Grief: How Much is Too Much? Understanding Bereavement

How much grief is too much? Image by lorettaflame.

How much grief is too much? Image by lorettaflame.

Friends and partners, parents, and sometimes children, die before us.  Love leads to loss. Loss leads to grief.  But how to know when someone is grieving too much?

What distinguishes prolonged grief disorder from normal sadness? Does being bereaved mean we are not depressed? Are we in danger of labeling normal grief as pathological?

Diagnostic and Statistical Manual Changes

Today, in the United States, to be considered a diagnosable mental disorder for insurance purposes, items must be listed in the Diagnostic and Statistical Manual. 

The most recent update of this manual is the fifth edition or DSM V. The DSM V contains updated criteria for major depression.  Being bereaved used to disqualify individuals from being labeled as depressed.  This edition allows the diagnosis of depression – even if one has recently suffered a loss.

As Dr. Ronald Pies, MD notes in the Psychiatric Times, major depressive disorder or MDD leads to a suicide rate of 4%, and “[d]isqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on a potentially life-saving treatment.”




Prolonged Grief Disorder

Others such as Dr. Prigerson had suggested that the DSM V add “prolonged grief disorder” to the list of psychiatric conditions.  When considering adding the diagnosis for the fourth edition of the DSM, researchers suggested the following criteria: “feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life.’  

Such a response to a death is not unexpected, however, the authors suggested a that they should not persist too long. “Symptoms must be present at sufficiently high levels at least six months from the death and be associated with functional impairment.” 

Ultimately, the researchers decided to stop excluding the bereavement from the criteria for depressive disorders in the Diagnostic and Statistical Manual, Fifth edition.

Predicting Abnormal Grief

Dr. Richard Friedman, MD states in his review of the change in the DSM, that “10 to 20% of bereaved people do not get over their grief easily and go on to develop a syndrome of complicated grief, characterized by an intense and persistent longing for the deceased, a sense of anger and disbelief over the death, and a disturbing preoccupation with the lost one.”  Targeting individuals who are likely to experience complicated grief could lead to better intervention.

In a study of 66 family members of Alzheimer’s patients, Dr. Melissa Romero of Northern Michigan University and colleagues determined that those who were most likely to experience “high levels of grief” were those who expressed “predeath grief, dysfunctional coping, depression, social support, and decreased positive states of mind.”  These factors accounted for “54.7% of the variance in postdeath grief.”

If you or a friend or family member is at risk for abnormal, prolonged grief, therapy may provide relief.  If MDD is suspected, a specialist may prescribe anti-depressants, but Dr. Pies argues ““treatment” of post-bereavement depression need not involve antidepressant medication, except in the most severe cases.”  Many people would agree with Dr. Richard A. Friedman when he writes,The medical profession should normalize, not medicalize, grief.” 

Moving On After a Loss

Both Dr. Pies and Dr. Friedman appear to agree that eliminating the “bereavement exclusion” could possibly lead to an overly zealous treatment of the grieving. With the exception lifted, in order to meet the diagnostic criteria,the person who has lost a loved one must only have a depression that has lasted more than two weeks. This is, of course, a very short period of time in light of a great personal loss. Yet, as Dr. Friedman explains, only the bereaved experiencing highly unusual symptoms or delusions would visit a psychiatrist so quickly.

Ordinary grief is part of life and loss.  But treating grief that has grown into major depression is valid and life-affirming. Unusual symptoms in those who have suffered loss are a warning sign of significant depression.  Clinicians need to take care when distinguishing normal sadness in the face of loss from abnormal grieving.

Grief which persists too long can shackle the living.

© Copyright 2014 Gina Putt, All rights Reserved. Written For: Decoded Science

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  1. Okay, so what if a person has gone through quite a number of losses of close family members in a short period of time, say five in two years, plus dealing with chronic illnesses in other family members? Does the new standard mean everyone should be medicated?Is there some magic formula for grief in such instances, and what is it (are we allowed two weeks each, or do we get bonus points for the compounding effect)? Indeed multiple losses of close family members in a short amount of time does shackle the living, but feeling pain is a sign that we are normal. How is medicating people for feeling normal feelings supposed to help? Welcome to the zombie nation.

  2. Dear Ms. Putt,

    Thank you for a moderate and balanced perspective on this often polarized issue. Thanks, also, for citing my 2012 article, in which I note that,

    “The person with moderate, uncomplicated grief is unlikely to seek professional or psychiatric help, within the first few weeks after the death of a loved one. Thus, the much-ballyhooed claim that clinicians using the DSM-5 will declare a normally grieving person “mentally ill” after just 2 weeks is exaggerated and misleading. In contrast, the grieving person in whom MDD develops often senses that something has gone terribly wrong, and may then seek professional help. Providing effective treatment for the grieving person’s major depression may actually help in “working through” the grief itself. Indeed, when symptoms of major depression intervene and go untreated, working through grief—and integrating it into one’s life—is made all the more difficult.” –
    See more at: http://www.psychiatrictimes.com/major-depressive-disorder/bereavement-and-dsm-5-one-last-time#sthash.J8MEJyqJ.dpuf

    I would add that, if clinicians carefully review the guidelines in the DSM-5, especially the footnote on p. 161, they will most likely not be “overzealous” in their approach to normal grief–which, of course, does not require professional treatment.

    You and your readers may also find my more recent take on this topic at:
    http://psychcentral.com/blog/archives/2013/05/31/how-the-dsm-5-got-grief-bereavement-right
    Best regards,
    Ronald Pies MD

    • Dr. Pies,
      I appreciate the time you have taken to further clarify the point that those suffering from normal grief are not likely to seek professional help. I look forward to reading your update on the topic. The DSM is a work in progress, but by noting that grief can develop abnormally, I feel the DSM V is a step forward.
      Gina