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Complicated Grief Is Complicated

Grief in the DSM-5

Ever since the earliest scientific study of grief there has been recognition that while for most individuals, grief is a normal—albeit difficult—transition, there are some individuals who have a more complicated reaction to a loss. These complications can be manifested in both physical and psychological health and well-being. Though loss is an event that most people will encounter multiple times in their lives, it also can be a severely stressing experience. Complicated grief has been acknowledged in the very beginnings of the scientific study of grief. Freud in his 1917 paper on mourning and melancholia is oft viewed as one of the earliest and defining contributions to the study of grief. Here Freud attempted to differentiate the normal process of mourning from a more complicated variant—that of melancholia or what we today characterize as a Major Depressive Disorder.

Yet, despite the wide recognition of the potentially deleterious complications of grief, it received little attention in past editions of the Diagnostic and Statistical Manual of Mental Disorders—the authoritative manual of the American Psychiatric Association that classifies varied forms of mental illness. In fact, the prior edition of the DSM—the DSM IV-TR only listed bereavement under “other conditions that might be the focus of clinical attention’’—a sort of catch-all category that includes a variety of conditions other than mental disorders such as sex counseling, occupational difficulties, social problems, or educational difficulties that might cause an individual to seek counseling. This is important as the DSM not only validates a diagnosis but also can establish a requirement for insurance reimbursement through its diagnostic codes.

As the American Psychiatric Association moved to create the newest edition of the DSM, the DSM-5, there were a number of initiatives, some highly debated and controversial, to recognize more complicated variants of grief.

Perhaps one of the most highly debated decisions in the DSM-5 was to remove the “Bereavement Exclusion” from the diagnosis of Major Depressive Disorder. The bereavement exclusion never existed in the first two editions of the DSM nor was it ever in the other major diagnostic system – The International Classification of Diseases (ICD). The bereavement exclusion was first introduced in the DSM-III. The bereavement exclusion was added at the recommendation of one of the Task Force member but there was very limited evidence underlying the suggestion. In fact, one of the reasons DSM III introduced the exclusion was to counter the common medical treatment of acute grief – particularly by primary care physicians who simply offered anti-depressive mediations to patients who were have normal, albeit painful, reactions to loss. Originally the bereavement exclusion was for the first year after a loss but that was reduced to two months in the DSM IV.

Yet the decision to drop the bereavement exclusion altogether in DSM-5 created a firestorm of controversy. The Association for Death Education and Counseling (ADEC) recommended in 2012 that the bereavement exclusion not be removed. In 2013 another group of grief scholars in the International Work Group on Death, Dying, and Bereavement also issued a paper opposing elimination of the exclusion. The arguments for retaining the bereavement exclusion noted that in many ways the early manifestations of grief were difficult to differentiate from depression – especially by primary care physicians who would be far more likely to prescribe anti-depressants. There was a concern then that such treatment had little evidence basis and, in fact, might distort the normal process of adjusting to a loss as well create a harmful dependence on anti-depressants. Underlying this was a fear that the pharmaceutical industry was behind or welcomed this change so as to gain access to a much larger market. In summation the arguments against the elimination of the bereavement exclusion suggested that mild depression is a common manifestation of grief and therefore there was danger of over-diagnosing depression and over-medicating the grieving patient.

On the other hand, the arguments for eliminating the bereavement exclusion were compelling. As stated earlier, such exclusion was not present in the two first editions of the DSM nor was it ever in The International Classification of Diseases (ICD). Moreover, neither the inclusion of the bereavement exclusion in the DSM-II nor its modification in the DSM IV had a firm evidentiary basis.

In addition, the exclusion seemed illogical. One, after all, could be diagnosed for depression after a series of any adverse events. Thus one could be diagnosed for a Major Depressive Disorder if one lost a job or for a missing beloved child but not for the loss of a spouse, parent, or child. Logically, it would seem that a depressive response to any adverse circumstance should be excluded.

Finally, it was argued that a diagnosis of a Major Depressive Disorder does not necessarily lead to the initiation of some form of pharmaceutical intervention. Watchful waiting is often a sound strategy in medical treatment. Thus just as a urologist may not remove an enlarged prostate or begin immediate pharmaceutical treatment but wait to see if it seems to be progressing to a malignant phase or impairing urological functioning so a psychiatrist – or even a family physician – might wait to see if other factors such as suicidal ideation, significant impairment in key roles, or a worsening depression might make medication necessary.

