Department of Psychiatry, Yale University School of Medicine, New Haven, CT.
J Psychiatr Pract. 2024 Jul 1;30(4):292-296. doi: 10.1097/PRA.0000000000000792.
There has been an ongoing debate regarding grief, whether it may be at times pathological, and whether it is different from depression. This article addresses those questions by tracking the changing course of the Diagnostic and Statistical Manuals of Mental Disorders (DSMs) since DSM-III and by reviewing the debate concerning grief and depression. At the time when DSM-III was being prepared in the late 1970s (it was published in 1980), there was a concern that normal bereavement (or grief) was being diagnosed as major depression. To address this concern, the editors of DSM-III added a category of "uncomplicated bereavement." The fourth edition of the DSM (DSM-IV), published in 1994, then followed by a minor change. However, the editors of DSM-5 decided to eliminate the bereavement exclusion entirely. Their concern was simply whether the individual did or did not suffer from major depression. Since an individual might not warrant a diagnosis of major depression but might still be experiencing grief, the DSM discussion leads directly into the question of whether grief-later called prolonged grief disorder-and depression are separate conditions. Advocates for prolonged grief disorder maintained that grief is different from depression but that patients may present with a mix of grief and depressive symptoms that are clinically difficult to distinguish. Advocates of separate conditions have in fact developed an inventory of symptoms that identify prolonged grief disorder. However, inasmuch as a typical grief presentation will include depressive symptoms, the clinical challenge is to distinguish prolonged grief disorder and major depression, as well as to distinguish both from normal grief. Given the temporal limits of an average consultation, this article argues that making the required distinctions is an unrealistic expectation. Finally, researchers have developed specific treatment programs for prolonged grief disorder, but a conflict between the 2 primary researchers involved and the generalities in which the programs are phrased have led to the suggestion of a different approach to treatment that replaces generalities with a person-centered approach.
关于悲伤是否有时是病态的，以及它是否与抑郁症不同，一直存在着争论。本文通过跟踪自 DSM-III 以来《精神障碍诊断与统计手册》（DSM）的变化过程，并回顾关于悲伤和抑郁的争论，来回答这些问题。在 20 世纪 70 年代末编写 DSM-III 时（1980 年出版），人们担心正常的丧亲之痛（或悲伤）被诊断为重度抑郁症。为了解决这个问题，DSM-III 的编辑们增加了一个“单纯丧亲”的类别。DSM 的第四版（DSM-IV）于 1994 年出版，随后进行了一些小的修改。然而，DSM-5 的编辑们决定完全取消丧亲之痛的排除。他们关心的只是个人是否患有重度抑郁症。由于一个人可能没有资格被诊断为重度抑郁症，但仍可能在经历悲伤，DSM 的讨论直接引出了悲伤——后来被称为延长悲伤障碍——和抑郁症是否是两种不同的疾病的问题。延长悲伤障碍的倡导者认为，悲伤不同于抑郁症，但患者可能同时出现悲伤和抑郁症状，临床上很难区分。分离条件的倡导者实际上已经开发出了一套可以识别延长悲伤障碍的症状清单。然而，由于典型的悲伤表现会包括抑郁症状，临床挑战是区分延长悲伤障碍和重度抑郁症，以及将它们与正常悲伤区分开来。鉴于平均咨询时间的限制，本文认为做出所需的区分是不现实的。最后，研究人员为延长悲伤障碍开发了特定的治疗方案，但涉及的两位主要研究人员之间的冲突以及方案中表述的一般性问题导致了一种不同的治疗方法的建议，即用以人为主导的方法取代一般性方法。
