point of view

From Context to Phenomenology in Grief Versus Major Depression Ronald Pies, MD

“There is a sanity to grief…given to all, [grief] is a generative and human thing…it acts to preserve the self.” — Kay Redfield Jamison, PhD, Nothing Was the Same

Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. At presentation he says, “I feel down in the dumps and weepy every day, Doc — really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV.

I wake up at 4 in the morning almost © Shutterstock every day, and I have zero energy. I can’t keep my mind on anything. I self, pay the bills, and so on, Doc, but ment after the death of a loved one. barely eat, and I’ve lost 10 pounds I’m just going through the motions. I Notwithstanding the tragic blow Mr. since Mary passed away. I hate being don’t enjoy life at all anymore.” Smith has suffered, experienced cli- around other people. Sometimes I Of course, you would want more nicians will be very concerned about feel like I didn’t really do enough for detailed information regarding Mr. a patient presenting with this picture. Mary when she was sick. God, how Smith’s mental status exam, personal Mr. Smith easily meets symptom and I miss her! I can still cook for my- and family history, etc, but how you duration criteria for MDD in both the would conceptualize his situation, Diagnostic and Statistical Manual Ronald Pies, MD, is Professor of Psychi- knowing only the information pro- of Mental Disorders, fourth edition atry, SUNY Upstate Medical University, vided might lead you to conclude (DSM-IV) and fifth edition DSM-5)( . Syracuse, New York; and Clinical Profes- that Mr. Smith merits a diagnosis of A previous bout of MDD in his his- sor of Psychiatry, Tufts University School major depressive disorder (MDD); or tory would strengthen the likelihood, of Medicine. that he has a condition “resembling” as would several other clinical find- Address correspondence to: Ronald MDD, but “not really” MDD. Per- ings I have omitted. Pies, MD, SUNY Upstate Medical Universi- haps you would conclude he shows And yet, according to DSM-IV ty, 301 Psychiatry and Behavioral Scienc- normal “non-disordered sadness” in criteria, Mr. Smith probably would es Building, 713 Harrison Street, Syracuse, the context of recent bereavement. not be diagnosed with a major de- NY 13210; email: [email protected]. This hypothetical highlights the pressive illness. He would simply Disclosure: The author has no relevant controversy surrounding the con- be called “bereaved” because he is financial relationships to disclose. struct of depression and its relation- still within the 2-month period that doi: 10.3928/00485713-20130605-09 ship to the “normal” grief of bereave- allows for use of the bereavement

