Prolonged grief as a mental disorder

It is my late wife’s birthday as I write this. Karina would have turned 76. I woke up early, so I could visit her grave, bring her flowers, and light a candle. I do this quite often, perhaps at least twice a month since she died almost three years ago.

This morning, as I picked up my phone from its charging dock, I couldn’t help but notice a New York Times banner that appeared on the screen. It carried the intriguing title: “How long should it take to grieve? Psychiatry has come up with an answer.” (NYT, 3/18/22) Amid the hourly news of the relentless bombing of Ukraine by Putin’s forces, this item stood out for me like an uncanny personal reminder.

It is a question that has bugged me both as a bereaved widower and as a sociologist. Indeed, I’ve been checking myself since Karina’s passing, comparing my experience of her death with the feelings discussed so compassionately and eloquently by authors like Elisabeth Kubler-Ross (“On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss”) and George A. Bonanno (“The Other Side of Sadness”). Both writers recognize the seriousness of grief, but I don’t remember either of them dwelling on its pathological dimension.

Grief itself is a normal human reaction. Indeed, both Kubler-Ross and Bonanno emphasize its healing properties as a psychological and sociological process. All societies have ways of helping their members deal with it. Some people recover from their pains faster than others. Some take longer. But now, the American Psychiatric Association thinks that intense grieving for more than a year is a red flag. It’s important to recognize this, says the APA, because, in the context of the ongoing COVID-19 pandemic, pathological grieving may be more prevalent than we think.

The New York Times piece, written by Ellen Barry, explores the implications of the inclusion of the new diagnosis of “prolonged grief disorder” (PGD) in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM is sometimes referred to as the bible of American psychiatry.

The inclusion of a new disorder typically follows years of debate and deliberation by experts not only on the symptoms but also the therapeutic and institutional implications. As an example, this new diagnosis effectively authorizes the inclusion of PGD in the list of medical conditions covered by insurance. Pharmaceutical companies will surely welcome it as a warrant to repurpose existing medications or design new medicines expressly for this ailment.

As a sociologist, I am accustomed to looking at such phenomena as diseases and crimes in their sociocultural context. The facts surrounding them, far from being self-evident, tend to be socially constructed. It is for this reason that physicians, who share this point of view, also think of medicine as a social science.

Moreover, times change. In 1952, the American Psychiatric Association listed homosexuality as a mental disorder. More than two decades later, following a comprehensive review of the data, the APA declassified it as a disorder, urging mental health professionals to lead in the campaign to erase the stigma that has long been associated with homosexuality. The World Health Organization followed suit in 1990 at its 43rd World Health Assembly.

How long will the condition now identified as “prolonged grief disorder” stand the test of time? I took a look at the eight symptoms associated with it, and, at once, I was struck by their generality and opacity, and by how easily the trained observer can be misled.

They are: “1. Identity disruption (e.g., the feeling that part of oneself has died). 2. Marked sense of disbelief about death. 3. Avoidance of reminders that the person is dead. 4. Intense emotional pain (e.g., anger, bitterness, sorrow). 5. Difficulty with reintegration (e.g., inability to engage properly with friends, pursuing interests, planning for the future.) 6. Emotional numbness. 7. Feeling that life is meaningless. 8. Intense loneliness (feeling alone or detached from others).”

As someone who has lost a loved one recently (yes, three years for me is not a long time to grieve), I am sure I have felt many of these symptoms at one point or another. I suppose these experiences come in varying hues and gradations and do not necessarily appear as one syndrome. But to imagine that they may be indicative of illness is to overdiagnose.

For instance, if you and your spouse have shared a world for more than 50 years, the death of the other would understandably entail the closure of a big chunk of that world. You may accept the reality of death, yet you may still be struck by its utter strangeness when it happens. You may not always feel the pain or the numbness, but you can sense it’s there. It’s a question of knowing when not to indulge it. The loss of meaning in what you do may come about in your unguarded moments as emptiness, but it doesn’t mean you have lost the will to live.

I do understand and fully sympathize with the thought behind the listing of prolonged grief as a disorder that requires professional attention. Some people may need help long before they realize it or admit it to themselves. This may be the case even with those who appear able to get back to their normal routines in no time at all.

But to reduce grief into a set of symptoms is to risk pathologizing one of the most profound of human experiences. It is to prioritize society’s preference for functionality and resilience over the slow grind of self-awareness.