A new chapter to be featured in the Palgrave Encyclopedia of Critical Perspectives on Mental Health explores the significance of recent developments to create grief-specific disorders within widely used psychiatric diagnostic classification systems. The author, Kaori Wada at the University of Calgary, explored the consequences and contradictions accompanying medicalizing grief.
She invoked a critical perspective to describe how medicalization supports psychopharmacological interventions, legitimizes a specific “monoculture” within the profession, and shapes how we construct personal narratives, interactions, and participation regarding what it means to mourn.
Wada framed the chapter and wrote:
“We stand at a critical juncture in the shifting landscape of how we understand grief––more specifically, how we draw the line between normal and abnormal grief and whether we should draw that line at all.”
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the 11th edition of the International Classification of Disorders (ICD-11) have both recently included or considered new grief-specific diagnoses. Persistent Complex Bereavement Disorder (PCBD) was identified as a condition for further study in the DSM-5, and Prolonged Grief Disorder (PGD) was formally included as a mental disorder in the ICD-11.
As Wada explored the consequences of medicalizing grief in these widely used classification systems, she clarified that she uses the term “medicalization” in a value-neutral way. The term does not necessarily imply that something is illegitimately or overmedicalized. Instead, medicalization refers to “the process of translating a human condition previously understood outside of medical language into treatable disorders, through the use of psychiatric language and a diagnosis-and-treat logic.”
However, Wada took a critical lens to examine the consequences now unfurling as grief is increasingly medicalized. She clarified her position:
“The medicalization of grief is therefore controversial because it may fundamentally alter the premises on which answers to the question of ‘what is mental disorder?’ have been defined and understood.”
Grief has been defined as “reactions to loss, encompassing both death-loss and non-death losses (e.g., divorce, relocation, job loss).”
Bereavement “refers to the situation following death loss.” However, Wada used grief and bereavement with respect to death-loss in this chapter. She also understands grief as influenced by cultural, as well as intrinsic and personal factors. For instance, there are cultural norms that “dictate in what way, and for how long, one should grieve for which relationships.”
“These norms are in turn powerfully shaped by social, cultural, and material conditions, and inherently contain value judgments about good and bad, moral and immoral, or healthy and unhealthy grief.”
Wada continued, “… I illustrate how the medicalization of grief, through the authority of psychiatric diagnosis, operates as a normative discourse, setting social expectations for ideal or healthy grieving.”
She proceeded to explain developments in grief-specific disorders and some contradictions and paradoxes that have surrounded the instantiation of grief-specific disorders. Wada begins by setting the foundation for this discussion by highlighting the statement in the DSM-5 which states explicitly that “‘An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one [emphasis added], is not a mental disorder’ (APA, 2013, p. 20).” This statement is considered the “norm-deviation clause,” and a similar one is included in the ICD.
“This overriding clause specifies that a diagnosis is applicable only when grief reactions are out of proportion, inconsistent with, or persist beyond the patient’s cultural and religious norms.”
Nevertheless, numerous developments in developing and establishing grief-specific disorders have taken shape.
Removal of Bereavement Exclusion and Addition of “Uncomplicated Bereavement” V-code
First, the bereavement exclusion was removed from the DSM-5, and a new grief-specific V-code was added. Because bereavement may often present as similar to depression and other mood disorders, the bereavement exclusion clarified that a diagnosis of depression could not be made if symptoms were better accounted for by the death of a loved one. This exclusion was removed at the time of the DSM-5 publication, and simultaneously, a new V-code was added.
V-codes refer to the Other Conditions That May be a Focus of Clinical Attention section of the DSM. In other words, these conditions are highlighted but not considered to be a disorder. The previous edition of the DSM-IV included “Bereavement” within this section. Then, the bereavement exclusion was removed, and the “Bereavement” V-code was changed to “Uncomplicated Bereavement.” Wada summarized how this seemingly minor alteration led to the formation of a new grief disorder:
“…this change simultaneously defined its mutually constitutive opposite––complicated bereavement–––as “a syndrome of intense and persistent grief that may co-occur with MDD, but is distinct from it.” This paved the way for the development of a new grief disorder category: PCBD [Persistent Complex Bereavement Disorder].”
