Category: Psychology

Grief

Grief is not considered a mental disorder.  It is not even listed by its own name, but goes under the title of “bereavement” in the DSM-IV.  Most English speakers will typically use the term of “grief” to describe their emotional reaction after the death or separation from a significant other.  The mental and physical symptoms are not readily distinguishable from a Major Depression or an Adjustment Disorder.  About 30% of grief reactions meet the criteria of a Major Depression, and about 10% have psychotic symptoms.

Professionals do not regard grief as abnormal if the worst of the suffering is over by 6 months; a year at the longest.  Death from suicide or a medical illness is increased significantly during the grief reaction.  The immune system is depressed, cortisol levels increase, and there is an increased risk of heart disease and cancerous malignancy during the course of a grief reaction.

Most mental health clinicians will not diagnose grief or bereavement before six months from the time of the loss, though the DSM IV gives 2 months as the guideline.  It is normal to have thoughts about actions one might have taken to save their life or keep the person as an intimate attachment.  Grieving individuals often feel as if they should have died, instead of their significant other.  They typically feel worthless, and experience a profound slowing of thoughts and actions.  There is often impairment in social and occupational functioning for several months.  It is even common to hear the voice of, or see a fleeting image of, the lost significant other.

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It is not the intensity of suffering, but the duration and quality of the suffering that differentiates depression from grief.  Visual and auditory hallucinations are common in grieving, but considered abnormal if they persist longer than 6 months.  Additionally, the hallucinations of a grieving person are always associated with the missing object; never with someone physically present or personally unknown to the bereaved.  For example, if a person experiences hallucinations of their dead father, after the death of their mother, and a voice tells them to kill their brother, this is less grief than a psychotic disorder.  Expressions of worthlessness and regret are directly connected to the missing object; otherwise the grief is likely part of a chronic mental illness.  Thoughts of death are focused on the missing object.  Desiring to die in the place of the deceased, or feeling that life is not worth living without their significant other, is expected and considered normal.  Harboring a plan to commit suicide unrelated to the missing object is severe Major Depression.

I hope this article clears up some of the confusion between normal grief or bereavement at the loss of a significant other, and the more unrelenting chronic forms of mental illness.  Many people are surprised to learn the level of suffering mental health professionals consider normal in the bereaved individual.  They are also surprised that auditory and visual hallucinations of the lost object are common and considered to be within normal limits.  As professionals do not recommend treatment for normal bereavement, family and friends of the grief stricken play an invaluable role.  Mental health professionals may be consulted if the condition fails to lessen, or even becomes increasingly severe.  Most importantly, do not criticize their emotional reactions to the loss.  It is best to be a kind and patient listener, rather than an ersatz psychologist.  Encourage the mourner to talk at their own pace and rate.  Encourage the bereaved to participate in life without being pushy or critical.  Also pay special attention to important dates in the relationship between the bereaved and the lost object.  Mourners may have worked through most of their grief, but find themselves falling to pieces during times when they would have been together; e.g., the Christmas holidays, birthdays, etc.  Please leave comments about this article on grief in the space provided below.

Autism & Asperger’s Disorders

The main contrast between Autistic Disorder and Asperger’s Disorder is severity.  Those most unfortunate tend to suffer with autism.  The main features of both disorders are impaired social relations, impaired social communication, and stereotyped/repetitive behaviors.  While many readers may be thinking of those they know who meet these criteria, it is not likely your friends suffer with either disorder.  Autism is a severe impairment leaving most sufferers institutionalized after adolescence.  Most, but not all, autistic patients become aggressive after childhood.  The aggression seldom has a precipitant; a root stimuli that escalated the frustration to violence.  Most autistic patients have very noticeable impairments of cognition and language development.  A huge difference between those who are classified as Asperger’s or Autistic Disorder is the normal cognitive and linguistic development of  Asperger’s patients.

Both disorders suffer with social impairment, though at a different level of severity.  There is difficulty using nonverbal (bodily) communication to regulate social interaction.  Eye contact is poor or eerily constant, and facial expressions are bizarre and not appropriate to the situation.  Bodily gestures are bizarre and inappropriate as well.  Both disorders exhibit a lack of age appropriate peer relationships.  It is rare that either disorder spontaneously desires to share their experiences for the enjoyment or interest of others.  There is an aspect of poor emotional reciprocity, where one fails to note and respond appropriately to the emotional needs of others.

Many child and adolescent schizophrenic patients share some of the social impairment of the autistic spectrum disorders, but they rarely share the stereotyped and repetitive movements.  These movements are bizarre and intense, such as hand flapping and twisting, finger flapping, and flipping objects.  There are often whole body stereotyped movements; e.g., an autistic patient of mine constantly put his arms around his head.  He sometimes twisted or grimaced while performing this wrapping of arms around his head.  Once one is exposed to autistic movements, they are hard to mistake for nearly any other disorder.  Asperger’s sufferers experience similar movements, but rarely so bizarre and intense as Autistic Disorders.  I have witnessed many forms of neurological movement disorders over the last 20 years, and none mimic those of the autistic spectrum disorders.

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There is an occasional diagnostic confusion with Obsessive-Compulsive Disorder.  Both Asperger’s and autism share an intense preoccupation with routines and rituals.  These restricted interests focus narrowly and to the exclusion of necessary routines one needs to accomplish each day.  It is difficult to label this as something other than a compulsion, though the diagnostic criteria for the autistic spectrum disorders make no mention of obsessions.  In my limited work with autistic patients, primarily while in training, every patient I observed suffered with severe obsessions.  The significant difference I noted was that the in the O-C, the cognitive obsession was strongly linked to the compulsive behavior.  For the autistic, the repetitive thoughts might result in nearly any behavior; related or not to the automatic repetitive thoughts.

While I have had to diagnose children with Autistic Disorder in institutions, I’ve never diagnosed someone with Asperger’s Disorder in my outpatient practice.  It is not uncommon to be referred a new patient with a diagnostic question regarding Asperger’s, but none have met the published diagnostic criteria.  Many people have difficulty with social relationships, and fortunately for them, it is rarely secondary to an autistic spectrum disorder.  A hallmark of these disorders is the bizarre and nonfunctional stereotyped/repetitive movements.  All the other symptoms overlap with other conditions.

In terms of treatment, most Autistic Disorders require institutionalization by mid-adolescence.  Those that are not aggressive, typically with nearly normal cognition, may be kept within the community.  Asperger’s Disorder is not generally treated on an inpatient basis.  The typical treatment is social skills training; making the patient aware of behaviors that distance or offend others.  These patients will never be socially comfortable or smooth, but the quality and success of their social interactions may be significantly improved.  Please leave comments about this article in the space below.