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exclusion (BE); and because, based or “mimics” mania, but is not “really” ly “resembles” MDD but is in fact solely on the facts presented, Mr. mania, based on the “context” of re- “something else.”) On the contrary, Smith lacks the features that would cent cocaine use. It actually might be the preponderance of clinical data “override” use of the BE, such as se- a legitimate example of a “false posi- strongly suggest that BRD does not vere functional impairment, suicidal tive” for mania, but in this scenario, we differ in any clinically important ideation, psychosis, morbid preoc- have good and sufficient medical rea- respects from non-BRD that meets cupation with worthlessness, or ex- sons, based on thousands of cases of DSM-IV symptom and duration treme guilt. Ironically, and paradoxi- cocaine-induced “manic-like” states, criteria for a major depressive epi- cally, if Mr. Smith’s wife had left to say that the “context” is critically sode.2,3 him for another man 3 weeks prior to important in rejecting a diagnosis of As to the claim that Mr. Smith is presentation, he would, in fact, meet bipolar disorder. Indeed, the cocaine merely showing “normal, non-disor- DSM-IV MDD criteria. use makes it quite “understandable” dered sadness,” this, too, requires a Some might argue that whereas that the patient developed manic-like demonstration that individuals like Mr. Smith’s clinical picture “re- symptoms. However, that does not Mr. Smith show no greater morbidity sembles” an episode of MDD, it is, render the manic-like symptoms a or mortality than the average “sad” in some sense, “not really” MDD. “non-disordered” state; nor would any or grieving person who does not But, absent empirical data, the notion physician opine, “Well, anyone would meet DSM-IV symptom and duration that his picture merely “resembles” have become manic under those con- criteria for MDD, but, to my knowl- major depression amounts to a kind ditions — that’s just normal!” edge, no empirical studies have dem- of metaphysical claim: it seems to But now, returning to Mr. Smith: onstrated this. posit an entity — let’s call it “not re- Are we justified in saying that his ally MDD” — that “mimics” a ma- condition is a non-disordered state “DISORDER” IN PSYCHIATRY AND jor depressive episode but is, in some because it occurred in the entirely GENERAL MEDICINE unspecified sense, another condition. “understandable” context of be- I believe these considerations A very rough analogy would be the reavement? In short, does Mr. Smith lead to the conclusion that psychoso- relationship of the viceroy butterfly fit the “viceroy” paradigm? To make cial “context” is not a reliable or ve- to the monarch butterfly. Both are that case, in my view, we would need ridical indicator of “disorder” versus orange-and-black butterflies, but are convincing evidence that someone normalcy. Indeed, as a rule, the rec- known to represent different species. with Mr. Smith’s clinical picture will ognition of “disease” or “disorder” For example, whereas the monarch likely show, for example, a different in general medicine is not “context butterfly feeds on milkweeds and degree of morbidity and mortality; a dependent,” once a certain threshold thereby absorbs a toxin that is dis- different level of functional impair- of suffering, impairment, and inca- tasteful to birds, the viceroy butterfly ment or clinical course; or a different pacity is crossed. Neither is knowl- lacks both these features; it “benefits” response to treatment than someone edge of the condition’s etiology nec- from its mimicry of the monarch but- with identical depressive symptoms essary in declaring it a “disorder.” terfly because birds avoid eating it. arising outside the context of recent Thus, a patient who experiences sud- In short, we can find differentiating bereavement. den, crushing substernal chest pain features of these two similar entities But notwithstanding some sur- radiating to the jaw, accompanied that allow us to say that the viceroy vey-derived data from the National by nausea, sweating, and irregular merely “resembles” the monarch. Epidemiologic Survey on Alcohol heart rate, usually receives a prelimi- To be sure, this type of argument and Related Conditions (NESARC) nary diagnosis of “ROMI” — rule has merit in certain clinical situations. study,1 there are few if any clini- out myocardial infarction — and is For example, a patient who develops cal studies of bereavement-related universally considered “disordered,” manic-like symptoms shortly after depression (BRD) that support the regardless of the “psychosocial con- snorting cocaine could rightly be said “viceroy” model (ie, that demon- text” of the complaints. If the patient to have a condition that “resembles” strate that Mr. Smith’s picture mere- says, “It all started when I opened a

