When Does a Broken Heart Become a Diagnosis?

Considerations on whether grief should be exempt from a diagnosis of depression

Posted Jan 25, 2012

A front page article in today's New York Times documents the increasing drama and controversy unfolding around the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders. A focus of the article is the contentious debate emerging about whether those grieving the loss of a loved one should be exempted from receiving a diagnosis of major depression. Such individuals are currently exempt, but there is now a plan to remove the exception for bereavement in the updated edition (DSM-V). A student of our doctoral program at JMU forwarded the article, and expressed anger and dismay at the ever expanding definition of mental disorder. A colleague of mine, Dr. Craig Shealy, concurred and wrote:

 One of the more tragic aspects of our current diagnostic system is its tendency to medicalize aspects of the human condition that are at the heart of who we are and have evolved to become. 

  The lack of understanding of the etiology and meaning of human need, emotion, and behavior causes so much suffering in our world.  Most egregious is our tacit acceptance -- as "mental health professionals" -- of these reductionistic concepts, which are related directly to a lack of vision, empathy, and depth in practice.  

 I share your grief that grief might be medicalized in this way. 

 Here was my reply to our program:

   Thanks for sending this along. I completely agree with Craig there must be a strong and passionate rejection of any attempt to reduce core aspects of the human experience that exist on the mental and cultural dimensions of reality to neurobiological mechanisms. To do so is unscientific and anti-humanistic, and can result in tragic, real world consequences.

   That said, the issue around grief and depression is complicated precisely because--as you know from our discussions and as I have posted on my Psychology Today blog in regards to both the definition of mental disorder in general and depression in particular--there is much conceptual confusion about what these entities are.

   Here is the issue in a nutshell regarding the exemption of grief. Let's start with the argument of why we should exempt it. If we conceptualize a mental disorder as akin to a medical disease and one gets a diagnosis when there presumably has been a psycho-neuro-biological malfunction within the individual, then we can clearly argue that grief following the death of a loved one should not be characterized as such because it is a normal aspect of the human condition and we should not conceptualize emotional suffering as a disease.

   But here is the catch...mental disorders are in fact descriptive categories of psychological patterns. Staying with the phenomena of depression, there many people who meet criteria for depressive episodes whose depression is completely understandable at the psychosocial level. I often ask people to envision an imaginary commercial of an impoverished, abused minority woman whose kids are having trouble and she feels humiliated, worthless and trapped. (I saw such situations over and over again in my work at Penn on the suicide attempter study). Should this woman be diagnosed with depression? At the level of understanding human suffering, clearly her depression is every bit as "understandable" at the psychosocial level as someone who becomes depressed after the loss of a loved one. Indeed, I would argue her depression is even MORE understandable. But, of course, there is no exemption from being diagnosed with depression if you are trapped in a crappy situation.

  The issue is further complicated by the fact that diagnoses are wrapped up in insurance payment issues and access to treatments. Should a bereaved individual (or someone in a crappy life situation, for that matter) not get access to treatment?

   These are the reasons that I, for one, am ambivalent about grief being an exception (the sole circumstantial exception). The problem with having it as an exception is that it actually provides at least an implicit affirmation that depression is a mental disease that is the cause of the person's problem. But this is NOT what depression is. We need to understand that depression is a descriptive label, and not necessarily a disease entity. (As articulated in my 'What is Depression?' blog, I further argue that depression is a state of psychological shutdown. Via this lens, we can see that some people have what should be characterized as depressive diseases, some have depressive disorders and some are exhibiting a normal reaction to entrapment, helplessness, loss, or humiliation).  

     So what should we do? My bottom line prescription is that we need to see the concept of "Health" as a bio-psycho-social phenomena (interestingly, the nursing profession sees this most clearly). We need bio-medicine to concern itself with the biological dimension of reality, we need psychology to concern itself with mental dimension, and we need the social engineering folks (sociological, economical, anthropological, political) to be concerned with the socio-cultural dimension of reality.

   In this light, the American PSYCHIATRIC Association (A BIOMEDICAL PROFESSION) should be charged with the classification of mental diseases, which are mental disorders reducible to biological malfunction (e.g., disorganized schizophrenia, autism, etc). 

   The American Psychological Association (or equivalent mental health organization) should be charged with the classification of mental disorders, which should be conceptualized as dysfunction in psychological patterns that result in clinically significant levels of distress.

   Note that, ala the famous social psychologist Kurt Lewin, psychological behavior is always a function of the person interacting with the environment. Through this lens, the death of a loved one is akin to an injury to the psychological system. Ideally, the healing will take place in the context of a relational system that comes together and supports the bereaved. If deemed necessary, professional treatment would be framed as the process of helping the person cope with the injury in as adaptive way as possible, with no implication that something was "wrong" inside of them other than the loss itself. (There are clear biomedical parallels here. For example, when my son Jon broke his arm, he suffered an injury to his biological system that needed medical treatment). This way we can treat people humanistically and be clear about why grief can be considered broadly as a health issue, but we do not need to make a category error by thinking of it as biomedical disease.