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Crazy Sad

The madness of pathologizing grief.

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Somewhere in the room we never go in is an old copy of Where The Wild Things Are, on which Max—the Max who was my son, who died in 2008—taught himself to read before he was 3. I hadn’t thought about the book for years, but last week when I read the obituary of Maurice Sendak, memories of reading to my son, and my pride and amazement when I realized he was reading it by himself, came flooding back. These were accompanied by “intense yearning” for him, “intense sorrow and emotional pain,” and “intense anger over the loss.” Since I feel that way at least once every day, it appears I could be suffering from what the American Psychiatric Association may soon stamp as an “adjustment disorder.” See you at the clinic, Joan Didion.

Every decade or so, the APA revises its Diagnostic and Statistical Manual of Mental Disorders, redrawing lines between normality and pathology. The next version, DSM-5, is due in 2013, and the proposed changes (online at dsm5.org) are even more controversial than usual. One of them deals with the treatment of grief-related depression. Until now, psychiatry has acknowledged that, within limits, symptoms of depression after the death of a loved one are part of the human condition. Accordingly, in its definition of “major depressive disorder” the existing DSM incorporates a “bereavement exclusion.” In the proposed new version, this is replaced by an ambiguously worded footnote. “People who have depressive symptoms as part of their grief will now be diagnosable with a mental disorder,” says NYU professor Jerome Wakefield, a leading opponent of the change, “and ­potentially be the target of treatments that they don’t need.” The revision could affect as many as 4 or 5 ­million people each year.

A similar change has been made to the diagnosis of “adjustment disorder.” The draft creates a new category of “adjustment disorder—­related to bereavement,” whose wording is so broad that it’s hard to imagine who might not be covered. Depression has strict diagnostic criteria, but this, Wakefield says, “is the first time that grief feelings—not depressive symptoms—have been pathologized. Practically everyone who is grieving will fall under this. They’re transforming our relationship to grief.”

Most of the research on bereavement deals with the death of a spouse. I have no experience of that loss, so perhaps a limit of twelve months, beyond which DSM-5 would say normal bereavement turns into an “adjustment disorder,” makes sense. But the proposal makes no explicit distinction between that commonplace event, which everyone who is married must at least contemplate, and the earth-shattering death of a child. After Max died, friends would say they couldn’t imagine what it was like for me, to which I would often ­respond: “Yes, you can. Anyone who has a child can imagine it.” But now I’m not so sure, since it appears that professional psychiatrists are having trouble doing so. Let me put this another way: If you don’t experience “intense yearning or longing” ... “on more days than not” for more than twelve months after the death of your own child, if you don’t have “a diminished sense of self,” you have a problem that goes deeper than anything contemplated in the DSM. There are some things in life to which one should never hope to become adjusted.

Have good intel? Send tips to intel@nymag.com.


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