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DSM-5 Hysteria: When Normal Mourning Becomes Neurotic Bereavement

When does grief over loss of a loved one turn into a mental disorder?
Allen Frances, M.D.
This post is a response to DSM 5 to the Barricades on Grief by Allen J. Frances, M.D.

There is a rising hysteria regarding the forthcoming DSM-5, the diagnostic manual of mental disorders due to be published by the American Psychiatric Association next year. As a clinical and forensic psychologist who has both utilized and taught the DSM-IV (1994) and current DSM-IV-TR (published in 2000) extensively, and who believes strongly in the clinical necessity of being well-trained in psychopathology and psychodiagnosis, let me add my two-cents to this increasingly heated public debate. (See also my prior posts on DSM-5 and its proposed diagnosis of Posttraumatic Embitterment Disorder, which discusses the differences between "normal" and pathological embitterment.)

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Currently, "Bereavement" is diagnosable in the DSM-IV-TR, but not defined as a mental disorder per se. It is what we call a "V code," which is a condition or problem related to but other than a mental disorder that may, nonetheless, become a focus of clinical attention and concern. Other examples of so-called V codes include Parent-Child Relational Problem, Partner Relational Problem, Borderline Intellectual Functioning, Religious or Spiritual Problem and Phase of Life Problem. It is crucial to note that none of these are considered mental disorders themselves. So, for instance, insurance companies typically refuse to pay for treatment of a V code alone. However, clinically speaking, such conditions often warrant watchfulness and, sometimes, require intervention.

DSM-IV-TR draws a distinction between natural or "normal" and pathological bereavement. As it should. When does a "normal grief reaction" become a debilitating, prolonged and potentially life-threatening mental disorder? Beareavement (V62.82) is a category that "can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss.) The bereaved individual typically regards the depressed mood as 'normal,' although the person may seek professional help for relief of associated symptoms. . . . The duration and expression of 'normal' bereavement vary considerably among different cultural groups. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss [my emphasis]. However, the presence of certain symptoms that are not characteristic of a 'normal' grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. These include 1) guilt about things other than actions taken or not taken by the survivor at the time of the death; 2) 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; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person." (DSM-IV-TR, pp. 740-741) 

Note that the clinician is encouraged to consider cultural differences in duration of mourning before diagnosing. (The DSM-IV-TR even allows for the experience of hearing or seeing the deceased person without necessarily pathologizing such phenomena!)  And that these symptoms of grief do not automatically demand the formal diagnosis of a mental disorder. This is reasonable, and not necessarily unusual or abnormal, especially during the first two months (a typical time-frame but still admittedly somewhat arbitrary) following the loss. However, when someone's bereavement symptoms become severe, debilitating and persistent, meeting diagnostic criteria for Adjustment Disorder (see below) or Major Depressive Disorder (with or without psychotic symptoms), it has crossed the threshold from V code (e.g., uncomplicated or simple Bereavement) to a diagnosable and potentially dangerous state of mind. It has become a mental disorder.

One danger in such cases is the very real risk of suicidality, which increases with clinically depressed individuals in general, and especially in someone who has recently lost a significant other. Another is the risk that the person is sliding slowly down a slippery slope into a full-blown major depressive episode. Once this happens, it can make it much more difficult for the patient to pull out of their depressive tailspin. (An untreated major depressive episode typically lasts at least 4 months, regardless of age at onset.) Moreover, once a Major Depressive Disorder develops, the person is at risk for repeated future major depressive episodes, since we know that major depression tends to be recurrent in many cases. ( More than 60% of individuals with Major Depressive Disorder, Single Episode, will likely have a second episode, and those with two or more previously have a 70--90% chance of future episodes.) And, when profound, major depression can engender psychotic symptoms such as hallucinations and delusions, which, in turn, make treatment more intrusive and difficult, and prognosis much poorer. So the treating clinician needs to be mindful of these risks, and watchful of when he or she may need to intervene so as to prevent potentially catastrophic deterioration of the patient's precarious mental state. This is one excellent example of what I call "clinical wisdom." (See my prior posts.)

