Is grief a disease? That is one of the crucial questions psychologists are asking as the American Psychiatric Association revamps its Diagnostic and Statistical Manual of Mental Disorders (DSM), used by millions of mental health professionals to diagnose patients, for a fifth edition due out in 2013.
A group of psychiatrists have spearheaded a movement to include ongoing grief as a disorder, to be labeled “complicated” or “prolonged grief.” Others have proposed, separately, that a mourner can be labeled clinically depressed only two weeks after the loss of a loved one. The problem with both potential changes is that more people’s grief will be diagnosed as abnormal or extreme, in a culture that already leads mourners to feel they need to just “get over it” and “heal.”
In January, more than 10,000 mental health professionals, concerned about the credibility of the science behind several proposed additions to the manual, including the potential addition of complicated grief, have signed a petition calling for an “independent review” of the DSM-5. Their concerns are worth taking seriously. Grief, even the ostensibly extreme variety that the DSM might include, is a universal and normal human reaction to the loss of a loved one. Unlike most disorders in the manual, it is a condition we will all experience. It is not a disease and it has no place in a book dedicated to listing mental disorders. In a culture that has largely turned grief into a private experience rather than a communal one, the decision to include grief in the DSM risks doing more harm than good, making it easier than ever to view those who are simply experiencing a painful rite of passage as abnormal.
A major problem with the proposal is that the symptoms of complicated or prolonged grief—such as yearning, sorrow, and sadness—look much the same as those of normal grief. The new diagnosis, spearheaded by two professors of psychiatry, Katherine Shear and Holly Prigerson, at Columbia and Harvard University respectively, would likely characterize complicated grief as a constellation of symptoms that can include intense feelings of sadness, bitterness, and loneliness; difficulty sleeping and concentrating, and detachment and agitation, among others. (Shear and Prigerson each have different definitions; it’s not yet clear what version would be adopted if it were included.)
But at least one large study found that these feelings were experienced by most mourners. And a survey we conducted on grief for Slate found that, out of nearly 8,000 people, the vast majority reported symptoms that resemble those of complicated grief. For example, 81 percent experienced sorrow; more than 72 percent reported overwhelming sadness, yearning, and nostalgia; and close to 60 percent reported trouble sleeping and feelings of longing. Even the advocates of including complicated grief in the DSM acknowledge that there is little qualitative difference between normal and pathological grief.
If the symptoms of complicated grief don’t look any different than those of normal grief, how can we tell the two apart? Right now, advocates for its inclusion argue that the major clinical difference between the two has to do with the duration of these symptoms. In their view, complicated grief can be identified as early as six months after a loss. But research indicates that many people are still in the grips of their grief at this point: In the Slate study, a quarter said they felt normal only “one to two years” after the loss. A mere 30 percent of the respondents reported feeling “normal” or symptom-free again within six months after a major loss. Another large study conducted by George Bonanno and his colleagues at Columbia University found that many mourners reported a long grieving process, with symptoms waning anywhere from six months post-loss to 18 months post-loss.
So what are the downsides of treating grief as a disease? For one thing, more people will be prescribed antidepressants that can have adverse physical and psychological side effects, including increased risk of suicide and addiction and withdrawal problems. (To date, the research has consistently shown that grief counseling and medications do not alleviate grief; they seem most helpful in the cases of people who had pre-existing mental health issues.) It also means that more people will feel shame and embarrassment about not grieving “properly” or getting over their loss fast enough. And the very language of “symptoms” and “duration” seems only to further diminish the significant event that precipitated these feelings in the first place—the death of a beloved person who can’t be replaced.
The inclusion of the diagnosis would be less troubling if we lived in a culture that better understood the fact that grief takes time—and knew how to support it. People used to wear mourning clothes for a year or more, and many cultures have mourning rituals that cluster around the first anniversary of a death. But in the 20th century, Americans began to see the experience primarily as a private and a psychological one rather than a communal one, popularizing Elisabeth Kübler-Ross’ tidy “stage theory” of grief (which moves from “denial” to “acceptance”), and valorizing a “muscling-through-it” approach, to damaging effect.
The truth is that grief is a profound emotional process with very real biological symptoms that can endure for months. For many mourners, grief brings with it feelings of isolation, since a person who occupied a crucial role in your life is gone. It’s easy to see how turning grief into a disease could lead to further feelings of being out of step with those around you—a feeling that already haunts many mourners.
It would be a shame for this to happen. Grief is part of what it means to be human—one of our most significant rites of passage. The majority of mourners do not need medical treatment. They need love, compassion, patience, and a little bit of understanding from their friends, families and colleagues. The truth about grief is that it hurts. It can hurt for a long time—even for years.
That’s because grief is intricately bound up with love. As Thomas Lynch elegantly put it, “Grief is the price we pay for being close to one another. If we want to avoid our grief,” he said, “we simply avoid each other.”