Posts Tagged 'classification'

Grief Is Not Depression

Last week some commotion arose over how grief – bereavement, mourning, feelings of loss – is treated in the concept text of the DSM-V. This is going to be the successor to the DSM-IV, the formal American Diagnostic and Statistical Manual of Mental Disorders. The new version 5 will be published in its final form by APA (the American Psychiatric Association) next year.

    The DSM is used by many professionals (not just in the US) as the defining, authoritative diagnostic handbook. Version 5 is eagerly awaited because the last official version dates from 2000, and is considered outdated in some respects.

Demeter Mourning For PersephoneMany critical commentaries cropped up because last week it became clear that the new DSM concept text, unlike the old one, no longer makes a clear distinction between severe grief and depression (major depressive disorder).

    The result of this omission is that in a case of bereavement after the death or departure of a loved one, if you for longer than a couple of weeks continue to suffer from feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, this natural mourning process could be diagnosed as depression.

    Worse, this mourning process might on the basis of such a diagnosis be treated with antidepressants in order to suppress the above-mentioned symptoms, instead of letting it run its natural course.

    A natural process of coping with loss and grief usually runs through several phases, from initial shock and denial to eventual acceptance. Such a process as a whole can often take over a year but in the end, for most of us it will be healing: you may even emerge from it as a stronger, more stable person than you were before.

Kubler-Ross DiagramEven though during some phases the symptoms of such a mourning process may look very much like the symptoms of depression, it would be plainly unwise to immediately start treating it medically in the same way as depression. This would in fact mean disturbing and preventing something that works as a natural healing process.

    This criticism on the new DSM approach was expressed very emphatically last week in a brief editorial Living with Grief in the prominent American medical journal The Lancet. The article strongly opposes the notion that grief could (or should) be classified as a form of illness. Of course sometimes depression can develop from too-prolonged grief, but this is not the usual case.

A few quotes from The Lancet:

    “Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated.”

    “Bereavement is associated with adverse health outcomes, both physical and mental, but interventions are best targeted at those at highest risk of developing a disorder or those who develop complicated grief or depression, rather than for all.”

    “Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one.”

    “For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.”

    Because I fully agree, I have nothing to add here. Except that I hope that all these critical reactions will succeed in putting a halt to the unfortunate, unwarranted, and counterproductive medicalizing of normal emotional reactions.

    Time for a different note. How would grief sound if it were music? Here is one of many efforts to catch it: “Grief” from the 1998 album Mesh & Lace by the group Modern English. A near-endless instrumental, but with song lines emerging at the end.
 

 
Modern English – Grief

For a full StayOnTop playlist, see the Music page


 tip: If you can clearly see an obvious primary reason why you feel intensely depressed, then ask yourself if your depression isn’t just grief.
    In that case, try to understand that while a road of depression may run in circles, the tortuous road of grief will in the end nearly always get you somewhere.


 

Classifying Depression

[...] not yet recovered from a horrible week. You will understand that some posting-gaps may be unavoidable when depressions keep knocking me out. So what happened to me this time? To answer that question, maybe we should classify first: what kind of depressions or moods we are talking about? By the way, don’t look too long into the symbolic black vortex below. It will make you dizzy. It may suck you in.

Black HoleBack to classification. Standard schemes are of little use to us here. Maybe you know about the Bible of formal, accepted psychiatry: DSM-IV-TR. The Diagnostic and Statistical Manual of Mental Disorders (DSM) in its fourth edition (IV), last text revision (TR). Basically, for major non-bipolar depressions the DSM-IV lists the following five subtypes:

    1. Melancholic (apathetic, underreacting)
    2. Atypical (sensitive, overreacting)
    3. Catatonic (mute, stuporous)
    4. Postpartum (after giving birth)
    5. Seasonal (recurring in autumn-winter).

