When GRIEF Becomes A Mental Illness
When Grief Becomes a Disorder
What is complicated grief, and how does it differ from depression?
By Dr. Sanjay Gupta
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Grief over the death of a loved one is a natural emotional response to loss and an inevitable part of life. As universal as grief is, the grieving process is a very individual experience. How deeply or long a person grieves depends on many factors, and distinguishing between normal grief and a debilitating condition like complicated grief or depression can be difficult.
As M. Katherine Shear, MD, professor of psychiatry at the Columbia University School of Social Work, puts it: “Grief is not one thing. It is a shorthand word for a complex, time-varying experience that is unique for each person and each loss.”
There is no timetable for the healing process. “In general, grief usually evolves over time from an acute form that tends to dominate a person’s mind to an integrated form in which the core features of sadness and yearning are much more subdued,” Dr. Shear says. When those feelings persist or intensify, the result may be a condition known as complicated grief or prolonged grief disorder (PGD). As much as 10 percent of all bereaved people experience complicated grief.
Complicated grief is marked by “broad changes to all personal relationships, a sense of meaninglessness, a prolonged yearning or searching for the deceased, and a sense of rupture in personal beliefs,” according to the American Psychological Association.
People with complicated grief often experience chronic sleep disturbances and disruptions in their daily routine. Studies have found that they are at increased risk for hypertension, heart disease, substance abuse, and suicidal thoughts. They may “try to avoid confronting the intense pain associated with the loss and this, paradoxically, ends up increasing the pain and interfering with the natural adaptive process,” says Shear, who is director of Columbia’s Center for Complicated Grief.
While complicated grief may resemble depression and the conditions do often overlap, they are not the same. “One reason for the confusion about grief and depression being the same is that the word depression also means sadness,” Shear says. “You might say to a friend, ‘Are you feeling depressed about [something]?’ intending to ask if your friend is sad. That is very different from meeting criteria for…major depressive disorder.”
RELATED: How Grief Can Make You Sick
“Depression is marked by persistent low mood,” says Richard Bryant, PhD, a professor at the School of Psychology at University of New South Wales in Sydney. “Depressed people do not have the central problem of missing the deceased and the associated emotional pain. Across many studies, this comes out as a distinct factor in distinguishing the two conditions, although often people can have both.”
To encourage timely diagnosis and treatment of grief-associated disorders, the American Psychiatric Association (APA) made a significant change in the current edition of its Diagnostic and Statistical Manual (DSM-5). Published in 2013, the DSM-5 eliminated the “bereavement exclusion” that major depressive disorder should not be diagnosed within two months of a loved one’s death, even if the patient met the criteria for depression.
The APA said the exclusion was removed, in part, because “bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode.” David Kupfer, MD, a University of Pittsburgh psychiatrist who chaired the DSM-5 task force, explained the change to the New York Times, saying: “If these things go on and get worse over time and begin to impair someone's day to day function, we don't want to use the excuse, ‘It's bereavement — they'll get over it.’ ”
Not all experts who treat grief agree. “We're so focused on healing as quickly as we can and being happy. Grief has to unfold over time,” says Joanne Cacciatore, PhD, associate professor of social work at Arizona State University and a traumatic grief counselor. “We shouldn't need to diagnose something that's one of the most common human experiences.”
Allen Frances, MD, professor emeritus at Duke who was chair of the task force on the earlier DSM-4, believes “DSM-5 is medicalizing the expected and probably necessary process of mourning that people go through.” Most people, Dr. Frances says, “get better with time and natural healing and resilience.”
But Shear stresses the importance of spotting signs of depression in a bereaved individual. “Losing a loved one does not protect people from depression,” she says. “Loss is a severe stressor, so it is associated with the onset or worsening of depression in some people."
Regarding complicated grief therapy, Bryant believes “psychological rather than pharmacological treatments are best.” In a study published last year in JAMA Psychiatry, Bryant and his colleagues found that exposure therapy, in which the bereaved relives the death of a loved one, combined with cognitive behavioral therapy can be very effective in treating survivors with PGD.
“This approach often involves revisiting memories of the deceased, processing these emotions, but also working on developing future strategies for coping,” Bryant says.
“We feel like talking about death will make it worse, because they might cry, but that’s okay,” says Cacciatore, who founded the MISS Foundation to provide support for families grieving the loss of a child. “It's important for people to understand they don't need to try and fix and change their grief. There's no cure and no pill for it.”
Video: When Grief Becomes a Disorder.wmv
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