Hum Homework #10

© 2022 The New York Times Company

NYTCo Contact Us Accessibility Work with us Advertise T Brand Studio Your Ad Choices Privacy Policy Terms of Service Terms of Sale Site Map Help Subscriptions

Do Not Sell My Personal Information California Notices

A DV E R T I S E M E N T

The latest edition of the DSM-5, sometimes known as “psychiatry’s bible,” includes a controversial new diagnosis: prolonged grief disorder.

By Ellen Barry

March 18, 2022

After more than a decade of argument, psychiatry’s most powerful

body in the United States added a new disorder this week to its

diagnostic manual: prolonged grief.

The decision marks an end to a long debate within the field of

mental health, steering researchers and clinicians to view intense

grief as a target for medical treatment, at a moment when many

Americans are overwhelmed by loss.

The new diagnosis, prolonged grief disorder, was designed to apply

to a narrow slice of the population who are incapacitated, pining

and ruminating a year after a loss, and unable to return to previous

activities.

Its inclusion in the Diagnostic and Statistical Manual of Mental

Disorders means that clinicians can now bill insurance companies

for treating people for the condition.

A DV E R T I S E M E N T

It will most likely open a stream of funding for research into

treatments — naltrexone, a drug used to help treat addiction, is

currently in clinical trials as a form of grief therapy — and set off a

competition for approval of medicines by the Food and Drug

Administration.

Since the 1990s, a number of researchers have argued that intense

forms of grief should be classified as a mental illness, saying that

society tends to accept the suffering of bereaved people as natural

and that it fails to steer them toward treatment that could help.

Did you know you can share 10 gift articles a month, even with nonsubscribers? Share this article.

A diagnosis, they hope, will allow clinicians to aid a part of the

population that has, throughout history, withdrawn into isolation

after terrible losses.

“They were the widows who wore black for the rest of their lives,

who withdrew from social contacts and lived the rest of their lives

in memory of the husband or wife who they had lost,” said Dr. Paul

S. Appelbaum, who is chair of the steering committee overseeing

revisions to the fifth edition of the D.S.M.

“They were the parents who never got over it, and that was how

we talked about them,” he said. “Colloquially, we would say they

never got over the loss of that child.”

A DV E R T I S E M E N T

Throughout that time, critics of the idea have argued vigorously

against categorizing grief as a mental disorder, saying that the

designation risks pathologizing a fundamental aspect of the human

experience.

They warn that there will be false positives — grieving people told

by doctors that they have mental illnesses when they are actually

emerging, slowly but naturally, from their losses.

Coping With Grief and Loss

Living through the loss of a loved one is a universal experience. But the ways

in which we experience and deal with the pain can largely differ.

What Experts Say: Psychotherapists say that grief is not a problem to be

solved, but a process to be lived through, in whatever form it may take.

How to Help: Experiencing a sudden loss can be particularly traumatic.

Here are some ways to offer your support to someone grieving.

A New Diagnosis: Prolonged grief disorder, a new entry in the American

Psychiatric Association’s diagnostic manual, applies to those who

continue to struggle long after a loss.

The Biology of Grief: Grief isn’t only a psychological experience. It can

affect the body too, but much about the effects remains a mystery.

And they fear grief will be seen as a growth market by drug

companies that will try to persuade the public that they need

medical treatment to emerge from mourning.

“I completely, utterly disagree that grief is a mental illness,” said

Joanne Cacciatore, an associate professor of social work at Arizona

State University who has published widely on grief, and who

operates the Selah Carefarm, a retreat for bereaved people.

“When someone who is a quote-unquote expert tells us we are

disordered and we are feeling very vulnerable and feeling

overwhelmed, we no longer trust ourselves and our emotions,” Dr.

Cacciatore said. “To me, that is an incredibly dangerous move, and

short sighted.”

‘We don’t worry about grief’

The origins of the new diagnosis can be traced back to the 1990s,

when Holly G. Prigerson, a psychiatric epidemiologist, was

studying a group of patients in late life, gathering data on the

effectiveness of depression treatment.

