Thursday's Therapy - Here Comes Psychology's New Diagnostic Manual–Run Griever, Run!

Thursday's Therapy

Here Comes Psychology's New Diagnostic Manual –

Run Griever, Run!

August 2, 2010

In the winter of 1992, Theresa Smith took her 14-month-old daughter, Scarlett, to Arizona for an extended visit with family. One night, as they headed to bed, Theresa's mother made a declaration: She would watch the baby the next morning. Theresa should take the day for herself.

We know relatively little about whether the pain that follows a loss is, in a health sense, necessary.

The following morning, Theresa kissed her mother and child goodbye and headed off for a rare day of leisure. This was the era before cell phones, and Theresa wasn't able to call home. So it wasn't until later that afternoon when Theresa learned that her baby daughter had died — she had fallen into the pool in her mother's backyard and drowned shortly after Theresa pulled out of her mother's driveway.

Scarlett was Theresa's only child, the center of her life, and so the months that followed were close to unbearable. Theresa cried every day. She considered suicide. She could not sleep. And, though she went back to graduate school, she found it hard to focus.

The nights were the worst. Theresa would go to the cemetery and sit, banging her head against Scarlett's headstone until her face was covered with blood. Eventually, the husband of a good friend started coming to retrieve her after he closed his restaurant for the night. He would take her back to her apartment, a place no safer from pain.

"At one point," Theresa says, "I wanted to smell Scarlett. And I looked and I went around the apartment, and I looked for her fingerprints, little spots where she had spit up milk. I just looked for her everywhere. She was all I wanted."

Today, Theresa is doing well. And she looks on this period of her life, the months of incredible pain and suffering, with a kind of distant pragmatism.

"It's a normal process of letting go of your child," she says. "You've got to go through all of this."

But is what Theresa went through a normal part of grieving, or did the death of her child bring on a mental disorder — major depression — that could have been, perhaps should have been, aggressively treated?

Change In Guidelines

Earlier this year, the American Psychiatric Association released a rough draft of its new Diagnostic and Statistical Manual of Mental Disorders, or DSM. It's a big book that lists all the mental disorders doctors can use to diagnose mental illness. One of the changes they're proposing is causing controversy.

Traditionally, the manual has warned doctors away from diagnosing major depression in people who have just lost a loved one in what's called "bereavement exclusion." The idea was that feelings of intense pain were normal, so they shouldn't be labeled as a mental disorder.

But the new DSM changes this.

{You've got to be kidding!}

Buried in the pages is a small but potentially potent alteration that has implications not only for people like Theresa, but ultimately for the way that we think about and understand the emotion of pain.

The DSM committee removed the bereavement exclusion — a small, almost footnote at the bottom of the section that describes the symptoms of major depression — from the manual.

{In other words, if you are sad after the death of your child for longer than two weeks, you may get slapped with a diagnosis of Major Depression, labeling you mentally ill for grieving over your child!}

The Difference

Dr. Kenneth Kendler, who is on the committee that decided to make this change, says it's not that the committee feels everyone who has a loss should immediately be diagnosed with depression. For Kendler, there is a clear, bright line between normal grief and clinical depression.

Grief is OK — depression is not. Depression, by definition, is dangerous and should be treated. Grief is normal and should not.

{Okay, that sounds better, but...this "expert" thinks grief's acute pain should even be over within a Matter Of Days... stay tuned...}

So how, exactly, does Kendler define grief?

"Typically, modest amounts of upset are fairly common — sometimes difficulty sleeping, crying over memories of the loved one," Kendler says.

According to Kendler, people in grief also often lack concentration. They frequently lose sleep, lose appetite, lose energy.

Now technically, these are also symptoms of depression. So what's the difference between grief and depression in Kendler's view?

Kendler says that in grief, the symptoms are less severe, and also, the acute pain doesn't last as long.

"Usually for days at a time. Not for weeks,"

{There it is! DAYS Not WEEKS that we will feel acute pain in our grief over our child--Come on! Get Real!}

Kendler says. There are "a few days of acute upset and then a much longer period of the longing, the tearfulness. But typically sleep, appetite, energy, concentration come back to normal more quickly than that."

{Nope, not with ANY child-loss parent I've talked to.}

In fact, in the new manual, if symptoms like these persist

FOR MORE THAN TWO WEEKS,

the bereaved person will be considered to have a mental disorder: major depression. And treatment, either therapy or medication, is recommended.

