What Constitutes “Too Sad”? Psychiatric Classification and the Pathologization of Grief

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From The Clinic: The Art of Psychiatry, we discuss grief, and the interface between grief and depression. Grief and depression symptoms overlap clinically, but the context for understanding of the symptoms and pursuant management decisions make a world of difference. Loss of a significant figure in one’s life requires a significant adjustment and sometimes a redefinition of one’s identity and life, which does not necessarily occur with major depressive disorder (MDD). Ultimately, treatment decisions including psychotherapy, group therapy/ support groups, enhancing socialization, and if indicated, psychotropic agents, do not differ much from other depression algorithms. A careful understanding of the grief ramifications on one’s life is essential for holistic, humane treatment.

Case Study

“Joshua” is a 78-year-old retired man with a remote history of anxiety in his 50s, which successfully improved with a combination of selective serotonin reuptake inhibitors (SSRIs) and improving psychosocial circumstances. He has enjoyed relatively stable mental health in the recent years until the passing of his wife June 3 months earlier following a short battle with cancer. June and Joshua celebrated their 55th anniversary earlier this year and share 3 children, as well as multiple grandchildren and great-grandchildren.

Since June’s death, Joshua has had significant difficulty adjusting to his life as a widower. He is tearful most days and has increasingly avoided visits with family, friends, and to places around their city that they frequented, as these reminders tend to trigger strong negative emotions. He does not think he has felt happiness since June’s death. He has caught himself multiple times thinking that he heard her voice or heard her moving around the home that he now lives in alone. He has never struggled with suicidality, but recently, he has found himself wishing to “join her.” He is having difficulty enjoying anything in her absence and spends most of the day watching television and waiting to go to sleep so that he has a reprieve from his thoughts.

He was referred to a psychiatrist by his primary care physician in the context of 25 lb weight loss over the past 3 months and an elevated Patient Health Questionnaire-9 score. His psychiatrist diagnosed him with adjustment disorder, recommended that he start an SSRI, and referred him to a grief group. She was initially concerned about his thoughts of wanting to be “with June,” but upon further interview, Joshua denied suicidal intent, plan, or lethal means access; so she was less concerned for active suicidal ideations that might necessitate hospitalization. She scheduled him for close follow-up and saw him frequently throughout the following months. After 6 months, Joshua had made good progress and regained much of the weight he had lost. He is now enjoying spending time with his family members and spends the weekends attending grandchildren’s sporting events. He still gets sad when thinking about June, but these thoughts no longer consume him, and he is able to look back fondly on happy memories.

Discussion

Grief is typically associated with the emotions and actions connected to the loss of something or someone of significance. Across cultures and history, grief has been generally understood as a natural and expected response to these losses. It reflects the depth of attachment and our capacity for meaning and connection. When viewed from the psychological lens, grief is conceptualized as an expected emotional and cognitive process in response to the loss of an object of significance. From an anthropologic perspective, conceptualization of grief is shaped by the cultural normal and rituals that guide how individuals may be expected to mourn. When considered from the medical lens, psychiatrists have attempted to reduce suffering by distinguishing between the expected and the pathologic; or what is considered to be normal grief versus “complex” or “persistent.” Further down the continuum (and further pathologized) is depression, which is considered to exist outside of loss or grief. The medicalization of grief, while intended to provide care for those with complicated suffering, reflects broader tensions between human emotion, cultural variability, and psychiatric categorization.

Cultural Contexts of Grief

Perceptions of grief have varied across centuries and continents. In ancient and pre-modern societies, grief was frequently a ritualized and relatively public experience. In ancient Greece, families sometimes hired professional mourners following the death of a loved one and held a “prothesis,” a ritual where the body was displayed, followed by the “ekphoroa,” akin to a public funeral procession.¹ Multiple indigenous cultures incorporated specific mourning rituals to mark members’ passing, such as the Lakota “wiping of tears” ceremony² and the Māori practice of “tangi,” a multiple-day series of speeches and songs that brings grief into the collective consciousness.³

Over time, some societies have gradually moved away from prescribed grief rituals to more individualistic experiences of loss. For example, in Victorian Era England, specific practices such as wearing black crepe for prescribed durations of time, specific mourning jewelry, and societal expectations that placed time parameters on widows’ re-entering society shaped the cultural experience of grief.⁴ This time period also marked a shift in the way loss was conceptualized, as euphemistic expressions for death (such as “passed away” and “departed”) became more popular in the contemporary lexicon,⁵ in some ways distancing individuals from grief experiences. Later, in the era surrounding WWI and WWII, earlier English grief rituals had become much less common and stoicism was further encouraged as the population was urged “carry on” in order to not let grief disrupt war efforts.⁶

Grief Under the Psychiatric Lens

In 1969, Elizabeth Kubler-Ross published the seminal On Death and Dying. While originally aimed at describing the emotional experiences of those facing terminal illness, the 5-stage model of grief that she set forth (denial, anger, bargaining, depression, and acceptance)⁷ received widespread adoption as a model of grief (Figure). Subsequent publications have encouraged a more nuanced approach to adoption of the model as the expectation of 5 stages may incompletely capture the grief experience,⁸ as grief is not necessarily linear and can vary dramatically across cultures and individuals. However, this idea of a model for grief took hold and was important for later, prescriptive conceptualizations of grief.