A DV E R T I S E M E N T

She noticed something odd: In many cases, patients were

responding well to antidepressant medications, but their grief, as

measured by a standard inventory of questions, was unaffected,

remaining stubbornly high. When she pointed this out to

psychiatrists on the team, they showed little interest.

“Grief is normal,” she recalls being told. “We’re psychiatrists, and

we don’t worry about grief. We worry about depression and

anxiety.” Her response was, “Well, how do you know that’s not a

problem?”

Dr. Prigerson set about gathering data. Many symptoms of intense

grief, like “yearning and pining and craving,” were distinct from

depression, she concluded, and predicted bad outcomes like high

blood pressure and suicidal ideation.

Her research showed that for most people, symptoms of grief

peaked in the six months after the death. A group of outliers — she

estimates it at 4 percent of bereaved individuals — remained

“stuck and miserable,” she said, and would continue to struggle

with mood, functioning and sleep over the long term.

“You’re not getting another soul mate and you’re kind of eking out

your days,” she said.

In 2010, when the American Psychiatric Association proposed

expanding the definition of depression to include grieving people, it

provoked a backlash, feeding into a broader critique that mental

health professionals were overdiagnosing and overmedicating

patients.

“You’ve got to understand that clinicians want diagnoses so they

can categorize people coming through the door and get

reimbursement,” said Jerome C. Wakefield, a professor of social

work at New York University. “That is a huge pressure on the

D.S.M.”

Still, researchers kept working on grief, increasingly viewing it as

distinct from depression and more closely related to stress

disorders, like post-traumatic stress disorder. Among them was Dr.

M. Katherine Shear, a psychiatry professor at Columbia University,

who developed a 16-week program of psychotherapy that draws

heavily on exposure techniques used for victims of trauma.

A DV E R T I S E M E N T

By 2016, data from clinical trials showed that Dr. Shear’s therapy

had good results for patients suffering from intense grief, and that

it outperformed antidepressants and other depression therapies.

Those findings bolstered the argument for including the new

diagnosis in the manual, said Dr. Appelbaum, who is chair of the

committee in charge of revisions to the manual.

In 2019, Dr. Appelbaum convened a group that included Dr. Shear,

of Columbia, and Dr. Prigerson, now a professor at Weill Cornell

Medical College, to agree on criteria that would distinguish normal

grief from the disorder.

The most sensitive question of all was this: How long is prolonged?

Though both teams of researchers felt that they could identify the

disorder six months after a bereavement, the A.P.A. “begged and

pleaded” to define the syndrome more conservatively — a year

after death — to avoid a public backlash, Dr. Prigerson said.

“I have to say that they were kind of politically smart about that,”

she added. The concern was that the public was “going to be

outraged, because everyone feels because they still feel some grief

— even if it’s their grandmother at six months, they are still

missing them,” she said. “It just seems like you’re pathologizing

love.”

Measured at the year mark, she said, the criteria should apply to

around 4 percent of bereaved people.

The new diagnosis, published this week in the manual’s revised

edition, is a breakthrough for those who have argued, for years,

that intensely grieving people need tailored treatment.

“It’s kind of like the bar mitzvah of diagnoses,” said Dr. Kenneth S.

Kendler, a professor of psychiatry at Virginia Commonwealth

University who has played an important role in the last three

editions of the diagnostic manual.

A DV E R T I S E M E N T

“It’s sort of an official blessing in the world,” he said. “If we were on

the planetary committee of the American Astronomical Society

deciding what is a planet or not — this one’s in, and Pluto we

kicked out.”

If the diagnosis comes into common use, it is likely to popularize

Dr. Shear’s treatment and also give rise to a range of new ones,

including drug treatments and online interventions.

Dr. Shear said it was difficult to predict what treatments would

emerge.

“I don’t really have any idea, because I don’t know when the last

time there was a really brand-new diagnosis,” she said.