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letter from the IRS, telling me that I tion who developed severe mitral Of course, context is clearly im- owed $50,000,” I doubt any compe- regurgitation while undergoing portant in working therapeutically tent physician would say, “Oh well, transesophageal echocardiography with the depressed patient. But even anybody would experience crushing (TEE), during which she experi- in psychotherapy, the issue of “con- chest pain, reading a letter like that,” enced “deep anxiety.”4 A subsequent text” must be carefully and critically and not treat the patient. TEE under general anesthesia, and scrutinized, and not confused with Some may object that, unlike in thus, “...without the emotional in- causality or etiology. Indeed, the psychiatry, there are biological tests volvement of the patient,” did not very concept of “cause” proves to in general medicine that can confirm provoke severe mitral regurgitation. be complex and elusive, when con- the presence of disease (eg, cardiac This change in psychological sidering the patient with depressive enzyme elevations in acute myo- “context” has important etiological complaints. cardial infarction). But this claim and management implications for is only superficially and generally the patient, but it does not render PATIENTS’ NARRATIVES AND THE true. Many medical and neurological the initial worsening of her mitral PITFALLS OF “CAUSALITY” diagnoses such as fibromyalgia, mi- regurgitation “normal” or “non- Some have argued in favor of clas- graine, tardive dyskinesia, and atypi- disordered.” By analogy: A major sifying depression based on the crite- cal facial pain, lack biological “tests” depressive syndrome that is “un- rion, “with or without cause.”5 They and yet remain recognized disorders. derstandable” because it occurs in a argue that this has been the tradition- Context is important when con- stressful psychosocial context such al approach of physicians for centu- sidering certain physiological re- as bereavement, job loss, etc, is not ries, and that only in recent decades, sponses to stress, which are general- thereby rendered nonpathological. roughly beginning with DSM-III, ly transient, functional, and adaptive have psychiatrists taken a disastrous in nature. A patient experiencing THE FALLACY OF MISPLACED turn away from this model toward persistent tachycardia while sitting EMPATHY one of “decontextualized” diagnosis. in a chair is clearly different from The fallacy of misplaced empa- Actually, this argument is dubious on one whose heart rate is 120 beats/ thy is predicated on the notion that, historical grounds, since physicians minute while climbing the stairs in a manner of speaking, “If I can in earlier centuries probably did not of the Washington Monument. (To readily understand why someone is adhere to a “with or without cause” prefigure my later distinction be- depressed, particularly on the ba- paradigm in identifying disease or tween grief and major depression: sis of my own experience, then, all disorder. According to medical histo- ordinary grief may be understood as things being equal, the depression rian H. Erik Midelfort, PhD: very roughly analogous to the adap- does not represent a disorder.” This “... for ancient and early modern phy- tive tachycardia related to normal is no less fallacious when applied to sicians, there was no clear bright line exertion; major depression may be “perfectly understandable depres- between disease and health. They did understood as roughly analogous sion” than when applied to pain in not, generally, decide that someone to myocardial ischemia under such the context of abdominal surgery. was suffering an understandable and conditions). A patient who complains of intense proportionate sadness and was not Similarly, the etiology of a dis- pain around the wound site after therefore ‘ill.’ They generally de- order (qua disorder) must indeed abdominal surgery is not denied a cided that if one were suffering, for be subject to contextual scrutiny, diagnosis of “postoperative pain,” whatever reason and whether pro- as with treatment considerations. much less denied pain-relieving portionate or disproportionate, they Proper medical care demands such medication, because we “under- would do what they could to help: scrutiny, including consideration stand the context” of her pain. As suggest music, friendship...less ‘dry of psychosocial context. For exam- one of my professors used to teach, food,’ and more ‘moistening’ foods, ple, Italian cardiologists reported a no physician would say of such a pa- more or less alcohol...[etc.]. But case of a 76-year-old woman with tient, “You’d be in pain, too, if you these remedies did not depend upon mild-to-moderate mitral regurgita- just had abdominal surgery!” a strict decision that so and so was