DSM-5 Adoption of Persistent Complex Bereavement Disorder as a “Condition for Further Study”
Second, Persistent Complex Bereavement Disorder (PCBD) was adopted as a condition for further study. A DSM working group reviewed two proposals for disorders: prolonged grief and complicated grief. Wada shared that instead of selecting one of these to create a new disorder category, the group compromised on establishing PCBD as a category for further study and consideration for inclusion in forthcoming DSM editions. One proposed criterion (Criterion E) on the list of symptoms for PCBD states that “The bereavement reactions are disproportionate or inconsistent with cultural, religious, or age-appropriate norms.”
Addition of Prolonged Grief Disorder to the ICD-11
Third, the latest edition of the ICD (ICD-11), released in June 2018, added Prolonged Grief Disorder. Prolonged Grief Disorder is characterized by “persistent preoccupation with the deceased accompanied by intense emotional pain” that is not considered normative given a person’s cultural and religious context.
Proposed Prolonged Grief Disorder in Forthcoming DSM Edition
Following these developments, the American Psychiatric Association (APA) released a statement in April 2020 with proposed changes toward the addition of Prolonged Grief Disorder in the next DSM revision. The proposed change was approved by the DSM steering committee and brought together the criteria envision for PCBD (identified as a condition for further study in the DSM-5) with the ICD-11’s newly adopted Prolonged Grief Disorder.
The APA endeavored to adopt the term Prolonged Grief Disorder for the new category. In an effort to collapse these two constructs into one, a number of changes were made to change PCBD into the proposed Prolonged Grief Disorder in the forthcoming DSM edition. Wada outlined the following changes:
- “Gateway symptoms,” or core symptoms of which an individual must experience at least one, were reduced from four to two.
- The three-factor symptom structure (i.e., core symptoms, reactive distress to death, and social/identity disruption) was modified to a single-factor structure.
- The number of Criterion C symptoms (i.e., non-core symptoms) was reduced from twelve to eight, with a diagnostic threshold of three, instead of six symptoms.
However, some distinctions were maintained in the APA’s proposal for Prolonged Grief Disorder (PGD). These included, according to Wada:
- No longer requiring the person “to experience symptoms persistently, ‘more days than not,’ over that twelve-month period. Instead, symptoms must be experienced ‘nearly every day for at least the last month’ to qualify for diagnosis (APA. 2020b).”
- Whereas the ICD-11 classifies PGD under disorders associated with stress, the DSM proposal aimed to include it in the depressive disorders section.
Given the overlap between the DSM description of Major Depressive Disorder and the proposed PGD, the DSM distinguished an exclusion criterion for PGD not included in the ICD-11, which is that “the symptoms are not better explained by another mental disorder.”
Issues and Paradoxes Surrounding Recent Developments
Wada articulated unresolved contradictions and paradoxes underlying these changes, and she also delineated potential issues and consequences.
First, she outlined the debate around diagnosis inflation, given frequently cited estimates that 9-10% of bereaving individuals classify as meeting criteria for Prolonged Grief Disorder. This statistic may be compared to the prevalence rate for Attention Deficit Hyperactivity Disorder (ADHD), which has garnered concerns about overdiagnosis and overprescription, which falls between 4-7%.
Moreover, the prevalence of prolonged grief symptoms has been estimated to double in the context of mourning violent death. In the context of the COVID-19 pandemic, the APA estimated that the prevalence rate of prolonged grief would increase to as high as 20%. Wada highlighted the risk for an “epidemic” of prolonged grief diagnosing:
“Grief is undeniably palpable as the casualties of COVID-19 grows worldwide; if the APA’s estimate is accurate, the world will also see an epidemic of this new mental disorder diagnosis in the coming years.”
In addition, Wada articulated the paradox around psychopharmacological intervention that has surrounded the debate around new grief disorder categories. Although proponents of new diagnoses have argued that grief-specific categories will prevent inappropriate medicalizing of grief, Wada highlighted that there have been increased efforts to develop a psychopharmacological intervention for grief as a result of new grief diagnoses.
“The idea of a certain kind of grief experience as a mental disorder is still new to many of us, and the image of grief-stricken people being medicated may seem like scientific fiction. Yet, in the same way that few predicted the prevalent use of medication for hyperactive children three decades ago, it may not be surprising that grief management or grief reduction medication will be developed and popularized in future decades.”
Wada cautioned the reader about “concept creep,” or the expansion of a concept’s boundaries, thresholds, and meanings to encompass a broader range of phenomena—in this case, prolonged grief disorder and its accompanying criteria. She cited evidence of concept creep occurring in proposed changes for the DSM for prolonged grief, including: (1) a reduction in the number of symptoms required to meet criteria and (2) the dropped requirement of symptoms persisting to “at least the past month” instead of for “more days than not” in the 12 months following a death.
