After Prince Albert died in 1861, Queen Victoria spent the rest of the century in black and in despair, determinedly filling all the nation’s spare corners with statues of her beloved — so much so that by 1880 people had begun to grow sick of the sight of mustachioed bronzes. For some, her grief was perfectly natural — pious, even. Others muttered that she had psychological problems: a form of “inherited melancholy”, perhaps, passed down from George III.
How long is too long to grieve? More than a century and a half after Albert’s death, American psychiatrists have come up with an answer. A medics’ handbook called The Diagnostic and Statistical Manual of Mental Disorders (DSM) — one of two publications used to diagnose psychiatric illnesses the world over — has added a new disorder: prolonged grief. It applies to those still intensely yearning after and preoccupied by a loved one more than a year after they have died, to the extent that it interferes with normal life.
The diagnosis is controversial. Grief is natural in humans and even, apparently, in animals. Going through it is an existential and social process, and slapping a medical label on it is, some say, like trying to pathologise love. Is it ever right to call grief an illness?
The diagnosis of prolonged grief disorder has its roots in the 1990s, in research by the American psychiatric epidemiologist Holly Prigerson. She found that while most people started to recover after about six months, a small group — about 4 per cent — were stuck in it for the long term.
The symptoms were different from depression, Prigerson proposed: there were usually no feelings of worthlessness, for example. Instead, it was defined by pining and craving, numbness and the feeling of having lost part of yourself. More recent studies have added to the description of the illness: sufferers can feel a physical aching for the lost person and may obsessively visit their grave or listen to recordings of their voice again and again. While the same person can be both grieving and depressed, clinical trials have found therapies that treat grief as a distinct entity — more like a stress disorder than a form of depression — have been effective.
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But not everyone in the field of mental health thinks the new diagnosis is helpful. “The risk is that if someone is told they have prolonged grief, they will use it as a stick to beat themselves with and will end up feeling even more stuck,” says Julia Samuel, a psychotherapist and author of Every Family Has a Story: How We Inherit Love and Loss. “You might think, ‘This is who I am now,’ and imprison yourself in the diagnosis.” Samuel worries sufferers might stop trying to make themselves better with non-medical interventions such as seeing friends and exercising.
“Another risk of a medical diagnosis is that other people might stay away, worried that if they don’t say the right thing they’ll make you worse. The word ‘disorder’ is so pejorative: it tells you you’re not coping, and it tells others they’re not qualified to help.”
Critics of the DSM’s definition say that, as grief is different for everyone, there can be no clear line separating “disordered” mourners from the rest.
Some, like Samuel, fear a diagnosis could make things worse for the sufferer, producing stigma and perhaps even pushing people towards unnecessary medication. The official diagnosis allows US clinicians to charge patients’ insurance companies for treatment and opens a potentially lucrative field for drug companies (naltrexone, a drug used in addiction to block the effects of opioids, is being tested as a treatment for grief).
Lucy Foulkes, an honorary lecturer in psychology at University College London and author of Losing Our Minds: What Mental Illness Really Is — and What It Isn’t, thinks that while there are benefits to the new diagnosis, it could be swept up in an unhelpful trend. “In cultural conversation we have expanded lots of medical definitions to include normal human emotions. PTSD, OCD, depression, bipolar disorder: these are now being co-opted by people who don’t need the diagnosis. It almost doesn’t matter what careful criteria you write in the DSM — once you unleash the idea of prolonged grief into popular consciousness, people will start to diagnose themselves.”
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But those who support the DSM’s decision emphasise the seriousness of the illness, which can lead to suicide, and the fact that treatments exist and have been proven to help. “There’s always a danger people will mistakenly diagnose themselves with any illness,” says Jennifer Wild, a consultant psychologist at Oxford University. “They can always go to a doctor and get a proper assessment.”
Prolonged grief, she argues, is not “natural” — it could be a hijacking of the natural grief process, the point at which it “gets stuck”. She says it is clear something is wrong with these patients, and if we don’t “medicalise” them with the right label, they will be slapped with the wrong one. “We see a lot of prolonged grief disorder in our patients who have been referred for PTSD or depression,” Wild says.
Foulkes sees a way through the debate. “Whether we call it a mental illness or not, the key thing is to recognise that some people are still suffering very badly a long time after a bereavement. And we should help them where we can.”