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fundamentally ‘ill’ while someone a patient-proffered, albeit erroneous, event…constitutes a psychic trauma else was merely sad for good, suf- etiology.”7 for the individual patient or not.” ficient, and proportionate reasons.” There are instances in which the (personal communication, 11/11/08) “obvious” cause of a patient’s de- TOWARD DEVELOPMENT OF A pression also turns out to be the actu- SCREENING TOOL Even more centrally, “causal- al, or at least, the proximate or prin- The conundrum we are discussing ity” is itself a problematic construct ciple, cause of the depression. This is often summarized as, “It’s hard to when applied to MDD, and the pa- seems almost self-evident, after, say, know where to draw the line between tient’s own “theory of the case” may the death of spouse or family mem- grief and depression” or, “it’s all a prove to be misleading or incom- ber. But sometimes, what seems self- matter of degree.” But that view is plete; eg, the patient may be unaware evident is simply wrong. (After all, challenged by many mood disorder of, or ignoring, the presence of an for hundreds of years, it was “self- specialists.9 I suspect the misconcep- underlying medical disorder; un- evident” that the sun moved around tion arose because of psychiatry’s resolved intrapsychic conflicts; or the earth!) When it comes to assess- overemphasis on symptom check- environmental stressors not related ing the depressed patient, there are lists, at the expense of understanding directly to recent bereavement.6 Phy- often multiple, overlapping causes the patient’s frame of mind or “world sicians in other medical specialties or concomitants, and the patient’s view” — what philosophers call, seem aware that the patient’s narra- recollection of temporal sequencing phenomenology. This superficial di- tive, in so far as it posits “causes” is not always reliable. As Gabbard agnostic orientation has been exac- for the presenting illness, must be has observed, erbated by the belief — misguided, evaluated respectfully, but not credu- “...often the stressor identified by the in my view — that it is “disrespect- lously. And this is precisely where patient (or therapist) is retrospec- ful” or “devaluing” to tell a recently the “depression with and without tively assumed to be the cause [of the bereaved patient that he or she has a cause” argument comes off the rails. depression] because it fits a particular depressive disorder; and that doing For example, James R. Roberts, MD, intrapsychic narrative — often one so “medicalizes” a perfectly normal a professor of emergency medicine, involving victimization. It’s rarely and adaptive human response to loss. notes that: that simple. Often there are multiple And yet, based on the best available, “Patients with many conditions tend stressors; issues involving adult de- albeit imperfect, data, the patient to lead physicians astray by overem- velopmental phases; dashed fantasies who meets MDD criteria in the con- phasizing diet, injury, ‘sleeping on it and hopes; and failures to live up to text of recent bereavement is proba- wrong,’ or other temporal or circum- the expectations of internalized par- bly not experiencing a “normal” and stantial scenarios. They scour the past ents…” (Gabbard G: personal com- “adaptive” response.3 Withholding and their environment for a layman’s munication, 12/31/08). a diagnosis of MDD seems an odd cause. The young woman with acute way of “respecting” a patient who gonococcal arthritis of the knee will Furthermore, there are immense may be at risk for further decompen- often relay bogus trauma; the elderly practical difficulties in applying sation or suicide; indeed, in my view, man with a thoracic dissection always the notion of depression “with” or doing so would be unethical. seems to have picked up a heavy ob- “without cause,” as Lars V. Kessing, Furthermore, when we explore ject the day before; and most patients MD8 has noted: the substantive differences between with appendicitis remember eating “…it is difficult in clinical practice ordinary grief and major depression, some bad tuna. While few clinicians to discriminate between different we are led to the conclusion that they would allow the pepperoni pizza or categories of depression on the basis are fundamentally different con- beer history deter an investigation of presence or absence of a psychic structs and states of being, notwith- for myocardial ischemia in a high- trauma or a stressful life event…the standing some overlap in symptoms risk patient with ‘indigestion,’ it’s inherent problem may be that it is dif- such as sadness, insomnia, and so- quite easy to relate extremity pain to ficult to decide whether a present life cial withdrawal. I have hypothesized