{After TWO WEEKS of acute upset, if you're still acutely upset, they will label you with a "Mental Disorder" because you are simply grieving over a child you have loved with all your heart for all of their earthly life! Give me a break! And treatment??? If they are this much out of touch with what grief over one's child is like, can you imagine what their Therapy for you would be like??? Now who in this picture is the one who really has a "Mental Disorder," I ask you!}

Now according to Kendler, this change will affect a small number of people — less than 30 percent of the bereaved.

{Try ALL of the CHILD-LOSS grievers!}

But Holly Prigerson, a researcher at Harvard University who studies bereavement, says that while there's no good research on what percentage of people will meet the criteria for depression after a loss, it's clear that most experience depressive symptoms far beyond two weeks.

{Well that's a start Holly. Now let's see if you can get any closer to what our Child-Loss reality is really like...}

"What we found," Prigerson says, "is that when you follow people — for example, between zero and six months post-loss — their depression symptom levels actually increase over time and peak at about six months post-loss."

{Well, now Holly, you've lost us. I Don't Know ANY Child-Loss Griever who has PEAKED OUT in Child-Loss Grief at SIX MONTHS!}

Because grief and depression look so much alike, Prigerson says, she worries that people who are suffering from normal grief will be told that they are sick when they are not, and encouraged to treat their symptoms when they don't need to.

{Exactly!}

That is potentially a problem, Prigerson says, because

we don't know whether the pain of normal grief actually helps people to process their loss.

{These people really are full of themselves. Why don't they just ask ONE Child-Loss Griever if their pain and tears yield them some comfort. They actually think we can process such a PAINFUL loss with NO PAIN???!!! These people are inhuman!}

What We Don't Know

{NO KIDDING! I can tell you There is a WHOLE LOT about Grief that you don't know!}

In some ways, it is shocking what we don't know about grief.

{Oh yes, you can say that again. And you call yourself persons in the "helping" field?Exactly how will you help us when you have such Unrealistic Expectations of us??? I can guarantee you we would feel worse under any one of your "expert's" care I have heard so far.}

Every day in America people die, leaving loved ones behind to struggle with the consequences. Yet we know relatively little about whether the pain that follows a loss is, in a health sense, necessary.

{I think it is high time you did MANY research studies on actual CHILD-LOSS grievers - BY asking US what it is like! Get your noses out of the outdated text books - come out of your ivory towers - come down into the Valley of the Shadow of Death that we live in, observe us and listen to us, then tell me you would be DONE with Acute Grief in TWO WEEKS.

If you have any skills at all, you would hear our pain, climb into our world, and see what this kind of loss actually does to a loving, grieving parent.

And then you would take off that Hideously Unrealistic Expectation of "TWO WEEKS of Acute Grief," and even the "Peaking Out of our Grief at SIX MONTHS" ~ YOU ALL are hideously OUT OF TOUCH WITH REALITY.

It is actually scary to me to think of any one of you trying to "help" one of us Child-Loss Grievers.}

"What underlies a lot of this discussion is: Is it harmful to interrupt a normal grief process by medicating?"

- Holly Prigerson, a researcher at Harvard University who studies bereavement

That is, does going through intense emotional pain make you emotionally healthier later by allowing you to emotionally process your loss?

{Oh my gosh, do they really have to ASK themselves such an Inane question?! How ELSE do they figure we will process our loss?

IT IS GOING TO BE INTENSELY EMOTIONALLY PAINFUL to process our child-loss grief! EVEN WITH A MILD ANTIDEPRESSANT THAT MIGHT BE PRESCRIBED, it will still be intensely painful....

IF IT IS NOT INTENSELY PAINFUL, IT IS NOT HELPING US GET IN TOUCH WITH THE REALITY THAT OUR CHILD IS G-O-N-E.

DOPING US UP TO NOT FEEL THE NECESSARY NORMAL CHILD-LOSS GRIEF would be cruel and inhuman.

Has any one of these "experts" ever had a child that they loved, raised, doted on, nurtured and bonded with? And then has this expert also lost this child? If so, that expert would KNOW: "YES" our pain is going to be intense as we work through grief over such a loss in a healthy way!}

Kendler says no.

{Oh no, another ignorant one.}

"Early on, there used to be the thought that there was this grief work, and that if you did not demonstrate lots of upset acutely after someone died, that later on there would be more distress," Kendler says. "But research has shown clearly that that concept is false."

{Now where, Dr. Kendler, did you ever find such research as this - in the wishful thinking camp?!

OF COURSE if you Don't grieve through your acute grief with "lots of upset" feelings, THIS GRIEF WILL NOT GO AWAY - It may go underground briefly, but IT WILL RESURFACE, I CAN GUARANTEE YOU - That is, IF - you stay in touch with the reality that your precious child is now GONE, (which last time I checked is the healthy way to go through life...IN TOUCH WITH REALITY!)}

Kendler points to research showing that people who are doing well two weeks after a loss also seem to be doing well one year later.

