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Grief or Depression? How to Tell When Grieving Goes Too Far. Part 2

by on Sep.02, 2011, under Grief & Coping

If — to use a bit of psychoanalytic jargon I should probably not entitle myself — the internal “object representation” of the lost person is “ambivalently held,” in other words, too equally constituted of love and anger, that anger can turn against the self. Once thought to be the psychological basis of depression, “anger turned inwards” still bears on some differences between depression and normal grief. For example, the depressed person, more than the person bereaved, may show signs of self-hatred, such as inappropriate and excessive guilt, loss of self-esteem, or feelings of worthlessness.

Let me hasten to return to the more familiar territory of diagnostic criteria.

Depression, when used in a clinical sense–not as a mood state almost everyone experiences from time to time, but as a syndrome of symptoms constituting a treatable mental disorder–can fall under a few different diagnostic headings.

The classic category of clinical depression is that of Major Depression, defined according to the Manual as the coexistence of multiple symptoms persisting day after day, for much of each day, over the course of at least a couple weeks. Some of the symptoms listed in the diagnostic criteria for Major Depression include changes common to both grief and depression: most notably, that of persistently depressed, sad mood, and preoccupation with thoughts of death. But also included among these criteria are symptoms more characteristic of pathological depression than normal grief: suicidal ideation, inability to make decisions, loss of the ability to enjoy anything.

The Manual goes a step further, to set a time limit of two months for a collection of depressive symptoms attributable to bereavement alone. This does not mean that the grieving process must normally end in two months, but that grief alone can result in many symptoms of an otherwise diagnosable clinical depression, for up to two months before raising the question of some more pathological process underlying this syndrome. At the same time, it is noted that certain features, when associated with the depressive syndrome, may call for earlier diagnosis and treatment-features such as suicidality, psychosis (loss of contact with reality), or inability to function.

In other words, the number of symptoms alone cannot make the differentiation between depression and normal grief, though the urgent nature of certain symptoms may make the early diagnosis and treatment of depression more defensible, even within a few weeks of bereavement.

The key elements in deciding when the grieving process has gone too far, justifying psychiatric evaluation and perhaps treatment are the simultaneous occurrences of multiple symptoms and their persistence, day after day, much or all of each day, for weeks or months after the loss-though for less time if present to an extent that impairs ability to function, impedes contact with reality, or creates suicidal risk.

Personal understanding of where this line, vague though it may be, is drawn by psychiatrists between grief and depression, gains added importance when we give thought to a few cautions.

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