Over time, the psychiatric classification of grief has varied as the field’s understanding of the concept has grown more nuanced. The DSM is now in its fifth iteration, with the most recent version (DSM-5-TR) released in 2022.⁹ DSM-I (1952)¹⁰ and DSM-II (1968)¹¹ did not include grief as a pathologic process. In earlier versions, responses to loss were framed broadly under “adjustment reactions.” DSM-III (1980) included a “bereavement exclusion” in its conceptualization of MDD, which stated that depressive reactions occurring within 2 months of a significant death should typically not be diagnosed as MDD.¹² This exclusion was continued in DSM-III-R (1987)¹³ and DSM-IV (1994).¹⁴

The most significant change in the DSM classification of grief occurred in 2013 with the publication of the DSM-5.¹⁵ The bereavement exclusion was excluded from this edition, enabling MDD to be diagnosed in the weeks following death and sparking concerns for the “pathologizing” of grief. DSM-5 introduced persistent complex bereavement disorder as a condition for further study,¹⁵ recognizing the condition as an area for further study, though not officially diagnosable. The 2022 DSM-5-TR introduced “prolonged grief disorder,” which introduced specific time frames for the pathologization of grief—namely, impairing grief lasting more than 12 months in adults or 6 months in children.¹⁵ The current DSM classification of adjustment disorder also makes exclusions for “normal bereavement” and prolonged grief disorder.¹⁵ The current text no longer includes a specific bereavement exclusion with MDD, but it does include information for clinicians to help differentiate between a major depressive episode and grief.¹⁵ In this current iteration, grief is characterized by intermittent intensity of dysphoria associated with reminders/thoughts of the deceased, the ability experience positive emotions, generally intact self-esteem, and thoughts of dying may be in the context of wanting to “join” the deceased. In contrast, major depressive episodes are more likely to be characterized by persistent depressed mood not tied to specific thoughts/preoccupations, pervasive unhappiness, self-critical ruminations, feelings of worthlessness and self-loathing, and thoughts of ending one’s life are more strongly associated with feeling worthless or feeling undeserving of life.

The DSM classification of grief was partly mirrored by the ICD classification of grief. Until the most recent iteration, earlier ICD versions had considered grief as a normal stress response that did not have a formal categorization, but which might be included in adjustment reactions or depressive episodes. The ICD-11 (released 2018, adopted 2019)¹⁶ included prolonged grief disorder for the first time, defined as a “pervasive grief response characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain” for at least 6 months. The code also includes additional language to exclude bereavement responses viewed as normative within the person’s cultural and religious contexts.

The DSM and ICD include “Z codes,” which are helpful for documenting additional factors that may impact well-being without rising to the level of a diagnosable mental health condition. “Uncomplicated bereavement” or “normal grief” is included as a Z code outside of MDD, adjustment disorder, and prolonged grief disorder.

Concluding Thoughts

The case shows the complexity involved in respecting grief as an expected human experience and identifying when clinical intervention may be required or beneficial. Diagnostic frameworks like the DSM and ICD-11 provide tools to help differentiate between expected bereavement and a pathological reaction that might benefit from treatment. Some elements of Joshua’s experience (sadness, insomnia, bereavement hallucinations) are not out of the realm of the expected grief response, but symptoms like weight loss, functional decline, and anhedonia point to a more profound process that warrants intervention in order to help reduce suffering. In this case, addressing his grief response like an adjustment reaction/moderate depression and treating with appropriate medications was helpful for gradually improving his well-being and ability to participate in his grief group. By employing multiple modalities (medications, grief support), his psychiatrist was able to respect the continuum between psychiatric pathology and an expected emotional response to loss.

Dr Angly is a third year resident in psychiatry at Baylor College of Medicine.

Dr Moukaddam is a professor of psychiatry in the Department of Psychiatry at Baylor College of Medicine and the director of outpatient psychiatry at Harris Health System. She also serves on the Psychiatric Times Editorial Board.

References

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