Grief is not a disorder and should be considered normal

Grief is not a disorder and should be considered normal

Have you been tearful and sad after the death of a loved one?  Did you notice changes in appetite, difficulty sleeping, troubles concentrating, and decreased energy for at least two weeks after the loss? Did you think that was a normal, healthy, and adaptive response to a major loss? Well, if you believe the new DSM-5 criteria approved by the American Psychiatric Association’s (APA) board of trustees, you would be wrong, as your reaction would now fit the criteria for major depression.

Under the DSM-IV criteria, you would have been right, as the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.   It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to months following a loss is associated with significant distress.

Times are changing though.  The APA Board of Trustees released a statement that noted the newly approved DSM-5 will remove the “bereavement exclusion.”

Now there are some persuasive arguments for this change. Probably strongest is that there is little difference between the development of depression from that of bereavement versus other life stressors, such as being diagnosed with advanced cancer or having gone through a marital breakup.  In other words, if you have an exclusion for bereavement, shouldn’t you also have an exclusion for other significant losses in life?

In addition, grief seen in bereavement is not completely benign.  There are a minority of bereaved individuals (approximately 10-20%) in which grief can become complicated and prolonged. For these individuals, complicated grief has been shown to have a significant detrimental impact on their ability to function and quality of life.  There are also individuals who truly developed profound depressive episodes shortly after the loss of a loved one.

I can’t help but see this as a broad overreach by the APA.  Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.  Yes, uncomplicated grief may cause significant distress, but for the majority of bereaved, it is an adaptive and healthy reaction to the loss of a loved one.   Furthermore, there is no evidence that medical interventions significantly improve outcomes or symptoms in the bereaved, outside of those with prolonged or complicated grief disorders.  Most bereaved individuals will adjust to a new life without their loved one, but this takes time – certainly longer than 2 weeks.

Eric Widera is Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics at the University of California, San Francisco, who blogs at GeriPal.

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  • Signify

    The ALA is overstepping by far. Grief is natural and normal, and lasting longer even than the DSM IV dictated – a few months is it – then one is to be over a death? But primary care physicians have gone off the wonk with pseudo-psychiatry and psychiatric diagnoses as well, and no one is addressing the effects.
    When patients present with physical symptoms and anxiety, for example, it is the anxiety that gets their attention. Where is the humanity in the labeling? Who, but billing departments and insurance companies, benefit? Not the patient seeing the primary physician, not the aggrieved relative, who, as the article states, will find themselves with the added stimatization from the
    Now, define “crazy.”

  • petromccrum

    This is absolutely ridiculous. Why do we have to “label” everything? Is no one normal anymore just because we have a strong emotional reaction.

  • militarymedical

    11 years ago, my 19 y.o. daughter (and youngest child) was killed on her way to work one sunny Fall morning. To say I grieved is an understatement; my then-husband and sons also grieved. We continue to miss her and mourn her loss and always will. Those first weeks were bleak beyond words, but that gradually lifted. We all returned to our work or schools within two weeks. A little over a year later, when I believed my grief had settled into depression, I sought assistance from my own PCP, who prescribed Prozac. After about six-eight months, I felt lifted up enough so that I was weaned off it. My initial reaction was normal and appropriate, I believed (still do); the depression was not, and not like me, and I preferred medication to talk-therapy. It was the right call for me. Certainly had anyone come up to me in those first weeks and said, “Sorry for your loss, here’s some Prozac,” I’d have punched him/her out. Really? How ridiculous can we get with diagnosing every emotion beyond rigid and arbitrary boundaries? To what end?

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