As you see, this list has a fundamental flaw. It is inconsistent. Numbers 1, 2 and 3 are based on criteria of mood and behavior: on the symptoms a depressive patient will show. Numbers 4 and 5 on the other hand are based on situational criteria: on the circumstances of a depressive patient. This makes these types rather arbitrary – we might just as well add an unlimited score of more situational depression varieties:

    6. Geriatric (at age 70+, especially in homes for the elderly)
    7. Alcoholic (recurring with the mornings-after)
    8. Inmatic (after being locked away in prison) –

and so on. But because all such situational varieties will show symptoms of either 1, 2 or 3 (Melancholic, Atypical, or Catatonic) this effectively leaves us with only those three as the different kinds of depression. In essence all three are modes of reacting to stimuli from outside, in three different patterns: underreacting, overreacting, or not reacting at all. For me, this is too thin. Therefore, let’s try something different.

    If we were to focus more on feelings instead of reaction modes, could we link different kinds of depression to different emotions? The most common shortlist of basic human emotions always comes up with the following sixpack:

Emotions Cocktail    1. Sadness
    2. Joy
    3. Anger
    4. Fear
    5. Love
    6. Surprise

Before you ask, yes I could certainly couple depression types to each of them: for example a Love-depression might torment you with the feeling that you really don’t deserve the love you give and get.

    Anyway, this list of feelings is not quite right, too. Sadness is the opposite of Joy. But the other ones are no opposing pairs. If Anger is the negative emotional reaction to someone else’s behavior, then where is its opposite? Shouldn’t that be something like Approval or Gratefulness? The opposite of Fear would be something like Courageousness or Boldness. The opposite of Love is missing here too: Hate. And what about Surprise? Unlike the other ones, this is not something that can last on its own, for hours or days or years. Surprise is a momentary reaction, not an emotion.

    In short, this list is inconsistent too. It also misses a few essential feelings: for example Indifference, which in my view should count as a true emotion or feeling in its own right: one that plays a very important role in some kinds of depression. Or another example, Hope? Why is Hope not in this shortlist of “basic emotions”?

    Sigh. All this gets us nowhere. Maybe we should try a color scheme. Yes, really. Apart from White and Black, the three primary colors are Red, Green and Blue. Depending from how we mix them, we can get endlessly more shades, such as cyan or violet. Now if we limit ourselves to 10 basic colors, we might link them to 10 different types of depression:


  1. White Depression
  2. Pink Depression
  3. Red Depression
  4. Orange Depression
  5. Brown Depression
  6. Yellow Depression
  7. Green Depression
  8. Blue Depression
  9. Gray Depression
10. Black Depression

I am the first to admit that this list is even more arbitrary than any other possible list.

    But to me, at least today, it makes some sense. Because now I can simply tell you this: over a week ago, my lapse started with a tsunami of Blue Depression that confined me almost paralyzed to my bed. This gradually became a seemingly endless state of Black Depression, pondering failure and death and more, which briefly got mixed with some razor sharp episodes of Yellow Depression when unexpectedly some friends visited me and I felt acutely how I would never ever fit in. Today, I first landed in an absolutely terrifying episode of Gray Depression where nothing mattered anymore, nothing at all, no matter whether I looked at the walls or the floor or out of the window. Writing this dull silly post late at night I still do feel terrible, but it has become more an Orange Depression now, one that has me forcing myself to do all those pointless things that I feel will be no help anyway, that will not help me at all. See?

    At least this color comparison may have helped me a little to find words for the inexplicable moods that like an unstoppable train railed and still rail over my nearly-dead-feeling self.

    I am afraid that for today, this is all I can produce by way of positive thinking. Next time better? If there is a next time, yes. I just cannot feel entirely sure at this moment.


 tip: Any time you see a list classifying something, from a list of feelings to a list of IKEA furniture, don’t take it as is.
    Try to come up with an alternative list of your own, classifying the same in a very different way. This may help you see some little things you wouldn’t have noticed otherwise.


 


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