THURSDAY, Feb. 16 (HealthDay News) -- The loss of a loved one
can trigger deep emotional turmoil, but is the grief that follows a
normal part of being human or is it a form of mental illness in
need of diagnosis and treatment?
That's the gist of a major debate now unfolding in the world of
psychiatry, as the American Psychiatric Association (APA) prepares
to issue the fifth edition of its seminal reference guide to mental
Diagnostic and Statistical Manual of Mental
The issue: For the first time, the manual -- a touchstone for
mental health professionals across the United States -- may
not exclude the concept of "bereavement" from the
constellation of behaviors and experiences that it deems worthy of
consideration when clinicians set out to diagnose a major
What does this mean? That feelings or outbursts accompanying the
passing of a family member or close friend -- such as crying,
insomnia, fatigue, confusion and profound sadness -- may now be
viewed as a treatable illness rather than as a normal reaction to
life's most shattering moments.
Needless to say, not everyone agrees with this shift in
"To me, grief is a normal condition, not to be tagged with a diagnostic code and to be treated," stressed Dr. T. Byram Karasu, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine and psychiatrist-in-chief at Montefiore Medical Center in New York City. "Everyone loses someone in their lives at some point. So, this would be classifying everyone at some point. No one would be immune to this."
"And that does not make sense, because grief is a normal and very healthy behavior," said Karasu, who also chairs the APA's National Task Force on the treatment of depression. "One has to feel joy as well as pain and depression, otherwise life is not worth living. And one should not interrupt the grieving by medication or psychotherapy. You have to feel the loss, and only by feeling the loss and recovering from it will the person become a better person. Interrupted grief will remain unfinished business."
Karasu's stance is in line with those expressed by the editorial
board of the British medical journal
The Lancet, which lays out its opposition to the new clinical approach in its Feb. 18 issue.
"Grief is not an illness," the journal's editors argue, noting that a diagnostic change in the APA's forthcoming manual would empower clinicians to interpret any post-loss despair that endures beyond a two-week window as a troubling sign of sickness rather than a standard sign of coping.
Lancet team suggests that, instead, an intense but normal
bout of grief can last six months to a year, depending on the very
individualized nature of the particular relationship that has been
severed by death.
"Medicalising grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed," the authors noted.
They acknowledged, however, that sometimes grief
can morph into something much more complicated, longer
lasting and "pathological." In such instances, true clinical
depression may ensue along the lines of a so-called "prolonged
grief disorder," a potentially new designation now under
consideration by the World Health Organization. And such patients,
the board agreed, might stand to benefit from some form of mental
The concern over exactly
when normal grief becomes a condition that perhaps requires
treatment is what's driving the notion of inclusion in the DSM,
said University of California, San Diego, psychiatry professor Dr.
"It is well recognized that the death of a loved one, just like any other serious stressor, [such as the] loss of a job, diagnosis of a fatal illness, divorce can trigger a clinical depression," he said. "The ensuing depressive syndromes are no less severe or debilitating when brought on by bereavement as they are after any other life event or, indeed, when the depression seems to occur out of the blue."
"Acknowledging that bereavement can be a severe stressor that may trigger a clinical depression in a vulnerable person does not medicalize or pathologize grief," he suggested. "Rather,
it prevents clinical depression from being overlooked or ignored,
and facilitates the possibility of appropriate treatment."
"This acknowledgment," Zisook cautioned, "does not mean that we think acute grief should end in days, weeks or even months. For some, it may last for years, whether or not there is also a clinical depression. But, acknowledging that clinical depression may also be present in some bereaved individuals may go a long way towards helping those individuals get on with their lives."
For University of Michigan Medical School psychiatry professor
Dr. Randolph M. Nesse, the debate boils down to a tug-of-war
between basic common sense on the one hand and science's search for
diagnostic consistency on the other.
"Everyone knows that grief is something that happens to everybody," he noted. "And just because an emotion feels bad doesn't mean it's wrong or unhealthy. Most often it's a common-sense response to a real problem."
"So, my take is that it would be senseless to eliminate the grief exclusion [from the DSM]," said Nesse, who is also a professor of psychology at UM's College of Literature, Science and the Arts. "But, because it can be so damn hard to figure out when an emotion is normal or not normal without really knowing what is going on in a person's life, there are undeniable advantages to having a neat, clean, simple check-box kind of classification system for diagnosing depression. It makes it easier. So, you include grief as a box to tick, whether or not there is a real problem to be diagnosed."
"But that is what is so troubling," he added. "Because when someone gets a diagnosis of depression it then encourages giving that person treatment. And the getting of that treatment then pushes the person being treated into believing they do indeed have a problem that needs treatment to begin with.
And that can be very unhelpful in many, many cases in which grief
is really a normal and healthy response to a life event."
For more on bereavement, visit
Mental Health America.
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