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4 principle domains in which grief tionnaire called the Post-Bereave- bereavement-related major depression and major depression differ phenom- ment Phenomenology Inventory differ from major depression associated with other stressful life events? Am J enologically: the relational, tempo- (PBPI), which expands these do- Psychiatry. 2008;165(11):1449-1455. ral, dialectical, and intentional. mains by means of targeted, dichoto- 3. Zisook S, Corruble E, Duan N, et al. The In relational terms, during ordi- mous questions.14 A predominantly bereavement exclusion and DSM-5. De- press Anxiety. 2012;29(5):425-443. nary grief, the individual is usually left-sided response on the PBPI is 4. Grimaldi A, De Gennaro L, Brunetti ND, able to maintain an emotional con- hypothesized to be more common et al. Downgrading mitral regurgitation nection with significant others; in with MDD; a predominantly “right- in the echo laboratory: a case of rheu- matic mitral restricted motion unmasked major depression, the severely de- sided” response, with ordinary grief. by emotional stress. J Cardiovasc Med pressed patient is typically on an It should be stressed that the PBPI is (Hagerstown). 2011 Feb 3. [Epub ahead “emotional island” and feels outcast still in need of field-testing and vali- of print] and alone. Furthermore, as Dr. Kay dation, and is referenced here chiefly 5. Horwitz AV, Wakefield JC. The Loss of Sadness. New York: Oxford University Jamison has noted, the normally for heuristic purposes. Press; 2007. grieving person is capable of be- 6. Pies RW. Depression and the pitfalls of ing consoled by significant others, CONCLUSION causality: implications for DSM-V. J Af- fect Disord. 2009;116(1-2):1-3. whereas the severely depressed per- The psychosocial context of a 7. Roberts JR: Diagnosing gout: the basics. son is usually inconsolable.10 patient’s depressive symptoms is un- Emergency Med News: 2010;32(3):10- In temporal terms, the griev- deniably important in understanding 13. Available at: journals.lww.com/em- news/Fulltext/2010/03000/Diagnosing_ ing individual usually feels that the one component of the depression’s Gout__The_Basics.5.aspx. Accessed “bad times” will eventually pass, and etiology, and in structuring psycho- May 23, 2013. that the future contains some hope; therapeutic treatment. However, the 8. Kessing LV: Endogenous, reactive and the severely depressed person often etiology of a depressive episode is neurotic depression — diagnostic stabil- ity and long-term outcome. Psychopa- feels as if time itself has “slowed often complex and richly over-de- thology. 2004;37:124-130. down,” and that the depression will termined; hence, the patient’s nar- 9. Zisook S, Shear K. Grief and bereave- never end.11,12 As Jamison described rative vis-a-vis psychosocial stress- ment: what psychiatrists need to know. World Psychiatry. 2009;8:67-74. her own experience with grief and ors should be viewed with respect, 10. Jamison KR: Nothing Was the Same. depression: “Time [spent] alone in but not credulity. Furthermore, the New York: Knopf; 2009. grief proved restorative; time alone presence or absence of disordered 11. Ghaemi SN. Feeling and time: the phe- nomenology of mood disorders, depres- when depressed was always danger- mood should not be determined by sive realism, and existential psychothera- 13 ous.” Ordinary grief may also be psychosocial context; but rather, by py. Schizophr Bull. 2007;33(1):122-130. understood in dialectical terms, in the nature, degree and duration of 12. Ratcliffe M. What is it to lose hope? that the grieving person engages in the patient’s suffering and incapac- Phenom Cogn Sci (published online 7/28/12). doi: 10.1007/s11097-011- a kind of “inward dialogue” between ity. Grief and depression are dis- 9215-1 hope and despair; in contrast, the tinct constructs, with fundamentally 13. Jamison KR: Lecture : “A Life in severely depressed person typically different phenomenology. Further Moods.” American Psychiatric Associa- tion Annual Meeting; May 2012; Phila- remains “hopeless” most of the time. research aimed at refining these dis- delphia, PA. Lastly, grief may be understood in tinctions should prove helpful in dis- 14. Pies R: After bereavement, is it “normal intentional terms; that is, we usu- tinguishing “proper sorrows of the grief” or major depression? The PBPI: 15,16 A Potential Assessment Tool. Available ally give ourselves over to grief, by, soul” from the potentially lethal at: www.psychiatrictimes.com/blog/ for example, participating in various disorder of major depression. pies/content/article/10168/2035804. Ac- mourning rituals. In contrast, we cessed on May 23, 2013. typically experience severe depres- REFERENCES 15. à Kempis T. Counsels on the Spiritual Life. London: Penguin Books; 1995. sion as an involuntary state — one 1. Mojtabai R. Bereavement-related de- that seizes or overwhelms us. pressive episodes: characteristics, 3-year 16. Pies R. The anatomy of sorrow: a spiritu- course, and implications for the DSM-5. al, phenomenological, and neurological Recently, my colleagues and I de- Arch Gen Psychiatry. 2011;68(9):920-928. perspective. Philos Ethics Humanit Med. veloped a potential screening ques- 2. Kendler KS, Myers J, Zisook S. Does 2008;3:17.

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