“This relaxation of the criteria leads us to question one of the possible consequences of concept creep––progressive dilution of meaning to the point of becoming preposterous. In this case, can a resurgence of intense grief for one month be considered “persistent” or “prolonged,” as the naming of the disorder categories suggest?”
Wada demonstrated that viewing grief as pathology when expressed “too much” and for too long is a newer reaction. However, throughout Western history and across time and cultures, social expectations do not reflect this more recent construal of grief. Wada cited examples from Romantic era Western Europe when brief mourning was to be avoided. Alternatively, deliberately holding onto grief and enduring emotional pain about the deceased was an honorable mark of living with a broken heart that demonstrated a moral depth, sensibility, and wisdom.
Medicalizing grief, such as establishing new diagnostic categories to capture it, implicitly constructs grief as a psychological thing. This is a relatively new phenomenon. But, as Wada described, doing so “locates grief within the prevailing discourse of a disease model, which in turn renders grief to be ‘privatized, specialized, and treated by mental health professionals.”
In contrast, other cultures maintain rituals and practices that promote continuing bonds with the deceased. Wada shared findings from one study conducted on Canadian undergraduate students in which religious women participants who had previous bereavement experience were more likely to believe that grief symptoms deemed pathological by the DSM-5 were healthy responses.
“Put differently,” Wada wrote, “the DSM-5 criteria for PCBD [Persistent Complex Bereavement Disorder] may be reflective of the normative idea of (ab)normalcy held by men, those who are secular, without previous experience of bereavement, and who think continuing bonds with the deceased is unhealthy.” Consequently, the label might function to pathologize those individuals who deviate from these values and practices.
Wada discussed the implications of relying upon modern-day Western constructs of grief and wrote that when legitimized and applied universally, it “can fundamentally change the ways people in other parts of the world construe their suffering and their place in the society, and thus their way of living.”
Proponents of grief specific disorders tend to cite the “norm-deviation clause” in the DSM—the clause that clarifies grief specific disorders ought only to be applied when grief presentations fall outside the confines of typical grief practices according to cultural and religious context—as preventing against undue pathologizing of diverse idioms of grief. However, Wada explicated numerous pitfalls to this argument.
When providers are drawing upon a checklist or descriptions of symptomatology, there is no embedded assessment of individuals’ cultural and contextual factors, nor insight into how the specific person’s grief presentation may be culturally informed. As a result, the provider is tasked with teasing apart what constitutes normal or healthy mourning.
“…. the norm-deviation clause puts a tremendous amount of weight on the clinician’s shoulders, as it expects to become sociological and anthropological arbitrators of what is normal, and to judge clients accordingly.”
This process of arbitrating normalcy is further complicated by an inevitable bias that a professional would be inclined to validate the knowledge from which they work and legitimize their role, Wada wrote:
“Medicalizing grief is intuitively attractive for grief professionals as it legitimizes their status and creates a public dependency, yet the grief profession itself may become the agent of the culture that polices grief.”
Notably, the controversy surrounding grief-specific disorders has featured numerous professional bodies and individuals resisting concept creep and other potentially harmful consequences. For example, in February of 2020, the Task Force on Diagnostic Alternatives of the Society for Humanistic Psychology (SHP, Division 32 of the American Psychological Association) released a statement that both commended efforts to improve diagnostic systems and expressed concerns that reductionist biomedical categories obscure sociostructural determinants of distress.
Wada joined these critiques to convey that these efforts reflect normative social expectations for mourning. In particular, these categories may more accurately capture what some scholars have referred to as a “happiness culture” in contemporary Western society—”striving for and return to optimal functioning is regarded as a moral duty,” Wada wrote.
Wada has put forward an argument that the trend to medicalize grief fits a pattern in popular Western culture, in which “psychiatric categories and language [are invoked] to ‘interpret, regulate and mediate various forms of self-understanding and activities.'”
She ends with what might be considered a note of cautious optimism; perhaps phenomena that become established as mental disorders may also be “depromoted, becoming a transient disorder in human history.”
“As stated in the [SHP] Task Force on Diagnostic Alternatives (2020), ‘accepted orthodoxies at any one time may be the myth of future generations.'”
Wada, K. (2021). Medicalization of grief: Its developments and paradoxes. The Palgrave Encyclopedia of Critical Perspectives on Mental Health. Preprint. 10.13140/RG.2.2.10287.46242 (Link)