Grief

Grief (pronounced greef)

(1) Acute mental suffering or distress over affliction or loss; sharp sorrow; painful regret; deep or intense sorrow or distress, associated especially with the death of someone.

(2) A cause or occasion of keen distress or sorrow.

(3) In online use (especially in gaming and dating from the late 1990s), to behave in an un-sportsmanlike way or take pleasure in antagonizing other players (used as “to grief”, “griefing” or “be griefed” etc (and vaguely similar to the verb sense of troll)); to exploit a glitch or execute an online prank that diminishes or ruins a website or other online experience for other users.

(4) In idiomatic use, as “come to grief”, to suffer disappointment, misfortune, or other trouble; to fail:

(5) In idiomatic use as “good grief”, an exclamation of dismay, surprise or relief which can be used also to convey approval or disapproval, depending on context, verbal & non-verbal.

(6) In idiomatic use, as “giving me grief”, an expression of (usually mild) annoyance.

1175-1225: From the Middle English greef & gref (hardship, suffering, pain, bodily affliction), from the Anglo-French gref, from the verb grever (afflict, burden, oppress), from the Old French grief (grave, heavy, grievous, sad), from the Vulgar Latin grevis & gravare (make heavy; cause grief), from the Latin gravis (weighty, heavy, grievous, sad) (later influenced by its antonym levis) and ultimately from primitive Indo-European gréhus, gwere & gwerə- (heavy).  The general sense of “suffering or hardship” (Emotional pain, generally arising from misfortune, significant personal loss, bereavement, misconduct of oneself or others, etc.; sorrow; sadness) evolved between the early thirteenth and fourteenth centuries; a doublet of grave.  The alternative forms were greefe & griefe, both long obsolete.  The expression “good grief” appears to date only from 1912 but has been used in historical fiction which long pre-dates the twentieth century.

The circa 1300 adjective grievous was from the Anglo-French grevous, from the Old French grevos (heavy, large, weighty; hard, difficult, toilsome) and was formed directly from grief.  The term grievous bodily harm (the famous GBH) was first used in English criminal law in 1803.  The circa 1300 noun grievance (state of being aggrieved) was from the Old French grevance (harm, injury, misfortune; trouble, suffering, agony, sorrow) from grever (to harm, to burden, be harmful to) and was first used in reference to a cause of such a condition from the late fifteenth century.  The verb is now most commonly found in the gerund-participle griefing and the derived noun griefer; the past participle is griefed and the noun plural griefs.  The related terms include grievance, grieve & grievous and grief is sometimes used as a modifier (grief-striken, grief-tourism et al).  Words which often overlap with grief include agony, anguish, bereavement, despair, discomfort, gloom, heartache, heartbreak, melancholy, misery, moroseness, mourning, pain, regret, remorse, sadness, sorrow, trouble, unhappiness, woe & worry.

The DSM-5-TR, ICD codes and Prolonged Grief Disorder (PGD)

In March 2022, the American Psychiatric Association (APA) released a revision to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 (2013)).  DSM-5-TR (text revision) includes some updated text and new references, clarifications to diagnostic criteria and updates to the ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes which have changed since the DSM-5 was published in 2013.  A text revision to an edition of the DSM is released when a number of changes to the text that accompanies the description of disorders and their criteria are warranted by new evidence or the need for more clarity.  The text of the DSM-5 had since 2013 received some minor corrections but DSM-5-TR is a systematic text revision based on a review of the literature of the last decade (and some re-evaluation of some earlier material).  By contrast, a new edition of the DSM is released when there are thought to have been sufficient advances in the field to support the creation, substantive revisions, and elimination of multiple diagnostic criteria sets or disorders.  There has within the profession been some discussion of the implications of this and some have suggested there’s no indication of support for the need for a DSM-6, some speculation the APA might adopt the conventions of the software industry and work instead towards a version 5.1, the first number indicating a major release, the second the agglomeration of minor revisions, a format well suited to digital editions.

