The very different experiences people have during bereavement raise three diagnostic questions. Two are quite simple to answer, the third is extremely
difficult.
First easy answer -- it is completely obvious to everyone (except the few
experts working on DSM-5) that it makes no sense to diagnose major depressive disorder in someone who has had just two weeks of normal grief.
Second easy answer -- it is equally obvious (and recommended by DSM-IV) that major depressive disorder should be diagnosed whenever the bereaved becomes suicidal, psychotic or has very severe symptoms and markedly impaired functioning. These are the two no-brainers.
The third and much tougher question is how to deal with grief that is so
prolonged and intense that it exceeds the expectably wide range of individual
and cultural variability. If there is anyone qualified to tackle this puzzling
conundrum, it is our guest expert, Dr. Holly Prigerson, a Harvard psychologist
who has spent her entire career researching grief and helping people to cope with it. She will shed light on when good grief turns bad.
My Question #1: What is the difference between good grief and bad grief -- when does normal grief become "prolonged grief" (PG)?
Dr. Prigerson: "Let's start with good grief. Although extremely painful, grief
is a normal process of accommodating to the new life that has to be lived in the absence of a loved one. Most of the bereaved manage to get through the worst of their grief and continue to function and to find meaning in life. Normal grief differs from PG in that it is not as intense, persistent, disabling and life-altering and is not experienced as a severe threat to the survivor's
identity, sense of self-worth, feelings of security, safety or hopes for future
happiness. Although normal grief remains with the bereaved person far into the future, its ability to disrupt the survivor's life dissipates with time. This is 'good grief' in the sense that it runs a natural course and is part of an
adaptive process.
Prolonged grief (sometimes also referred to as complicated grief) is
relatively rare -- experienced by about 10 percent of the bereaved, though rates may vary depending on the circumstances.
This is grief that does not resolve naturally and persists far into the
indefinite future as a defining feature severely adversely affecting the life
of the survivor. The person is incapacitated by grief, so focused on the loss that it is difficult to care about much else. The bereaved ruminates about the death and longs for a reunion with the departed, feeling unsure who s/he is and where s/he fits in. Life is flat and cardboard, offering little meaning or purpose, and the future holds no prospect of joy, satisfaction or pleasure. S/he feels devalued and in constant turmoil, with an inability to accommodate to (if not a frank protest against) life without the beloved.
PG is defined by its symptoms, duration and intensity. The symptoms are yearning intensely for the person, identity confusion, difficulty accepting the loss, bitterness, emotional numbness, inability to trust others and feeling stuck in the grief. These are present every day, cause significant functional impairment and remain intense, frequent and disabling a year after the death."
My Question #2: How is PG different from Major Depressive Disorder (MDD)?
Dr. Prigerson: "The symptoms, risk factors, course, outcomes and response to treatment for PG are different from MDD. For example, intense, persistent yearning for the deceased person is specifically a characteristic symptom of PG,
but is not a symptom of MDD (or any other DSM disorder). Feeling bitter because your love has been taken from you, feeling that a part of you died along with the deceased, feeling emotionally numb and unable to connect emotionally with others since the loss and feeling unsure of who you are without the deceased
are all symptoms of PG, not MDD. Sadness, loss of appetite and poor concentration and sleep are symptoms of MDD, not specifically of PG.
This is not to say that people with PG cannot also have MDD. These may
co-occur as do symptoms of depression and anxiety. It's like a fruit bowl -- if
you see an apple, then there's a good chance you'll also see an orange. In the
context of bereavement, survivors are likely to experience symptoms of both
depression and grief. But the characteristics that define an orange, or grief, are not the same as those that define an apple, or depression."
My Question #3: Are there cultural variations in the experience of grief that need to be considered in deciding if good grief has turned bad?
Dr. Prigerson: "Of course culture plays an enormous role in the outward
manifestations of bereavement, but for the most part, the inward experience of grief is universal and shows striking consistency across cultures. Mammals
(humans, chimps, elephants, monkeys, prairie voles, etc.) are hardwired to form strong attachments -- it is an essential part of what makes us mammals. We are programmed by our biology to yearn for our lost loved ones and to protest the rupture of a treasured relationship with them. Across cultures, there is a small
but significant minority of people whose grief becomes all-consuming and who suffer an enduring failure to thrive."
