This past March, the American Psychiatric Association (APA) released a new text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Known as psychiatry’s Bible, the DSM hasn’t undergone any major revisions since the publication of its 5th edition in 2013. The goal of this revision is to provide further clarification on certain psychological disorders, greater cultural inclusivity in the mental health field, and updated criteria for diagnosis.
One revision, in particular, a diagnosis called prolonged grief disorder, has been the subject of controversy for decades. Historically, clinicians mostly ignored prolonged symptoms of grief, as it was seen as a normal and appropriate response. This was done through the “bereavement exclusion” statement in the DSM, which mandated that major depressive disorder not be diagnosed within a year of the death of a loved one. Diagnosis of mental illness involves an abnormal response to an event, but grief, no matter how severe, was never seen as unusual. Therapists treated depression, but didn’t “worry about grief.”
Since the 90s, however, researchers such as epidemiologist Holly Prigerson have advocated for a diagnosis that would provide treatment for those suffering from debilitating grief. Prigerson studied depression treatment in older populations and found that, although treatment was often successful, feelings of grief lingered even after depressive symptoms faded. Bereavement poses a unique emotional challenge in contrast to depression, as one must not only confront internal thoughts and behaviors but also adjust to a new external social environment. Grief and depression seem to operate very differently, and therefore may require specialized treatment.
Feelings associated with loss, such as longing or isolation, prove to be much harder to dispel than other symptoms of depression, creating a large push for the DSM to explicitly address grief independently. Years later, with the DSM now containing this diagnosis, patients experiencing multiple symptoms of grief for at least 12 months will be able to bill insurance and gain easier access to specialized therapy for their condition.
Furthermore, the inclusion of the disorder in the DSM opens the door for extensive research in treating grief. One pharmaceutical treatment that could be promoted through this revision is the use of Naltrexone for grief. Naltrexone, which is traditionally used for substance use disorders, may provide a unique treatment for prolonged grief by decreasing one’s emotional reliance on a bereaved loved one.
Another treatment promoted by this diagnosis is a 16-week psychotherapy program originally created by Katherine Shear for victims of trauma. The program utilizes exposure therapy to habituate someone to whatever events or ideas are causing an individual immense stress. In practice, this program has been even more effective than antidepressants or other depression treatments. By designating prolonged grief as an independent disorder, this DSM revision will create more opportunities for unique treatments like these to become accessible.
However, a large portion of clinicians and researchers still advise against the inclusion of prolonged grief disorder in the DSM. An estimated 4% of bereaved individuals will qualify for a diagnosis of the disorder, but this may point to a larger issue of overdiagnosis. Clinicians must take immense care when considering a diagnosis, and diagnosing too soon or with too mild symptoms may actually worsen one’s mental health. Pharmaceutical companies may capitalize on this disorder to push new drugs. Individuals dealing with loss may over-monitor themselves or seek unnecessary medication to avoid a normal grieving process.
Professor of social work Joanne Cacciatore emphasizes that when an individual is labeled “disordered” by a professional, “they no longer trust themselves and their emotions.” Many may pathologize their own responses to loss whether or not it’s actually abnormal. By creating a direct pipeline from grief to diagnosis, this new revision may create widespread reliance on clinical treatment. As a result, some believe public resilience to death and loss could potentially be put at risk. Bereaved individuals may rush to label their attachment to a lost loved one as disordered or abnormal despite it being a natural response.
Though it’s true that this new diagnosis will create a spike in those seeking treatment, some question whether that’s a problem. Perhaps even more than the 4% of bereaved individuals would benefit from treatments like Shear’s. Diagnosis certainly isn’t a light topic, but it may be the most effective option available. The extra visibility given to grief treatment through the DSM may help destigmatize therapy and motivate thousands to seek the help they need.
Despite the immense debate surrounding the effect of loss on our mental health, this new addendum to the DSM reveals how our perception of grief is constantly evolving. Hesitant professionals argue that grief must remain an independent process of resilience, but current research and emerging treatments say otherwise. Bereavement isn’t a challenge thousands should be facing alone, and the inclusion of prolonged grief disorder in the DSM-5 is one way clinicians are changing that.