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Aggrieved Over Grief as a Diagnosis in DSM

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To paraphrase Ronald Reagan, there they go again. The American Psychiatric Association is considering adding grief as yet another diagnosis to the more than 300 that already exist in the Diagnostic and Statistical Manual of Mental Disorders.

In recent times, we have seen numerous diagnoses du jour added to the DSM. Perhaps the nadir of this folly occurred about two years ago when the APA added internet addiction to the appendix of the DSM. True, researchers did not include it in the body of the text, but when a diagnosis enters the appendix, it is tantamount to a popular baseball player falling a few votes short of the Hall of Fame. In time, internet addiction, like several borderline Hall of Famers, will likely make the final cut into the psychiatric bible or Cooperstown.

Now comes grief.

DSM-5, which is scheduled to be published in 2013, may end up including grief as a new disorder by eliminating what has been known as the "bereavement-exclusion" to major depression.

I am not the only one who is unhappy about this. New York Times reporter Benedict Carey, who helped to demystify mental illness with his "Lives Restored" series last year on highly functional schizophrenics and others with severe mental disorders, cited a new report by Jerome Wakefield of NYU and Dr. Michael First of Columbia University that argues in favor of retaining the bereavement-exclusion.

Wakefield and First, who wrote their "special article" in the February issue of World Psychiatry, the official journal of the World Psychiatric Association, rejected the studies relied upon by DSM researchers as inconclusive.

I agree with Wakefield and First and with the editorial in World Psychiatry, written by Mario Maj, chairperson of the World Health Organization working group on the classification of Mood and Anxiety Disorders. As Maj, a faculty member in the Department of Psychiatry at the University of Naples, wrote, "bereavement-related depression is significantly less likely than other loss-related depression to be associated with treatment seeking and substantial functional impairment, and is marked by significantly lower levels of neuroticism and guilt."

This is not to say that grief at the death of a loved one is simply an innocuous reaction about which we should not worry. Grief can paralyze a person for long periods of time. Yet it tends to resolve itself after a few months unless the bereaved party has a history of major depression, other mental illness, or suicidal thoughts. In those cases, grief may indeed rise to the level of a major depressive disorder.

My concern is that if we add grief, or internet addiction or "Facebook Depression" (a subject I wrote about last year), to an already-growing number of diagnoses, we are likely to find that nearly everyone on this planet suffers from mental illness. We have already reached a state where psychiatrists are frequently diagnosing children with schizophrenia and bipolar disorder, diagnoses that almost never took place a decade ago. Where does it all end?

Anointing grief as the latest disorder will be a "further step in psychiatry's attempt to pathologize normal human processes," as Mario Maj wrote.

No one denies that the loss of a loved one can be searing. Grief no doubt has more validity as a diagnosis than internet addiction or Facebook depression, two phenomena that seem driven more by temporary technological disappointment, than by deep-seated mental illness.

But if one thinks about it, grief also tends to be temporary in nature. I remember crying at the funeral of my late psychiatrist, Dr. Michael McGrail, in May 2007. Less than a month later, however, I wrote a remembrance of him in the L.A. Times in which I indicated that he "left me equipped to handle his loss."

I still keep a photograph of Dr. McGrail nearby and can still see his smile, can still hear him say, "Don't go down that road, Robert."

I would offer that same advice to the APA. When it comes to adding grief to the DSM, don't go down that road.

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