My Question #4: What are the risks of PG?
Dr. Prigerson: "It is not an exaggeration to say that many people experiencing
PG no longer see a point in living. The odds that a bereaved person will be
suicidal are six times higher if he has PG. A desperate few take their own
lives; many others seriously consider doing so. Some perish of medical illness
in the wake of bereavement -- dying either literally or figuratively of a broken heart. PG is associated with heightened risks of heart attacks,
cancer, being hospitalized for a serious health event, more disability days,
dramatic increases in drinking and smoking and changes in
eating."
My Question #5: What are the ways of overcoming the risks and harms of PG?
Dr. Prigerson: "People with normal grief usually don't need treatment, but
people with PG may benefit from treatment aimed at reducing their distress and associated dysfunction and avoiding the risks mentioned above.
The treatment for PG is quite specific and different than the treatment for MDD. One form of cognitive behavioral therapy for PG targets its core symptoms -- emotional and behavioral withdrawal, difficulty forming new connections and re-engaging with others, craving a reunion with the deceased and viewing all new activities as vapid and unsatisfying. CBT addresses the bereavement challenges in the language most particular to that person (e.g., feeling like a third wheel in a 'couples' world,' being out of practice and uninterested in relearning how to meet and talk with new people, feeling angry and unattractive and unpleasant to be around, feeling that no one will compare favorably with the deceased and so on). The goal
is to help the bereaved re-engage and re-attach to new people and new social
resources -- to invest again in living their lives."
My Question #6: What is usual course and prognosis of PG?
Dr. Prigerson: "People with prolonged grief can remain in a state of chronic
mourning for years, sometimes decades, even a lifetime."
My Question #7: Normal grief is clearly not a mental disorder, but how about PG -- should it be considered a mental disorder?
Dr. Prigerson: "There would be pluses and minuses to including PG in DSM.
Pluses first. PG has distinctive symptoms and course; causes substantial distress, disability and health risks; and responds best to treatments that specifically target it. If recognized as a disorder, PG might be better understood, detected, studied and treated -- and insurance companies would more likely reimburse its care. But there is an important downside -- inclusion might be misunderstood as a medicalization of grief, reducing its dignity, turning love into pathology and implying that survivors should quickly forget and "get over" the loss. Some bereaved may be insulted by labeling their distress as a mental
disorder. This stigmatization would not be the intent, but might be an
unintended consequence."
Thank you, Dr. Prigerson, for laying out the issues so clearly. People differ
greatly in how they grieve; it is perhaps the most intense and most personal of all life's hardships. The vast majority have normal grief -- extremely painful but expectable, haunting in bursts but gradually resolving as life eventually (largely, but not completely) moves on. For some few, bereavement triggers a major depressive disorder fully equivalent to depression arising from others of life's severe stressors. PG is a third outcome -- the bereaved is enduringly devastated by the death of the loved one, and loses the desire or ability to participate in life.
Each reaction to bereavement requires a different approach -- for normal grief, time and family and cultural supports; for depression, psychotherapy and sometimes medication; for prolonged grief, it is often useful to try a cognitive
behavior therapy addressing the existential experience of loss.
Grief is complicated and elusive -- one size definitely does not fit all.
Although the three categories are extremely useful, they are imperfect and overlapping guides to sorting all of the tremendous variation in the way people experience their grief and their attitude towards it. Normal grief resolves, but never completely. Choosing a duration to separate normal from prolonged grief
is necessarily arbitrary. The decision whether and when treatment is desirable for prolonged grief must be tailored to individual and cultural preference and to clinical judgment. Not everyone with PG will want or need, or necessarily benefit from, the label or treatment for it. Some will feel insulted that their grief, however prolonged, is seen as anything but a testimony to undying love.
It is important to respect the legitimacy of all forms of grief, but also to provide a helping hand to those who need it. Dr. Prigerson has provided a light at the end of what may otherwise feel like a long, dark and never-ending
tunnel.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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