She added, “I really am in favor of anything that helps people,

honestly.”

A loop of grief

Amy Cuzzola-Kern, 54, said Dr. Shear’s treatment helped her break

out of a terrible loop.

Three years earlier, her brother had died suddenly in his sleep of a

heart attack. Ms. Cuzzola-Kern found herself compulsively

replaying the days and hours leading up to his death, wondering

whether she should have noticed he was unwell or nudged him to

go to the emergency room.

She had withdrawn from social life and had trouble sleeping

through the night. Though she had begun a course of

antidepressants and seen two therapists, nothing seemed to be

working.

“I was in such a state of protest — this can’t be, this is a dream,”

she said. “I felt like I was living in a suspended reality.”

A DV E R T I S E M E N T

She entered Dr. Shear’s 16-session program, called prolonged grief

disorder therapy. In sessions with a therapist, she would narrate

her recollection of the day that she learned her brother had died —

a painful process, but one that gradually drained the horror out of

the memory. By the end, she said, she had accepted the fact of his

death.

The diagnosis, she said, mattered only because it was a gateway to

the proper treatment.

“Am I ashamed or embarrassed? Do I feel pathological? No,” she

said. “I needed professional help.”

Yet, others interviewed said they were wary of any expectation

that grief should lift in a particular period of time.

“We would never put a time frame around when someone should or

shouldn’t feel that they have moved forward,” said Catrina

Clemens, who oversees the victim services department of Mothers

Against Drunk Driving, which provides services to bereaved

relatives and friends. The organization encourages bereaved

people to seek mental health care, but has no role in diagnosis, said

a spokesperson.

Filipp Brunshteyn, whose 3-year-old daughter died after an

automobile accident in 2016, said grieving people could be set back

by the message that their response was dysfunctional.

“Anything we inject into this journey that says, ‘that’s not normal,’

that could cause more harm than good,” he said. “You are already

dealing with someone very vulnerable, and they need validation.”

To set a year as a point for diagnosis is “arbitrary and kind of

cruel,” said Ann Hood, whose memoir, “Comfort: A Journey

Through Grief,” describes the death of her 5-year-old daughter

from a strep infection. Her own experience, she said, was “full of

peaks and valleys and surprises.”

A DV E R T I S E M E N T

The first time Ms. Hood walked into her daughter Grace’s room

after her death, she saw a pair of ballet tights lying in a tangle on

the floor where the little girl had dropped them. She screamed.

“Not the kind of scream that comes from fright,” she later wrote,

“but the kind that comes from the deepest grief imaginable.”

She slammed the door, left the room untouched and eventually

turned off the heat to that part of the house. At the one-year mark,

a well-meaning friend told her it was time to clear out the room —

“nothing worse than a shrine,” he told her — but she ignored him.

Then one morning, three years after Grace’s death, Ms. Hood woke

up and returned to the room. She sorted her daughter’s clothes and

toys into plastic bins, emptied the bureau and closet and lined up

her little shoes at the top of the stairs.

To this day, she is not sure how she got from one point to the other.

“All of a sudden, you look up,” she said, “and a few years have gone

by, and you’re back in the world.”

A DV E R T I S E M E N T

Your business internet is goingUltraIt’s ultra-fast, ultra-simpleHow Long Should It Take to Grieve?Psychiatry Has Come Up With anAnswer.Give this article 1.2KHolly Prigerson, a professor of sociology in medicine, has worked to include prolonged grief as a classified,diagnosable psychiatric disorder. Hiroko Masuike/The New York Times

“I completely, utterly disagree that grief is a mental illness,” said Joanne Cacciatore, an associate professor of social work at Arizona State University who operates the Selah Carefarm, a retreat for bereaved people. Adriana Zehbrauskas for The New York Times

Dr. M. Katherine Shear, a psychiatry professor at Columbia University and a founding director of the Center for Prolonged Grief, has been studying the condition since 1995. Yana Paskova for The New York Times

HEALTH PLAY THE CROSSWORD Account