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Comments on Diagnosis Including Symptoms of Turbulent Grief

To the Editor: I was very pleased to read the study by Mardi J. Horowitz, M.D., and colleagues (1) investigating a new diagnosis to include symptoms of turbulent grief. We need a better, deeper, and fuller understanding of the grief process. This well-designed study has already contributed to our appreciation of the specific features of grief in contrast to depressive diatheses. I would, however, like to challenge the criteria upon which the authors base their recommended diagnosis.The authors hinge their phenomenological findings on a 14-month time period for grieving spouses. In my clinical experience, the duration of grief reactions does—and should—vary widely depending on the nature of the loss and the connection to the deceased. A parent grieving over the loss of a child may have "unbidden memories" and many of the other "complicated grief" symptoms (2) for many months past 14 without their necessarily indicating a pathological process. Indeed, we would be troubled were it otherwise. On the other hand, these same symptoms significantly present even 1 year after the death of a distant, elderly, and unfamiliar relative would be highly suggestive of pathology (3).

Is it possible to create a diagnosis that reasonably encompasses such a highly individualized process? It behooves us to do so if classification leads to improved study, easier access to treatment, and greater appreciation of this universal inevitable human experience. Such a diagnosis becomes problematic if it encourages judgment, pathologizes an individual's struggle, and leads to alienation just when connection is most needed. One solution is to define grief as complicated only when it leads to severe, consistent, and ongoing dysfunction in conjunction with the identified behaviors and mental phenomena.

Our society is actually unique in requiring its denizens to grieve in compartmentalized, constrained ways. In Rwanda, where children die far more frequently than in America(4, 5), "complicated grief" would be an unnecessary diagnostic category, not because Rwandan parents are "used to it" but rather because their society incorporates a support system that allows for extensive open grief and thereby facilitates deeper resolution and better functioning. This helps us to see that people who are significantly grieving warrant treatment and that treatment can help them, even when their condition does not warrant a diagnosis.

REFERENCES

1. Horowitz MJ, Siegel B, Holen A, Bonanno GA, Milbrath C, Stinson CH: Diagnostic criteria for complicated grief disorder. Am J Psychiatry 1997; 154:904–910[Abstract]
2. Eisenbruch M: Cross cultural aspects of bereavement: a conceptual framework for comparative analysis. Cult Med Psychiatry 1984; 8:283–309[Medline]
3. Eisenbruch M: Cross cultural aspects of bereavement: ethics and cultural variations in the development of bereavement practices. Cult Med Psychiatry 1984; 8:315–347 [Medline]
4. Knapp RJ: Beyond Endurance: When a Child Dies. New York, Schocken Books, 1986
5. Shapiro E: Grief as a Family Process. New York, Guilford Press, 1994

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