Abstract
It has been suggested that pathological grief should become either a separate category of mental disorder or be integrated within existing, extended classifications in systems such as the Diagnostic and Statistical Manual of Mental Disorders. Despite strong arguments for inclusion, and advancements by scientists toward development of diagnostic classification, there has been a lack of critical evaluation. Several issues need further scrutiny and clarification. These concern the definition of pathological grief, the distinction of pathological from normal grief, its relationship with other disorders, and the lack of agreement among scientists about criteria for pathological grief. Further research needs to focus on delineation of syndromes that comprise “pathological grief,” and on derivation of acceptable, valid, diagnostic criteria. Evaluation of the ramifications—both positive and potentially negative—associated with the revision of the diagnostic status of pathological grief needs also to be undertaken.
Near the end of his life Sigmund Freud was consulted by a woman who had become depressed following the death of her husband. After listening to her, Freud quietly stated, “Madam, you do not have a neurosis, you have a misfortune.” (Wahl, 1970, p. 137)
I know of only one functional psychiatric disorder whose cause is known, whose features are distinctive, and whose course is usually predictable, and this is grief, the reaction to loss. Yet this condition has been so neglected by psychiatrists that until recently it was not even mentioned in the indexes of most of the best-known general textbooks of psychiatry. (Parkes, 1986, p. 26)
THE EMOTIONAL REACTION to the loss of a loved one, grief, encompasses intense personal anguish for most people, and is associated with increased risk for a variety of psychological and somatic ailments Middleton et al. 1993, Parkes 1996, Shuchter & Zisook 1993 and Stroebe & Stroebe 1987. In some cases, these reactions reach an intensity and/or duration that could, according to criteria adopted in standard classification systems, be labeled “mental disorder” (Schut, de Keijser, van den Bout, & Dijkhuis, 1991). Foremost among such systems are the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994), and the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992). Pathological grief has indeed been suggested as a separate diagnostic diagnosis category by bereavement experts for inclusion in the DSM system.
Should “pathological grief ” (or “complicated grief,” as some contemporary writers prefer) be included as a separate diagnostic category of mental disorder in future editions of such manuals? Given the citations included above, it is easy to see that the answer to this question may not be simple. In fact, changes have recently occurred in diagnostic categorization, between the third and fourth editions of the DSM, reflecting clearer recognition and incorporation of pathological grief within the current system. This would seem compatible with the establishment of pathological grief as a diagnostic category in future editions. It is possible that pathological grief will either become a separate category, or that bereavement will be incorporated, for example, as a stressor within a category of event-related disturbances, including posttraumatic stress disorder (PTSD), in the next edition of DSM (and/or ICD). Since DSM and ICD are accepted as the leading guides for practitioners, inclusion could be expected to have far-reaching impact. 1
There are reasons to argue in favor of such a development, and, as we shall see below, some experts have made strong cases in support of this. Nonetheless, there has been an absence of discussion in the scientific literature about readiness for, and implications of, establishing a category of pathological grief. A number of key issues need clarification. Critical are those that concern the nature of pathology in the grief domain, for example: How does one define pathological grief? What are valid criteria for a classification of pathology? It is also important to raise questions about the impact of creating a category of mental disorder on the psychological phenomenon of grief itself: What changes in the conception of grief would be likely to follow? What societal implications and health-care consequences would such a development bring about?
Concerns about provision of appropriate care for the bereaved underlie the need to address these unresolved issues. On the one hand, some bereaved people need and benefit from counseling or therapeutic assistance in one form or another—and may not have access to this if there is no diagnostic category for pathological grief. On the other hand, it is important to develop valid guidelines for whether and when bereaved people need such help and to ensure that provision of therapy is appropriate.
Given that many experts are currently arguing in favor of including pathological grief in formal categorizations of mental disorders, it would seem timely to pause and consider a number of critical issues relating to such a revision. The primary purpose of this article is to open discussion on key points, and to identify unresolved issues that bear on the possible addition of pathological (or complicated) grief to diagnostic manuals
