What is the correct amount of grief? How much bereavement constitutes an appropriate portion? And when does the expected sorrow of loss cross over into something else to be reckoned with — a mental health problem?
The newest update to the Diagnostic and Statistical Manual of Mental Disorders arrived earlier this month with an expected — if long debated over — addition: the identification of a condition known as "prolonged grief disorder." The terminology has been over a decade in the making, spurred in part by inquiry surrounding the intersection of bereavement and depression. Yet it arrives now at a moment of uniquely fresh and widepread grief, a time of, as the American Psychiatry Association notes, "several ongoing disasters that have caused death and suffering, such as COVID-19, the wind-down in Afghanistan, floods, fires, hurricanes and gun violence."
But what makes grief become a classifiable disorder? And should it even really be considered one?
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Grief is an expected — if frequently underestimated — element of all our lives. In contemporary culture, the loss of a loved one may bring a few days off from work, possibly classified as "vacation" time, and flowers and casseroles from friends. Those are all helpful, but there's often an unspoken expectation to not take too long getting over it. It's as if it's somehow excessive to still be actively mourning after a few months.
"The number one thing I hear when people come into my office for the first time is that they think they're grieving wrong," author and grief counselor Claire Bidwell Smith told Salon back in 2020. "That's a lot due to the cultural messages that grief should be short, it should be kept to yourself or hidden, you should get through it quickly. Let's pack up those boxes. Let's move on. So people think they're doing it wrong."
The external pressure to be productive, to not make others uncomfortable, can make it difficult to conceptualize what healthy grieving is even supposed to look like. But the new parameters for prolonged grief disorder as explicated in the Diagnostic and Statistical Manual of Mental Disorders — considered the psychiatric bible when it comes to defining disorders and diagnosing them — set some clear distinctions for when a person might need help. "The bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents," says the American Psychiatry Association, "with the circumstances around the death. These grief reactions occur most of the day, nearly every day for at least a month. The individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning."
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Dr. Ash Nadkarni, an associate psychiatrist and an instructor at Harvard Medical School, says that she's observed the phenomenon in her own patients, especially since the pandemic.
"The diagnosis of prolonged grief disorder is indicative of incapacitating feelings of grief," she says, "with the individual experiencing an intense longing for or preoccupation about the deceased or the circumstances around the deceased person's death for at least six months after the loss." Nadkarni adds that "additional symptoms include emotional numbing, identity disruption, disbelief about the death, intense emotional pain and a feeling that life is meaningless."
Yet as is often the case with the Diagnostic and Statistical Manual of Mental Disorders, or DSM — the publication that used to consider being gay a disorder — there is ample room here to question what is and is not a psychiatric condition. In expanding its criteria over the years for conditions like behavioral addictions and trauma, the publication has spurred debate over overdiagnosis (and ensuing overprescription) and harmful bias. As Sarah Fay, author of "Pathological: The True Story of Six Misdiagnoses," told Salon recently, "There isn't a single DSM diagnosis that has an objective measure." Assigning labels can shape our perception of our emotions and behaviors, so we need to approach the diagnostic process with an understandiing of its limitations.
Kassondra Glenn, a psychotherapist and contributor with Prosperity Haven Treatment Center, says, "The inclusion of prolonged grief disorder has been met with a lot of controversy. On one hand, it has the ability to validate experiences in the context of a diagnosis-centered society. It also has the ability to provide expanded insurance reimbursement to therapists and mental health professionals."
But, she continues, "On the other hand, there is always the possibility that a diagnosis will be overused. Over-pathologizing grief or abusing the prolonged grief disorder diagnosis has the potential to cause harm. It is always important to consider the benefits and drawbacks of diagnosis on a case-by-case basis. Covid is changing our perceptions of grief rapidly. There is widespread grieving for lost loved ones, normalcy, and the planet. It is particularly important not to over-pathologize this experience, as it is still ongoing. There is a line between learning to be with grief and the point at which the continued intensity may be a larger issue. As this is a new diagnosis and we are experiencing unprecedented global crises, this line is still being defined."
The total of our losses is still being counted. Today in the US, 850 people will die from Covid. More than 140,000 American children — that's 1 out of every 500 — has experienced what the journal Pediatrics calls "Covid-19-associated orphanhood or death of a grandparent caregiver." For many of us, the "long-term" part of our grief has not yet even kicked in. And the prolonged isolation and anxiety of the pandemic has made the already devastating experience of death all the more challenging, creating conditions ripe for what the journal Basic Clinical Neuroscience hauntingly describes as "incomplete grief."
Dr. Manish Mishra, the medical reviewer for AddictionResource.net, notes how these types of losses, among others, may lend themselves more to extended bereavement.
"I've seen how bereaved families often display signs of prolonged grief disorder," he says. "It is more common in people who lost their romantic partners or children. Most of the time, the death is sudden, usually due to accidents and murder. Many deaths due to Covid can make this condition more prevalent nowadays."
Dr. Mishra sees this rise in prolonged grief as a challenge for providers to pay extra attention to caregivers and survivors. "This condition makes it important for healthcare professionals to also check-in with the families of those who died from Covid," he says, "especially those who were very healthy and young. Many families were also not given a chance to see or visit their deceased family members in the hospital. This can have an effect on their coping and moving on process."
And Dr. Nadkarni echoes this, saying, "The significance of prolonged grief disorder at this time surrounds the expectation that cases of this disorder will rise with the pandemic. There is the concern that prolonged grief disorder may become a major public health concern, with a heightened need for both effective treatments and access to such treatments."
We mourn collectively now, in a way that's unprecedented. Yet we still mourn alone, because every grief is unique, just as every single person we lose was unique. In an ideal world, we would do a lot better to normalize the grief process, and simultaneously offer more resources for survivors struggling deeply. For all of us, though, grief is never something that can be done wrong, or that runs on a particular timeline. At best, it's a sorrow to be lived with. "I really think that you can be resilient and create a meaningful life," says Claire Bidwell Smith, "and still have functioning work and relationships, and still be grieving, really grieving, truly grieving."
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