Commonweal: Thinking about Grief as a Medical Disorder
In March 2022, the American Psychiatric Association (APA) announced a revision to its widely influential Diagnostic and Statistical Manual of Mental Disorders. The revised manual, known as DSM-5-TR, included a new diagnostic category: prolonged grief disorder (PGD). The announcement ignited a firestorm of controversy.
“Pathologising grief is an insult to the dignity of loving relationships—it proclaims grievers as mentally ill and will too often result in the careless prescription of antidepressants or other drugs to treat enduring symptoms, without consideration of the context.” So wrote the authors of a short and scathing article in the medical journal The Lancet Psychiatry,
As scholars collaborating on a volume about grief that brings together theoretical reflections on grief with the actual experiences of grieving individuals, we think it is useful to ask whether grief should be conceptualized as a mental disorder and what the likely consequences of treating it this way will be.
The criteria for categorizing PGD, for example, are very clear. For an adult who has had someone close to them die, PGD can be diagnosed if, after a year, they exhibit intense yearning and/or longing for the deceased or a preoccupation with thoughts or memories of the deceased.
In addition, diagnosis requires that at least three of the following symptoms be frequently present since the death of the deceased and every day for the month prior to diagnosis: identity disruption, a sense of disbelief about the death, avoidance of reminders of the death, intense emotional pain, difficulty reintegrating into everyday life, emotional numbness, a feeling that life is meaningless, and intense loneliness.
While these symptoms are used for diagnostic purposes, the DSM makes clear that many more symptoms may be experienced by those suffering from PGD, including guilt, decreased self-care, loss of appetite, hallucinations, bitterness, anger, sleep disruptions, and suicidal ideation.
no clinician views grief itself as an abnormal human response to loss. Labeling some kinds of grief as a disorder is simply a recognition that grief can take on an unhealthy form that may require psychiatric intervention. The DSM revision does not designate all grief as a disorder; rather, it sets the criteria for disordered grief.
We do not have the medical or scientific background to assess all the criteria set out in the DSM, but one criterion stood out to both of us—namely, that PGD is only appropriately diagnosed if symptoms persist for longer than a year after the death of a loved one.
For example, there is notable debate in the supporting literature about the prevalence of prolonged grief. It is estimated that between four and ten percent of those who experience the loss of a loved one will suffer from PGD.
Allen Frances, who was chair of the taskforce that put together the DSM-4, has complained that the DSM-5 has dramatically expanded diagnostic categories without due caution or warnings, led to overdiagnosis, and directly facilitated the marketing of psychotropic drugs to patients with these newly diagnosed disorders.
In a series of books and journal articles spanning decades, Hacking systematically explored what, with apologies to Kant, might be called science’s categorical imperative. That is, scientists appear almost unconditionally obligated to impose categories on phenomena to control the world. Nowhere is this truer, says Hacking, than in medicine. Hacking’s work is helpful in thinking about grief because he shows how the classifications we assign to people are not neutral labels. Classifications affect the people classified and over time those who are labeled often work to change the characteristics assigned to those classifications, creating a kind of feedback loop. He gives a provocative name to the process: “Making up people.”
For our purposes, the idea that a diagnostic category can lead “patients” to see themselves in novel ways, just as it leads friends, families, coworkers, and others to see them in new ways, helps us understand that a new diagnosis like PGD is unlikely to be applied simply to those experiencing extreme and debilitating grief. Once such a disorder enters the zeitgeist as a way of being in the world, it will often be discussed in the popular press, debated in social media, displayed in characters on television and in movies, etc. We can then expect individuals to experience their own grief accordingly and diagnose themselves as suffering from a grief disorder.
Consider two problems that are likely to follow, reshaping how many will grieve: the pathologizing of loving bonds at the heart of grief and, in turn, a medicalized goal of weakening or severing these bonds instead of integrating them into a better future for those grieving. The first has to do with the fact that one important strand of thinking about grief embedded in the APA diagnosis is that grief is a kind of post-traumatic stress disorder related to an unhealthy attachment to a deceased loved one. The emphasis on the symptom of “yearning,” for example, highlights the conceptualization of grief as a disordered attachment. The difficulty with this way of thinking about grief can be seen in how Prigerson explained the condition in a podcast created for health-care professionals. When asked whether grief is an expression of love, Prigerson downplayed the connection. She noted that a lot of people think of grief as a manifestation of love because it “just feels right,” but she thinks it is best to conceive of grief as wanting or craving something that one cannot have.
The second problem with a new diagnostic category coming to shape identity is what Hacking referred to as a “looping effect.” In addition to the way individuals come to see themselves as suffering from a condition that must be treated, physicians begin to search for treatments to address new disorders. Elliott has noted how this happens when pharmaceutical companies develop drugs to treat new conditions and then work to persuade patients and physicians of the need for the newly developed “treatments.” Elliott writes, “People diagnosed as sufferers of the condition in question begin to think of themselves differently, interpreting problems such as shyness or distractibility as symptoms of an illness that can be treated by the drug being marketed. I