When does intense grief become a mental disorder?

Over the past two years, grief and loss have defined the lives of most Canadians. Some lament the loss of friendships. Others mourn a job they loved, a routine they cherished, or a time when they weren’t so worried about a deadly virus.

As Canada’s death toll from COVID-19 nears 38,000, millions are also mourning the loss of loved ones – parents, grandparents, aunts, uncles and siblings. For a time, funeral gatherings were made impossible by pandemic restrictions, leaving many people to bear the heavy weight of grief alone.

Most will be able to continue, the weight getting lighter with each passing year. But at a time when grief has become communal in a way rarely seen in human history, the American Psychiatric Association has released new guidelines on how to understand and deal with intense grief after death. , adding “prolonged bereavement disorder” to their diagnostic manual – the newest addition of a disorder in nearly a decade.

The decision follows a long and contentious battle in the mental health field that spans decades to determine whether intense grief symptoms could be classified as a mental disorder or are just normal parts of the experience. human.

“People who aren’t trained in mental health care talk about a person who lost a son, and ‘he was never the same’,” said Dr. David Gratzer, psychiatrist at the Addiction Center. and Toronto Mental Health. “Or ‘she lost her child in an accident and couldn’t get over it.'”

“There has been some debate about how to understand this from a diagnostic textbook perspective.”

This month, the committee behind the latest revision of the Fifth Diagnostic and Statistical Manual of Mental Disorders released a set of criteria for diagnosing protracted bereavement disorder, marking the end of that debate. In it, the disorder is characterized as experiencing intense craving for 12 consecutive months after a profound loss, to the point where functioning at work or home has become difficult.

Including prolonged bereavement disorder in the diagnostic manual has more immediate ramifications in the United States, as American psychiatrists can now bill insurance companies for bereavement treatment. For Canadian psychiatrists, this decision is interesting to watch and may lead to a pause if a patient is in intense pain after the death of a loved one.

“When I see someone who has lost someone and who continues to struggle many months after the loss, and it undermines their ability to function day-to-day, I’m going to stop for a moment and ask, ‘Is is this really part of a normal reaction? Or is it something different? Said Gratzer.

In terms of treatment, people struggling with prolonged grief disorder showed significant improvement after undergoing targeted therapy that focused on coping with loss. Naltrexone, a drug used to treat addiction, is also being tested to treat prolonged grief, with the rationale that the two disorders share similar symptoms.

The inclusion of prolonged bereavement disorder in the latest revision of the diagnostic manual comes as many struggle with deep feelings of loss due to the COVID-19 pandemic. About 37,500 people have died from the virus in Canada, and the Canadian Grievance Alliance estimates that those deaths have left more than three million mourners across the country.

The prevalence of grief is something psychologist Saunia Ahmad has noticed in her clients during the pandemic.

“A lot of people had family members who died, if not from COVID, then things that seem to be related to COVID, like not getting medical attention in time,” said Ahmad, director of the psychology clinic at Toronto. She added that the grief has become acute for some due to their inability to do anything because of the pandemic measures, such as visiting friends for comfort or traveling to see family.

In general, Ahmad said lingering feelings of grief are normal. Many mourn a loss year after year, and especially struggle on special dates like birthdays and anniversaries.

This normalcy has been central to the argument against defining a bereavement disorder for decades; that grief can be resolved over time, and diagnosing someone with a disorder risks pathologizing natural feelings of sadness and longing.

Ahmad said that over time, people’s grief tends to become less intense. But research over the past few decades has shown that there is a distinct minority of bereaved people, around 5-15%, who struggle with intense, debilitating grief that lingers beyond what is expected.

“This diagnosis is really for a subset of people who may be in severe pain,” Ahmad said.

Conversations about mental health and grief date back to Sigmund Freud, who explored the topic in his 1917 book Mourning and Melancholy. But the case for classifying intense grief as a disorder only began in the 1990s, when research was conducted to determine the prevalence of intense grief, as well as its symptoms.

In 2010, the American Psychiatric Association began consulting on grief as a disorder, listing it as an area needing further study in the first edition of its fifth diagnostic manual, published in 2013. Six Years Older later, other studies were submitted for review, and the public was invited to comment on the definition of protracted grief disorder in 2020. In September, a diagnostic criterion was agreed upon.

For Gratzer, the long and detailed process of viewing intense grief as a disorder speaks to how mental health care is studied and defined.

“There are no biomarkers in mental health, which is a fancy way of saying we can’t do a blood test to see if someone has depression,” he said. “We have problem descriptions and put them together in terms of a larger disorder.”

Announcing the decision to include the new disorder in the revised manual, the American Psychiatric Association said it hopes the news will lead to a better understanding of how grief manifests and when it’s appropriate to ask for help. help as people continue to recover from the pandemic, which “can make prolonged bereavement disorder more prevalent.

If you are grieving, support and resources are available through the Toronto branch of Bereaved Families of Ontario: https://bfotoronto.ca/ or you can contact the Ontario Crisis Line at 1-866-531-2600.


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