Currently, DSM-IV-TR excludes grief from the diagnoses of both Adjustment Disorder with Depressed Mood (when normal bereavement is in process) and Major Depressive Disorder (prior to two months of persistent symptoms), the latter being the more serious and debilitating of the two. In Major Depressive Disorder, it specifies that "after the loss of a loved one, even if depressive symptoms are of sufficient duration and number to meet criteria for a Major Depressive Episode, they should be attributed to Bereavement rather than to a Major Depressive Episode, unless they persist for more than 2 months or include marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation." (p. 355) These exclusions were presumably designed to prevent clinicians from pathologizing normal grief reactions. Which makes sense. But what happens when it becomes confusing for clinicans to differentiate "normal" bereavement, sadness, grief or mourning from a major depressive episode or Adjustment Disorder with Depressed Mood? In such cases, what one considers a "normal" grief reaction could, especially in someone who has suffered from depression before, be mistaken for a much more serious and perilous mental health problem. People who have experienced traumatic losses during childhood of parents, siblings, close family members or friends, are at greater risk to react to later losses by falling into clinical depression as opposed to the "normal" bereavement experienced by those who have not suffered such prior traumatic experiences. As are those who may be genetically and temperamentally predisposed toward depression (Major Depressive Disorder is 1.5 to 3 times more common among first-degree biological relatives of MDD sufferers than among the general population).

Interestingly, DSM-5 also proposes to limit exclusion of Bereavement in the diagnostic criteria for Adjustment Disorder. And this too makes clinical sense. It suggests including a new subtype of Adjustment Disorder, Related to Bereavement: "For at least 12 months [my emphasis] following the death of a close relative or friend, the individual experiences on more days than not intense yearning/longing for the deceased, intense sorrow and emotional pain, or preoccupation with the deceased or the circumstances of the death. The person may also display difficulty accepting the death, intense anger over the loss, a diminished sense of self, a feeling that life if empty, or difficulty planning for the future or engaging in activities or relationships. Mourning shows substantial cultural variation: the bereavement reaction must be out of proportion or inconsistent with cultural or religious norms." This important addition would allow for the diagnosis of an Adjustment Disorder in such cases if, and only if, the symptoms persist beyond one year, are clinically significant, and cause marked distress that is in excess of what would be expected or cause significant impairment in social or occupational or academic functioning. In such cases of prolonged grief, we might be seeing in this seeming lack of resiliency, some previously latent, undiagnosed or undetected depressive condition now triggered and brought to the surface by the death of a loved one. Pre-existing personality disorders (e.g., Borderline, Dependent, Schizotypal or Paranoid Personality Disorder) may also complicate the bereavement process quite significantly, sometimes manifesting in psychotic symptoms requiring an additional diagnosis and more intensive treatment.

Failure by clinicians to recognize and diagnose serious depressive conditions in bereaved patients is both dangerous and irresponsible. It is also naive. There must be some middle ground found between overdiagnosing and underdiagnosing. In some cases, proper diagnosis can be life-saving. It seems to me that much of the hysteria surrounding these proposed changes in DSM-5 center around two key issues: First, the psychiatric medicalization of normal aspects of the human condition. And second, stemming from the first, the concern that such hypermedicalization will lead to even more medication being prescribed to "treat" such patients. This is something that has sadly already been happening now in psychiatry and psychology for some time, and especially in recent decades. Blaming or scapegoating the DSM-5 is not a solution. If psychiatrists and psychologists are truly concerned about this tragic trend, the solution is to reconsider how we conceptualize symptoms like depression, anxiety, psychosis, addiction, anger or rage, and abandon tendencies to reduce such phenomena to biological, neurological or genetic causes--and accordingly treat them medically or pharmacologically. (See my prior posts on anger , depression and addiction, for example.) Physicians, psychiatrists, psychologists and other mental health professionals must take a step back, right now, and rethink the very nature and meaning of mental illness. And, therefore, the way we treat it. (See my prior post.)

There is nothing in the DSM-IV-TR or forthcoming DSM-5 (so far as I know) that dictates or even recommends medicating patients. The decision to do so depends solely upon the treating physician or clinican. And these decisions are informed (or misinformed) not merely by a diagnosis per se, but by the way clinicians interpret and understand the underlying nature of a patient's symptomatology. Doing away with DSM-5 will do absolutely nothing to rectify such misguided treatment approaches. Indeed, it would be an immense loss of invaluable collective clinical wisdom. The problem here resides not in the diagnoses, but in the doctors, their dubious physiological explanations of mental disorders and their increasing overreliance on medications. While psychiatric medication may sometimes be essential to effective treatment, its overuse has become epidemic today. Psychotherapy, including psychodynamic, existential and cognitive-behavioral approaches, which is seen by psychiatry as becoming more and more obsolete or insignificant in treating serious mental disorders, has as much and, in most cases, far more to offer patients than psychopharmacology alone, whatever their diagnosis may be. (See my prior post.)

 

Stephen Diamond, Ph.D., is a clinical and forensic psychologist in LA and the author of Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity.

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