{Yeah, I guess if you've had a lobotomy...if you are doing well in two weeks, you have definitely had some body parts removed, and so those same body parts will still keep you from feeling anything one year later. Only problem is, I don't think getting your brain sliced in two to achieve this is a real healthy solution.}

But Prigerson and several other researchers don't agree that the research is clear. They argue that at this point, we just don't know whether emotional pain in the wake of death allows you to come to terms with your loss, or if you can be just fine without it.

{Oh my goodness, you were going real good with that first sentence. BUT BEING "JUST FINE WITHOUT EMOTIONAL PAIN" DURING GRIEF? WHAT PLANET DID YOU JUST STEP OFF OF?}

While Normal, Grief Is Treatable

{Oh NO, this is not where you are going to tell us that YOU ALL are the QUALIFIED Therapists to "Treat" us, are you? I think I'll take that lobotomy instead...}

But to Dr. Sid Zisook, one of the psychiatrists who has argued for removal of the bereavement exclusion, this academic question doesn't matter. The dangers of depression, he says, are perfectly clear.

I'd rather make the mistake of calling someone depressed who may not be depressed than missing the diagnosis of depression, not treating it, and having that person kill themselves.

{Dr., can you honestly not tell if someone has grief and not Suicidal Depression? Are you going to treat everyone for schizophrenia because you are not skilled enough to accurately diagnose schizophrenia? Maybe you should consider referring on to someone more specialized in the field...}

- Dr. Sid Zisook

And just because pain after loss is normal, Zisook says, doesn't mean you shouldn't treat it.

"I mean, [pain] is a normal consequence of breaking a bone. But that doesn't mean that we don't treat the pain. We treat the pain vigorously," Zisook says.

{Okay, sometimes a mild "anti-depressant" might be helpful to help us as we process our extremely painful grief - If we agree we would like to try it-, but that doesn't mean you have to slap a diagnosis of "Major Depression" on us.

"Anti-depressants" are prescribed for P.M.S. sometimes, but the doctors don't slap an extra diagnosis of "Major Depression" on us just because these types of medications can serve to lessen some of the agony.}

Medicalizing Our Experiences

But for some people, the real issue raised by the bereavement exclusion is philosophical — or maybe the better word is existential. Dr. Allen Frances, the famous psychiatrist and a former editor of the DSM, says that

More and more, psychiatry is medicalizing our experiences.

That is, it is turning emotions that are perfectly normal into something pathological.

{YES! Someone finally gets it!}

Over the course of time, we've become looser in applying the term 'mental disorder' to the expectable aches and pains and sufferings of everyday life.

And always, we think about a medication treatment for each and every problem.

- Dr. Allen Frances

From Frances' perspective,

If you can't feel intense emotional pain in the wake of the death of your child without it being categorized as a mental disorder, then when in the course of human experience are you allowed to feel intense emotional pain for more than two weeks?

{Oh, I am so thankful there is at least ONE therapist that "Gets It"! Please, Dr. Frances, please, please, please, Teach your colleagues some Compassion and Common Sense. They are really scaring me. Please don't unleash them onto any one of us grieving Child-Loss Parents!}

This perspective is also shared by Theresa Smith, the woman who lost her daughter 20 years ago.

"I grieved her just as hard as I loved her," Smith says. "I had to. It wouldn't have meant anything if I hadn't."

(Highlights mine)

*****

As my good friend, grieving mother Danielle Helms exclaimed to me last night,

"Two Weeks???!

It would take longer than that to grieve over my CAT!"

*****

Scriptures for Grieving Parents:

The Apostle John speaking, then God speaks from His throne:)

Then I saw a new heaven and a new earth, for the first heaven and the first earth had passed away, and there was no longer any sea. I saw the Holy City, the new Jerusalem, coming down out of heaven from God, prepared as a bride beautifully dressed for her husband. And I heard a loud voice from the throne saying,

"Now the dwelling of God is with men, and He will live with them. They will be His people, and God Himself will be with them and be their God.

He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away."

He who was seated on the throne said,

"I am making everything new!"

Then He said, "Write this down, for these words are trustworthy and true."

He said to me: "It is done. I am the Alpha and the Omega, the Beginning and the End. To him who is thirsty I will give to drink without cost from the spring of the water of life. He who overcomes will inherit all this, and I will be his God and he will be my son..."

~Revelation 21:1-7

picture: thanks to @LillyAnn

The Current DSM-IV Manual picture from Amazon.com

http://www.npr.org/templates/story/story.php?storyId=128874986