural -- if a little too hideous or too fabulous to be routine? Just as teenagers in soul-pounding love do not need to be treated (except by Dr. Time...), people who have just lost what seemed to them the infinite do not need to be seen as "mood-disordered."

To judge a person who is grieving with all her heart and soul as a candidate for medication is among other things a way of saying YOU don't have the time or skills or inclination to be her listener. Remember the photo of the village woman in Indonesia, after the tsunami, who knelt beside the sea? She was waiting for it to give back her children, and their village. So she was dealing not only with the loss of her children, but of the community that would have remembered her children. While few people would have had what it took to help her manage, I don't imagine many regarded the photo and thought: "Prozac!" It wasn't really a medical moment, was it?

By the way, for the best of all reasons, I am a big believer in psychopharm for people who really need it.

[Norman Costa]

Depression and mania at Downton Abbey

It's fascinating watching the emotional lives of the occupants of Downton Abbey. There is grieving and loss that are handled in typical upstairs British style. The expectations for self and others are specified to an extent that they could be put in a landed gentry users guide.

The point of this observation is that there is a significant cultural component to determining what is normal and what should be viewed as disturbed or dysfunctional.

Season 1 is on Netflix.

[Ruchira]

Dear Rekha, thanks for weighing in. I appreciate your insight, given your recent loss which you had shared with me with much sensitivity and poignancy. Hope you are doing well.

[kegelmaster]

i understand clearly that a person should acknowledge that he is greiving for losing a loved one. I would say that it is normal only if grief is not seen in a person for too long. However, if it took so long for a person to go back to his normal life then i guess that where medical treatment should come in.

[Louise Gordon]

Norman,

Are you saying that violating "norms" means that something is amiss with an individual's brain?

I thought Bruce Levine's article on why he is a dissident psychologist was very good. It is about corruption within the pharma-psychiatric system, with its tendency to medicalize normal behaviors:

http://www.alternet.org/story/153634?page=entire

[Norman Costa]

@ Louise:

Hi! All I am saying is that this is how the problem is approached. You'll notice that there is nothing here that references any kind of testing (blood, neurology, DNA, self-report of behaviors or feelings, etc.) If anyone looks at this and says it looks a bit loosey-goosey, they are right. There is a significant cultural and political component to making judgments about disorders. In the old Soviet Empire, and still today in Russia, political dissidents can be classified as mentally ill and confined for treatment. In Vietnam, withholding your labor in protest or for better conditions is a crime against the state. The same was true in the Soviet Empire.

The DSM is an interesting and strange thing. As an aid to diagnosis, it was designed to allow practitioners to classify the observed behaviors of people. The DSM does not say, "...and a score of such-and-such on Carter's emotional development scale." What is very interesting from your question on something amiss in the brain is that psychological science is being trumped by neuro-cognitive-behavioral research. I posted on this in Facebook: http://www.bbc.co.uk/news/health-16854593 - Brains may be hard wired for addiction.

"Addiction to drugs is a major contemporary public health issue, characterized by maladaptive behavior to obtain and consume an increasing amount of drugs at the expense of the individual’s health and social and personal life. We discovered abnormalities in fronto-striatal brain systems implicated in self-control in both stimulant-dependent individuals and their biological siblings who have no history of chronic drug abuse; these findings support the idea of an underlying neurocognitive endophenotype for stimulant drug addiction."

Some types of psychological therapies have been shown to actually 'rewire' the brain. However, this is all very new.

Big Pharma and all other big and rich corporate persons are a threat to us on many levels. Practitioners/psychiatrists who prescribe are doing a very poor job of monitoring the effects upon their patients.

[Norman Costa]

@ Louise:

There is also an environmental component to mental disorders. For example, in the Vietnam War about 40 percent of the soldiers tried hard drugs. Of those, half became drug addicts (20 percent.) When they returned to the States, the addicted population dropped, almost immediately, to 5 percent.

There was a diagnosis of environmentally induced schizophrenia. It was used to describe the response of some offenders to incarceration. This is not my area, so I don't know if they still use the diagnosis.

Even when we associate brain function or morphology with disorder, we usually find interactions with experience and environment. The same is true for DNA. There are markers for sociopathy genetic material, however, not all people with the genetic predispositions will become sociopaths.

[Louise Gordon]

Norman,

Thank you for your answers. Of course, in this country, too, via "loosey-goosey" diagnoses, people can be denied their freedom if psychiatrists deem them a danger to themselves or others and can have unwanted treatment forced on them. Some people are even forced to take unwanted medication at home, I suppose because there is not enough money to keep people warehoused in institutions. Forced ECT is also still happening in the United States.

I'd say psychiatrists are doing a very poor job at a lot of things, not just monitoring Rx effects on their patients. Many of them seem, however, to be very good at receiving money from Pharma for pushing the pills.

Here is an interesting article by Paula Caplan on psychiatrists lying to their patients to enforce compliance with drug regimens that can be and are known to have been harmful:

http://www.psychologytoday.com/blog/science-isnt-golden/201201/powerful-psychiatrists-push-false-theory-unknowing-souls

"There are markers for sociopathy genetic material, however, not all people with the genetic predispositions will become sociopaths."

Maybe they become psychiatrists.

[Norman Costa]

@ Louise:

Your last sentence - Funny!

[Louise Gordon]

Norman,

Happy you like my Funny!

Louise

[Account Deleted]

Hi, I think if someone is suffering from mental disorder or something else then he/she should join rehab center. Occupational therapy assist people and they heal all problems, any type of disorder, everything. They encourage people to live independently.