In the end, the DSM-5 removed the bereavement exclusion from the diagnosis of a Major Depressive Disorder. However, it did caution that responses to a loss as well as other adverse circumstances may include some of the criteria associated with depression such as weight loss, insomnia, rumination, or poor appetite. In addition, in an extensive footnote, the DSM-5 carefully outlines that while in grief, the prevailing affect is one of emptiness in a Major Depressive Disorder it is a long sustained depressed mood and an inability to ever expect pleasure or happiness. Moreover, the DSM-5 notes the typically grief comes in waves that lessen in intensity and frequency over time while a depressed mood is more persistent. Furthermore, even in grief, bereaved individuals may experience moments of positive feelings as well as humor that are generally not found in depression. The DSM-5 also states that bereaved individuals are likely to retain feelings of self-worth and self-esteem generally not present in depression. Finally the DSM-5 affirms that while symptoms such as suicidal or negative ideation can occur in grief, they are generally focused on the deceased. For example, a bereaved individual may wish to “join” the deceased or feel guilty about any significant omissions or commissions in their relationship such as failure to visit more often or say something unkind to the deceased. In depression, feelings are more likely directed at self. Here the individual is likely to feel worthless and any suicidal ideation arises from that or the inability to cope with the challenges faced or the pain experienced.

As of the writing of this chapter, it appears that the dire consequences predicted by opponents of the change have not yet appeared. There do not seem to be any commercials from pharmaceutical companies urging bereaved individuals to seek or discuss medications with their physicians. Nor is their evidence in a significant increase in prescriptions for antidepressants. Yet, careful studies in the future will need to assess whether this change was a blessing or a bane to the bereaved.

Perhaps the least controversial decision was to continue to include Bereavement as a V-code or “other conditions that might be the focus of clinical attention.’’ Such a continuation simply acknowledges that individuals may seek grief counseling as they cope with a significant loss.

Two other changes were also relatively non-controversial. The DSM-5 removed the exclusion of grief from Adjustment Disorders. Adjustment Disorders are defined a response to a stressing life change such as divorce or death that seems out of proportion to the event itself, beyond the culturally expected norm, and impairs the individual’s ability to function in key educational, social, occupational, familial, or other important roles. Here there is again specific notation that such symptoms are way beyond the cultural expectations of normal bereavement.

A second change was to allow Separation Anxiety Disorder —once a diagnosis exclusively used with children and adolescents—to be applied to adults. Again, the criteria emphasize that this is a recurring fear of separation or death that impairs the individual’s ability to function in key roles. In this disorder, individuals are reluctant to leave home or attachment figures and may have nightmares with themes of separation. The DSM-5 while noting that this criteria should be applied with some flexibility, that generally the condition should be minimally and persistently present for at least four weeks in children and adolescents but typically for six months in adults. The DSM-5 makes the distinction that while grief involves yearning for the deceased, fear of separation, perhaps triggered by a loss, from other attachment figures is the central factor in Separation Anxiety Disorder.

The DSM-5 also retained the diagnosis of Post-Traumatic Stress Disorder. This, too, may be a manifestation of a complicated grief as it can arise from witnessing or learning about a traumatic event such as a violent or sudden death that result in a series of symptoms including intrusive memories, flashbacks, or dreams as well as other symptoms that last longer than a month and once again impair the individual’s ability to function in key roles.

Finally the DSM-5 did create a “candidate” disorder Persistent Complex Bereavement Disorder, listed in the Appendix, under the category “Conditions for Further Study.” As a candidate disorder, listed in the apeendix, the Reviewing Committee affirms that there is a body of evidence suggesting a form of disorder yet not enough to fully specify the features of such a disorder. Basically it is a call to the field to continue research that can carefully delineate the characteristiocs of such a syndrome. Indeed, the very use of the term – Persistent Complex Bereavement Disorder – seems to imply that the Reviewing Committee was unwilling to give primacy to either of the two underlying proposal.

The DSM-5 in many ways represented a significant advance in the diagnois and treatment of varied forms of mourning. To a certain extent, it answered Freud’s challenge of near a century ago to distinguish mourning and melancholia—differentiating normal grief from depression. And, most importantly, it took the first significant, albeit small, steps to acknowledge complications in the grief process. Yet, the discussion and debate that ensued indicated that far more needs to be done.

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