A recent video from a wild animal park in Scotland documents movingly the last dramatic days of  Pansy, an elderly female chimp.   Having lived together for more than twenty years, Pansy's two old friends and her daughter sense that her end is drawing near.   Here is how the New York Times describes their parting as it was captured on the video:

"They gathered around her and caressed her in the ten minutes preceding her death. When she died, they inspected her mouth and lifted her head and shoulder to try to shake her into life. The animals stopped grooming and left her after her death; although her daughter later came back to build a nest and lie by her all night long....the animals were quieter than normal and lost their appetites after the death."

The researcher comments: "we were careful to avoid anthropomorphism, but it became very difficult not to realize some of these things are strikingly similar to human responses to dying individuals."  

Mammals grieve. It is the flip side and necessary price of that quintessential mammalian characteristic-attachment to our loved ones. We start life attached to a milk bearing mother who we need not only for her nourishment, but also (as Freud, Harlow, and Bowlby all emphasized) for her warm and fuzzies. Our lives consist of a series of attachments and losses. And then we die and others grieve for us. Man is not alone as a social, caring, empathic, and grieved for social animal. We are just doing what mammals do.

Which brings us back to DSM5 and grief. DSM IV has an exclusion criterion that restricts the diagnosis of Major Depressive Disorder when individuals have recently lost a loved one (i.e. in the past two months).  This was included because so many people have symptoms exactly like major depression as part of their normal, temporary mammalian grieving.  The similarity of grief and depression should occasion no surprise. Our vulnerability to  depression may arise at least in part as an overshoot of the normal grieving reaction.

DSM5 suggests removing the
DSM IV bereavement exclusion and would allow the diagnosis of Major Depressive Disorder even in the immediate aftermath of the loss of loved one- so long as the person meets the required symptom thresholds for a period of two weeks.

Drs. Pies and Zisook, in a well thought out Psychiatric Times posting,  present the best defense of this (I think basically indefensible) proposal. They are worried about the likely current  underdiagnosis of depression and its delayed treatment in some grieving individuals.  They would like to quickly identify those who are not likely to recover from their symptoms of depression, who will need psychiatric treatment, and who  are at risk for a worse course (and even suicide) if not diagnosed early and treated promptly. Pies and Zisook see the death of a loved one as just another stressor (though, of course an especially powerful one) that can trigger a major depression which needs to be diagnosed and medically treated just as would any other major depression.  

Undoubtedly, they are right about some very small fraction of all grieving individuals. But (as I pointed out in a previous blog), removing the bereavement exclusion would result in a tremendous overdiagnosis of major depression among the grieving- the vast majority of whom are having a perfectly normal (if devastating) experience and will recover on their own with time, the support of surviving loved ones, and the cultural rituals that have been invented precisely to get us through the mammalian experience of loss.

My concern about overdiagnosis has something to do with the overuse of medication, but there is a much larger question that brings us back to Pansy, her daughter, and her friends. As Arthur Miller put it, when someone dies "attention must be paid". Attention to the loved one who is lost and attention to those left behind grieving the loss. And for the vast majority, the appropriate attention is not prescribing a pill of psychotropic medication. The medicalization of grief sends just the wrong message to the misidentified "patient" and to the surviving family. Grief is not an illness-it is part of the expectable human, or better the mammalian, condition. To mislabel grief as a mental disorder reduces the dignity of the life lost and of the survivors' reactions to its loss. We would be substituting a half baked, superficial, and depersonalizing medical mourning ritual for the solemn, time tested death rituals that are at the heart of every culture - including Pansy's.

Then there is the larger public policy question.  Do we really want to be a society that recommends popping a pill for every problem- including the expectable mammalian reaction to losing someone precious. We have to trust that resilience is also built into the mammalian genome and into the family and cultural supports that buttress us during periods of loss. Mammals grieve their losses. It is adaptive to do so-we couldn't really love well enough if we didn't feel great pain on the loss of love. But mammals also lick their wounds and move on and love again. If they didn't, we wouldn't be here.

This brings us back to the legitimate and well intentioned concerns raised by Dr. Pies and Zisook. Suppose someone does have an unusually severe, dangerous, and complicated grief that obviously requires medical intervention. The DSM IV bereavement exclusion is flexible and provides no impediment to diagnosis and treatment - it already includes wording to allow the diagnosis of major depression for bereavements that include "marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation."  The DSM5 proposal to eliminate the bereavement exclusion altogether would add those cases of grief that resemble mild depression, precisely the ones most likely to resolve on their own. The clinician can also diagnose "Depressive Disorder, Not Otherwise Specified" if clinical judgment cries out for a diagnosis and nothing else works. DSM IV can already deal with the issues raised by Pies and Zisook- there is no need for DSM5 to create an army of normal grievers mislabeled as having a mental disorder.

The more general point is that the diagnostic system should not be stretched so far that every aspect of human suffering, or discomfort, or eccentricity is labeled a mental disorder and treated with a medication. Most grieving people have much to be unhappy about and are responding perfectly appropriately to their loss and altered m. We should respect and normalize, not medicalize, the pain of their normal grief.   

You are reading

DSM5 in Distress

Balancing Patient Freedom With Safety And Well Being

The rationale for court mandated outpatient treatment

"Please empathize with me, Doctor!”

How to train doctors to be more empathic

A Checklist To Stop Misuse Of Psychiatric Medication In Kids

MD's should not prescribe first, ask questions later