When Does Grief Become Mental Illness?

We should continue our cultural tradition of recognizing grief as a normal (and expected) human experience. If anything, the grieving person may benefit from support and sympathy, rather than being diagnosed as mentally ill and treated as such.
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Imagine that you are a mental health professional and you meet with a new client who describes the following symptoms: "I haven't been sleeping well. I don't have much of an appetite and I've lost a few pounds in the last month. I feel sad most of the time and once a day I find myself crying. Basically it's all I can do every morning to get myself out of bed and start the day."

What would be your "diagnosis" and "treatment plan" for the above person? In reality, both would depend in large part on the context in which these symptoms appeared. If the person reporting them told you that a child, spouse, or parent had died of cancer a few weeks earlier, chances are you would conclude that this person was experiencing grief. On the other hand, if these symptoms were something that this client had experienced several times before, and for no apparent reason, you might suspect he or she was suffering from a depressive disorder. Depending on this context, your ideas about the most appropriate "treatment" would almost certainly be very different.

The Jan. 25, 2012 edition of the New York Times includes an article titled "Grief Could Join List of Disorders." The subject is a pending decision by the American Psychiatric Association, in the forthcoming revision of its Diagnostic and Statistical Manual (DSM) to eliminate the current exclusion of grief as a result of the loss of a loved one from the diagnosis of depression. In effect, a grieving person who exhibits the above symptoms for as little as two weeks or more may soon qualify for a diagnosis of "major depressive disorder." This amounts to opening the door to "diagnosing" what until now has been thought of as normal grief as a serious depression, and therefore treating it as such.

In defense of this pending decision, some have argued that bereavement and depression have much in common; therefore they should be treated in the same way (including, presumably, using medication). Others argue that some grief-struck individuals find themselves going over the edge into total dysfunction or suicidality. This may be the case, but the fact is that these individuals have always been the exceptions, not the rule. Given the way our culture has responded to problems such as anxiety and difficulty sleeping, it is highly likely that we stand poised to try to eradicate grief on a mass level through medication. Keep in mind that in today's world of defensive medicine it's a short step from thinking that someone may be experiencing some symptoms of depression to believing that they must be given medication for it.

In her book, The Year of Magical Thinking, Joan Didion chronicles the many "symptoms" an individual may experience when they are grieving the loss of a loved one as she records the year following the death of her husband and closest confidant, the writer John Gregory Dunne. To be sure it is a raw, unvarnished, and wrenching account. At the same time, it is clearly bereavement that she is describing. We must respect it for what it is and allow individuals the dignity of grief.

My colleague Dr. Barbara Okun and I have coined the phrase "the new grief" to refer to the process that families experience after a loved one has been diagnosed with a terminal illness. By this we do not mean to imply that grief has ceased to exist, or that bereavement has fundamentally changed. On the contrary, as long as we as humans are able to form interpersonal attachments we will grieve those attachments when they are lost. Our attachments enrich our lives, and in a sense they define who we are. When we lose someone we love, we lose a part of ourselves. To say that it is "abnormal" to grieve such a loss for longer than two weeks seems to fly in the face of what it means to be human.

What we have noted from the families we have interviewed is that some family members begin to experience some of the symptoms noted above even before their loved one dies. This appears to happen in what we call the upheaval stage of family grief. It seems to be the result of the stress that a prolonged terminal illness creates not only on the terminally ill patient, but on his or her family members as well. The protracted process of dying that is the result of modern medicine's ability to arrest terminal illness and stave off death creates unprecedented stresses in families seeking to cope with this protracted crisis. One concern we have is that these "symptoms" may also be erroneously "diagnosed" as a major depression, and therefore treated out of the context in which they occur.

An Alternative to Diagnosing Grief

The National Center for Complementary and Alternative Medicine is a repository of information and research findings on the effectiveness of what are commonly called "complementary" treatments. Increasingly, patients with cancer and other potentially terminal illnesses are turning to these treatments, not in place of medical care, but in addition to medical care. These treatments include meditation, yoga, and massage, among others. An increasing body of sound research (see the NCCAM site) is indicating that these treatments can reduce stress and improve the overall quality of life of these patients. If practiced regularly they may even extend the life of these patients. What we would recommend is that not only patients, but their loved ones as well, avail themselves of these complementary therapies as soon as possible. Doing so will not by any means prevent grief, but it may help to ameliorate the chronic stress that comes with coping with terminal illness, and which can can complicate the grieving process.

We should continue our cultural tradition of recognizing grief as a normal (and expected) human experience. It may vary in intensity and duration from person to person, and also depending on the nature of the loss. If anything, the grieving person may benefit from support and sympathy, rather than being diagnosed as mentally ill and treated as such.

For more by Joseph Nowinski, Ph.D., click here.

For more on mental health, click here.

For more information, or to join the conversation, visit www.newgrief.com.

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