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Grief and the DSM: A Brief Q&A

In academic and clinical circles, there has long been a concern with differentiating between grief -- seen as a normal transitional experience -- and more complicated reactions to loss.
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Is grieving a medical condition, a mental illness? In effect, this question will be answered with the long-awaited and much-anticipated revision of the Diagnostic Statistical Manual of Mental Disorders (DSM), which was released by the American Psychiatric Association this month. The new edition of the manual is called the DSM-5.

Grief therapists, clinicians and researchers have extensive interest in the revision. And for individuals who have suffered a loss because of the death of a loved one, the revised manual is significant. This new version may lead to increased use of medication in treating individuals who have experienced a loss.

Throughout the DSM revision process by a committee of clinicians, there were a number of proposals to make changes in the manual that relate to the universal human experience of grief. There were also suggestions to add categories that would address complicated (i.e., severe) grief reactions. This Q&A explains the controversy around grief in the DSM-5 and what this newest edition of the manual will mean for bereaved individuals who seek help.

1. What is the DSM and what makes it so important?

The DSM is a guide to the diagnosis of mental illnesses created and updated by the American Psychiatric Association. It sets criteria and standards for defining and classifying mental illnesses. Used extensively by psychiatrists, physicians, psychologists, counselors, social workers, and other mental health practitioners, the manual provides a guide to diagnosis and treatment of mental illnesses including depression, anxiety, adjustment disorder, bipolar disorder, and schizophrenia. It is well accepted, and many insurance companies require the assignment of a DSM code by a treating clinician before considering reimbursement. Earlier this month, the newest edition of the manual, the DSM-5, was released.

2. How will the DSM-5 address grief?

First, let's look at the previous edition of the DSM (DSM-IV-TR*), which listed bereavement as a "Z -- or previously V -- Code," lumping grief into category of psycho-spiritual conditions such as near-death experiences and a variety of spiritual crises deemed worthy of clinical attention. While someone struggling with the roller coaster of emotions and reactions often felt in grief might seek professional counseling or assistance, their response to loss, which could include overwhelming sadness, loss of appetite, moodiness, lethargy, sleeplessness, did not necessarily indicate that this person had a mental illness. Moreover, the DSM-IV included the so-called "bereavement exclusion," which said that neither adjustment disorders or depression should be diagnosed in the immediate aftermath of a significant death.

In the deliberations over the new edition of the DSM, there were a number of suggestions that the DSM-5 specifically address the minority of bereaved individuals whose grief is crippling. Some members of the committee argued that this severe reaction to grief could be handled by including diagnoses such as "complicated grief disorder" or "prolonged grief disorder," recognizing that while most people have grief reactions within a typical range, 10 to 15 percent of grievers have severe reactions to the loss of a loved one and thus may need treatment that includes prescription medication and counseling.

The DSM-5 committee believed there was no consensus at present for the addition of prolonged grief disorder and complicated grief. Instead, the committee removed the "bereavement exclusion" from both depression and adjustment disorders. What this means in its simplest terms is that a person who is grieving a loss potentially may be diagnosed with depression or an adjustment disorder It is the removal of the bereavement exclusion from these diagnoses that has become highly controversial.

3. What's the thinking behind the change?

In academic and clinical circles, there has long been a concern with differentiating between grief -- seen as a normal transitional experience -- and more complicated reactions to loss. One of the first significant writings on grief -- Freud's essay, Mourning and Melancholia, first published in 1917, tried to do just that.

Basically the argument for removal of the bereavement exclusion is that it does not make sense to exclude bereavement if the symptoms fit the criteria for depression while other stressors, such as divorce or job loss, are not excluded. Put simply, if someone is able to be treated for depression following a job loss, why shouldn't someone who is grieving the loss of a person be any different? To proponents of the bereavement exclusion, denying such a diagnosis when the symptoms merit it does not make sense, deprives clients of needed help, and may even give a message that grief somehow shields someone from depression.

4. What concerns are being expressed about this change?

The change has generated significant controversy -- for both theoretical and practical reasons. The underlying research has been disputed. Those who oppose removal of the exclusion believe that the research has a difficult time differentiating symptoms of depression from that of normal grief, but unlike depression, those symptoms, in most bereaved individuals, abate within six months.

The very practical concern is that individuals experiencing grief will have a greater likelihood of being prescribed antidepressants. This "medicalization" or pathologizing of grief may be embraced by pharmaceutical companies, which may now see an emerging market of grievers open to the suggestion to consult a physician if they are struggling with a loss. Opponents of the removal of the exclusion note that by some estimates, almost 80 percent of antidepressants are prescribed not by psychiatrists but by primary care physicians who often spend a short time with patients and may have limited training in differentiating grief from depression.

5. What does this mean for individuals struggling with grief?

It's important to recognize that grief is a normal reaction to a significant loss and that sadness is part of grieving. Research has shown that most grievers are resilient. Be careful of treating loss and the emotions that accompany it with medication. Certainly, if necessary seek help such as support groups or grief counselors -- often hospices, hospitals and funeral homes offer referrals or even provide services. Recognize that a prior history of depression or other mental illnesses such as anxiety disorders may create risks for more complicated reactions. If grief is severely impairing your ability to function in key roles or you are engaging in behaviors destructive to self or others or having persistent suicidal thoughts, it is essential to seek professional help from someone trained in the treatment of loss to decide whether medication -- along with therapy -- might be helpful.

*The movement to Arabic numerals from Roman numerals is a recognition that continued research will likely lead to faster revisions of the DSM. Future modifications will then be listed as 5.1, 5.2 etc.

For more by Kenneth J. Doka, M.Div., Ph.D., click here.

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