Think back to the last time you suffered a major loss — particularly the death of a friend, loved one, or family member. You were knocked for a loop, of course. You cried. You felt a piercing, painful sense of loss and longing. Maybe you felt like the best part of you had been ripped away forever.
You probably lost sleep, and didn’t feel much like eating. You may have felt this way for a few weeks, a few months, or even longer. All this belongs to the world of ordinary bereavement — not of clinical depression.
Yet the two constructs of “normal grief” and major depression are a source of continued controversy and confusion — and not just among the general public.
Many clinicians still find it hard to disentangle grief and depression, inspiring countless debates over “where to draw the line” between normality and psychopathology.
But the problem is not one of “fuzzy boundaries.” Grief and depression occupy two quite different psychological territories, and have vastly different implications with regard to outcome and treatment.
For example, ordinary grief is not a “disorder” and doesn’t require treatment; major depression is, and does. Unfortunately, the inner worlds of grief and depression are hardly glimpsed in the symptom check lists of our present diagnostic classification, the DSM-IV. And, alas, it’s not clear that the DSM-5 will bring great improvement in this regard.
What is Grief Anyway?
The classic studies of bereavement, performed by Dr. Paula Clayton in the 1970s, made it clear that some depressive symptoms were often present early in the course of grieving, sometimes lasting several months after the death of a loved one. Indeed, sadness, tearfulness, sleep disturbance, decreased socialization, and decreased appetite are features seen in both normal, adaptive grief and in major depression — sometimes confusing the diagnostic picture.
Clinicians therefore look at other “objective” features of the patient’s presentation to help make the diagnosis. For example, in ordinary bereavement, the grieving person is generally able to carry out most activities and obligations of daily living, after the first two or three weeks of grieving. This is not usually the case in episodes of severe major depression, in which social and vocational functioning is markedly impaired for many weeks or months. Moreover, early morning awakening and pronounced weight loss are more common in major depression than in n uncomplicated bereavement.
But by themselves, observational data do not always distinguish ordinary grief from clinical depression, especially during the first few weeks of bereavement. Accordingly, my colleague, Dr. Sidney Zisook, and I have tried to describe the phenomenology or “inner world” of grief, as distinct from that of clinical depression. We believe that these experiential differences provide important diagnostic clues.
Thus, in major depression, the predominant mood is sadness tinged with hopelessness and despair. The depressed person often feels that this dark mood will never end—that the future is bleak, and life, a kind of prison-house. Typically, the depressed person’s thoughts are almost uniformly gloomy. If an optimist sees life through rose-colored glasses, the depressed person sees the world “through a glass darkly.”
The writer William Styron, in his book, Darkness Visible, describes depressed individuals as having “their minds turned agonizingly inward.” Their thoughts are almost always focused on themselves — usually in a self-negating way. The severely depressed person thinks, “I am nothing. I am nobody. I am rotting away. I am the worst sinner that ever walked the face of the earth. Not even God could love me!”
At times, these nihilistic thoughts reach delusional proportions — so-called psychotic depression. And, despite the best efforts of friends and family to “cheer up” their depressed loved one, the sufferer is often inconsolable. Neither love, nor riches, nor the blessings of art and music can penetrate the core of despair. Suicide becomes an ever more tempting option—and often, the only option the sufferer can imagine.
The Inner World of the Bereaved
The inner world of the bereaved is unquestionably one of loss and sadness, but it differs in crucial ways from that of the depressed. In depression, sadness is constant and intractable; in bereavement, it is intermittent and malleable. The bereaved individual typically experiences sadness in “waves”, often in response to some reminder of the deceased. Usually, painful recollections of the loved one are interspersed with positive thoughts and memories. Unlike the seriously depressed person, the grieving individual usually feels that life will someday get back to “normal”, and that she will once again feel like her “old self.” Suicidal intentions are rarely present, though the bereaved may fantasize about “joining” or “reuniting” with the deceased.
Unlike the severely depressed person — alone on an island of self-loathing — the bereaved person usually maintains her self-esteem, as well as an emotional connection with friends and family. Perhaps the hallmark of ordinary grief, as psychologist Kay Jamison has noted, is the ability to be consoled. Indeed, in her book, Nothing Was the Same, Jamison astutely distinguishes between the grief she felt after the death of her husband, and her frequent periods of severe depression.
“The capacity to be consoled,” she writes, “is a consequential distinction between grief and depression.” Thus, during her bouts of major depression, poetry was of no consolation to Jamison; whereas during her grief, reading poetry was a source of comfort and solace. Jamison writes: “It has been said that grief is a kind of madness. I disagree. There is a sanity to grief… given to all, [grief] is a generative and human thing…it acts to preserve the self.”
Since they are distinct conditions, grief and major depression can occur together, and there is clinical evidence that concurrent depression may delay or impair the resolution of grief. Contrary to widespread claims in the media, the DSM-5 framers do not want to limit “normal grief” to a two-week period — which would be foolish, indeed. The duration and intensity of grief is extremely variable, depending on a variety of personal and interpersonal factors. Research by Dr. George Bonnano has found that after the death of a spouse, chronic grief was associated with pre-loss “dependency” upon the deceased spouse. In contrast, more resilient subjects showed less interpersonal dependency, and greater acceptance of death. Resiliency was by far the most common pattern observed, with most of the bereaved showing a return to relatively normal functioning within 6 months of the loss.
What are the implications of all this for the DSM-5? I believe that symptom check lists alone provide only a narrow window into the patient’s inner world. The DSM-5 should provide clinicians with a richer picture of how grief and bereavement differ from major depression — not just from the observer’s perspective, but from that of the grieving or depressed person. Otherwise, clinicians will continue to have difficulty distinguishing depression from what Thomas a Kempis called, “the proper sorrows of the soul.”
Acknowledgments: Thanks to Dr. Sid Zisook for his comments on this piece, and to Drs. Charles Reynolds and Katherine Shear for their important research contributions.
For Further Reading:
Bonanno, G. A., Wortman, C. B., Lehman, D. R. et al: Resilience to loss and chronic grief: A prospective study from pre-loss to 18 months post-loss. Journal of Personality and Social Psychology, 2002;83: 1150-1164.
Jamison KR: Nothing Was the Same. Vintage Books, 2011.
Pies R, Zisook S: Grief and Depression Redux: Response to Dr. Frances’s “Compromise” Psychiatric Times Sept. 28, 2010. Accessed at: http://www.psychiatrictimes.com/dsm-5/content/article/10168/1679026
Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008; 3: 17. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442112/
Zisook S, Shear K: Grief and bereavement: what psychiatrists need to know.
Zisook S, Simon N, Reynolds C, Pies R, Lebowitz, B, Tal-Young, I, Madowitz, J, Shear, MK. Bereavement, Complicated Grief, and DSM, Part 2: Complicated Grief. J Clin Psychiatry. 2010;71(8): 1097-8.