Psychiatry: Far From the Madding Grief?

The Diagnostic Statistical Manual of Mental Disorders is the official classification manual developed for use in clinical, educational, and research settings; it is published by the American Psychiatric Association (APA) and is regularly revised. The fifth edition (DSM-5) is expected to appear in May 2013. In the DSM’s current edition (DSM-IV), feelings of sadness and associated symptoms (e.g., insomnia, poor appetite, and weight loss), following the death of a loved one are excluded from the criteria for a Major Depressive Disorder (MDD), but a cautionary clause states that if these symptoms continue beyond two months and impair the individual’s psychological, social and occupational functioning, she may be given an MDD diagnosis.

The DSM-5 Working Group for the Mood Disorders has recently proposed the removal of the bereavement exclusion from the diagnostic criteria for a Major Depressive Disorder (MDD), arguing that the available evidence does not support distinguishing bereavement from other stressors that underlie MDD.

This proposal has led to a controversial debate on the advantages and disadvantages of distinguishing between the cases that involve individuals who develop major depression in response to bereavement and those who develop depression following other severe stressors. For instance, Allen Frances, the lead editor of DSM-IV, is concerned that removing the bereavement exclusion will result in over-diagnosing and over-treating non-pathological grief by labelling it MDD.

The proposed change also raises concerns about lowering the diagnostic thresholds for disorder categories, including MDD, as this may lead to inappropriate medical treatment of vulnerable populations. Some maintain that this adjustment will better address a grieving individual’s needs, however, as she will be able to receive some therapeutic help while coping with loss; in addition, her expenses will be covered by insurance companies, as her concerns will be a legitimate health condition.

Grief is a complex process, through which the individual mourns the loss of a loved one, negotiates the demands of the new world without the loved one in it, and adjusts her new way of being-in-the-world without that person.

What worries me about diagnosing the multifaceted and complex grief experience as depression is its influence on the patient’s conceptualization and understanding of her grief and her concomitant response. If she takes her grief experience as a form of illness, without due appreciation of its true complexity two things may occur. First, she may become less inclined to discover the qualitative and subjective features of grief experience, to situate it in her interpersonal relationships, and to negotiate her own response, relying instead on the psychiatric language of depression which lacks depth because it is merely an operational framework designed to facilitate diagnosis and treatment across different settings. Second, the psychiatric language, which lacks the subjective context of the grief encounter by virtue of focusing on the patient’s observable symptoms not her life as a whole, may direct the patient’s attention away from her personal experience of grief towards an impersonal illness. (I addressed similar concerns on the epistemic influence of psychiatric diagnoses, in particular, on the influence of mood disorder diagnosis on self-insight, here, and  the DSM diagnoses at large on self-concepts, here.)

Does it matter if the grieving person engages with her subjective experience of grief using her own language, rather than the psychiatric language of depression? Some empirical evidence suggests that it does. For example, James Pennebaker’s empirical work on the value of writing about traumatic experiences on the subject’s well-being demonstrates that when individuals write about traumatic experiences by deeply engaging with the associated emotional difficulties in their lives, significant physical and mental health follows. This is called the disclosure phenomenon. Pennebaker’s studies indicate that writing about deep feelings related to a traumatic experience is associated with a significant drop in physician visits and has a beneficial influence on immunity. While some positive outcomes of the disclosure phenomenon can be attributed to a reduction in inhibition, Pennebaker and his colleagues argue that basic cognitive and linguistic processes involved in writing are a more significant factor in these positive outcomes. Support comes from the observed connection between language and health outcomes: thoughtful and deep writing, which draws causal and insightful connections between the events and emotions, as well as the use of positive emotion words in expressing trauma, leads to better health outcomes. In the case of grief, therefore, perhaps the individual will better cope with the loss of a loved one, if she is encouraged to explore her feelings connected to his presence in her life, the sadness that comes with his loss, and so on.

Whether the alteration of the diagnostic criteria for the MDD by removing the bereavement exclusion criteria and diagnosing grief-associated emotional difficulties as depression will lead to the problems I suggest here is largely empirical. It depends on the person, the psychiatric context in which she receives diagnosis, and the particular therapist who diagnoses her. But we must pay attention to the moral psychology and reasoning of the persons most influenced by these changes. At the next meeting of the American Psychiatric Association in Philadelphia in May 2012, the representatives of the DSM-V task force will answer questions pertaining to these changes. I look forward to hearing whether they have fully considered the complex ramifications of change.

**The photo is taken in New Orleans, at the 2010 Meeting of American Psychiatric Association (APA) when I participated the meeting for the Association for the Advancement of Philosophy and Psychiatry. Various societies participating at the APA meeting found a way to advertise their respective groups, and this mannequin introduces us the Society for Clinical Trials and American Thoraric Society.