Is Emotional Pain Necessary? Traditionally, the American Psychiatric Association's manual of mental disorders has warned doctors away from diagnosing major depression in people who have just lost a loved one. The idea was that feelings of intense pain were normal, so they shouldn't be labeled as a mental disorder. Now, the group is changing those guidelines.

Is Emotional Pain Necessary?

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On a Monday morning, it's MORNING EDITION from NPR News. I'm Steve Inskeep.


And I'm Renee Montagne.

INSKEEP: The idea has been that feelings of intense pain are normal, so they shouldn't be labeled a mental disorder. Now, the new manual coming out is making a controversial change, as NPR's Alix Spiegel reports.

ALIX SPIEGEL: In the winter of 1992, Theresa Smith took her 14-month-old daughter, Scarlett, to Arizona for an extended family visit. And one night, as they headed for bed, Theresa's mother made a declaration. She would watch the baby the next morning. Theresa should take the day for herself.

MONTAGNE: That morning, my mother was busy. She was doing some stuff with lawyers in New York. She was - had a restaurant or something, and she was irritated. And I said, Mom, I said, let me take Scarlett with me. I said, it's no problem. And then she stopped what she was doing and she goes, oh, no, no, no, no. We're going to be just fine, we're going to be just fine.

SPIEGEL: But they weren't just fine. Later that morning, Scarlett accidentally fell into a swimming pool. She drowned. Scarlett was Theresa's only child - literally, the center of her life. And so the months that followed were close to unbearable.

MONTAGNE: The nights. At one point, I wanted to smell Scarlett, and I looked - and I went around the apartment and I looked for her fingerprints, little spots where she spit up milk. I just looked for her everywhere.

SPIEGEL: During those months, Theresa says she cried every day. She considered suicide. And though she went back to graduate school, she found it hard to focus. She says she went to the cemetery every single night.

MONTAGNE: I would bang my head against her headstone until my face was all bloody. And I would lay there, and I would cry all night. And it got to the point where one of my friends, her husband had a restaurant in town, and she would call. And she goes, when you close up, go to the cemetery and get Theresa, and take her home.

SPIEGEL: Today, Theresa is doing well - very well. And she says she has no regrets about the pain that she went through.

MONTAGNE: It's a normal process of letting go of your child.

SPIEGEL: And do you think what you went through is normal?

MONTAGNE: Yeah. Yeah. I mean, it was hard and it was crazy, but it's okay. It's grief. You've got to go through all of this.

SPIEGEL: So what, in Kendler's view, is grief?

D: Typically, modest amounts of upset are fairly common, sometimes difficulty sleeping, crying over memories of the loved one.

SPIEGEL: People in grief, Kendler says, also often lack concentration. They lose sleep, lose appetite, lose energy. Now, I will tell you that these symptoms are also all symptoms of depression. So what's the difference between depression and grief, in Kendler's view? The symptoms of grief are much less severe, he says. And also, according to Kendler, in normal grief, acute pain doesn't last that long.

D: Usually for days at a time, not for weeks. For a few days of acute upset, and then a much longer period of the longing, the tearfulness. But typically sleep, appetite, energy, concentration come back to normal more quickly than that.

SPIEGEL: But Holly Prigerson, a researcher at Harvard who studies bereavement, says that while there's no good research on what percentage of people will meet the criteria for depression after a loss, it's clear that most experience depressive symptoms far beyond two weeks.

D: What we found is that when you follow people, their depression symptom levels actually increase over time, and peak at about six months post-loss.

SPIEGEL: And because grief and depression look so much alike, Prigerson says she worries that people who are suffering from normal grief will be told that they are sick when they are not, and encouraged to treat their symptoms when they don't need to - which is potentially a problem, Prigerson says, because of the following...

D: We don't know if the pain of normal grief actually helps people in some way to process their loss. What underlies a lot of this discussion is: Is it harmful to interrupt a normal grief process by medicating?

SPIEGEL: Ken Kendler says no.

D: Early on, there used to be the thought that there was this grief work, and that if you did not demonstrate lots of upset acutely after someone died, that later on there would be more distress. Research has shown clearly that that concept is false.

SPIEGEL: But Prigerson doesn't agree that the research is that clear.

D: I don't think we have the data to answer that. I think the jury's out.

SPIEGEL: But to Sid Zisook, one psychiatrist who's argued for removal of the bereavement exclusion, this academic question doesn't matter. The dangers of depression, he feels, are perfectly clear.

D: I'd rather make the mistake of calling someone depressed who may not be depressed, than missing the diagnosis of depression, not treating it, and having that person kill themselves.

SPIEGEL: And just because pain after loss is normal, he says, doesn't mean you shouldn't treat it. Broken bones are painful, he points out.

D: It's a normal consequence of breaking a bone. But it doesn't mean we don't treat the pain. We treat the pain vigorously.

SPIEGEL: Allen Frances is a famous psychiatrist, a former editor of the Diagnostic and Statistical Manual. And he says more and more, psychiatry is medicalizing our experiences, turning emotions that are perfectly normal into something pathological.

D: Over the course of time, we've become looser and looser in applying the term mental disorder to the expectable aches and pains and sufferings of everyday life.

SPIEGEL: This perspective is also shared by Theresa Smith, the woman who lost her daughter close to 20 years ago.

MONTAGNE: I grieved her just as hard as I loved her. I had to. It wouldn't have meant anything if I hadn't.

SPIEGEL: Alix Spiegel, NPR News, Washington.


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