New ICD-10-CM codes have been added to flag and monitor suicidal behavior and non-suicidal self-injury and these can be used without the requirement of another diagnosis and in total there are over 50 coding updates for substance intoxication, withdrawal and other disorders.  The innovation in the use of the ICD-10-CM codes relation to suicidal behavior is interesting.  It’s long been understood suicidal behavior can be a useful tracking mechanism or flag for clinical attention and these codes are now available to all clinicians without the need for a mental disorder diagnosis.  The suicidal behavior codes can be applied to individuals who have engaged in potentially self-injurious behavior with at least some intent to die as a result of the act and the evidence of intent can be explicit or inferred from the behavior or circumstances.  Many suicide attempts don’t result self-injury and the changes reflect the analysis of the statistical data which indicated the previous focus on self-harm and injury meant the extent of the disorder was in many ways underestimated.  It should mean the always interesting phenomenon of “suicide attempts” undertaken in the in absence of suicidal intent becomes better understood or at least quantified.

The new diagnosis of Prolonged Grief Disorder (PGD) has been added to the trauma- and stressor-related disorders chapter.  Noted for centuries, much recent research and clinical experience has indicated there are those who experience a persistent inability to overcome their grief for the loss of a loved one for at least a year or more, with intense yearning or preoccupation with thoughts or memories of the deceased person almost every day since the death (and it’s noted that in children and adolescents, this preoccupation may focus on the circumstances of the death), symptoms severe enough to impair day-to-day functioning.  As part of the diagnosis, the duration and severity of the bereavement reaction must clearly exceed what is expected based on standards related to the individual’s social, cultural, or religious background. This does not imply people feeling grief periodically one year or more after the loss of a loved one have the disorder but those with intense and impairing grief after one year may be considered for the diagnosis.  Prior to the fifth edition, the DSM did not distinguish between “normal” and prolonged grief but PGD may be considered an evolution given the DSM-5 did include a category of persistent complex bereavement disorder (known also as traumatic grief (TG) & complicated grief (CG)) as a “condition for further study” and the first draft of a proposal was in 2018 submitted to the DSM Steering Committee and the Review Committee on Internalizing Disorders, a white paper circulated for discussion before being approved by the Board of Trustees.

The DSM editors clearly were sensitive to suggestions the creation of prolonged grief disorder might have the effect of pathologizing grief and there has long be the criticism that psychiatry increasingly has attempted to list as disorders much that has for centuries been considered part of the “normal” human condition.  To clarity things, the editors note the diagnosis is not a medicalization of grief and the diagnosis is intended only for those individuals who meet the criteria: something dramatically different from the grief normally experienced by anyone who loses a loved one; a grief intractable and disabling in a way that typical grieving is not.  Grief continues to be thought of as something healthy but not if ongoing.

One internally significant technical change is also noted: there are now no unique DSM codes.  The codes that appear in DSM-5-TR are the ICD codes that are equivalent to the DSM diagnoses given the version of the manual and only ICD-10-CM codes are used because this is the version of ICD that is in effect in the United States.  Although based on the World Health Organization’s (WHO) ICD-10 codes, ICD-10-CM codes in DSM-5 (and thus DSM-5-TR) have been modified from ICD-10 for clinical use by the US Centers for Disease Control (CDC) and Prevention’s National Center for Health Statistics (NCHS) and provide the only permissible diagnostic codes for mental disorders for clinical use in the United States. In the United States, the use of ICD-10-CM codes for disorders in DSM-5-TR has been mandated by the Health Care Financing Administration (HCFA) for purposes of reimbursement under the Medicare system. Although it sounds nerdy, it’s an important advance in standardization which should improve record keeping, data collection, retrieval, and compilation of statistical information.

One change which was expected was the update to the terminology to describe gender dysphoria based on updated and more culturally sensitive language.  (1) desired gender is now experienced gender, (2) cross-sex medical procedure is now gender-affirming medical procedure” and (4)  the companion terms natal male / natal female are now individual assigned male / female at birth.  Whether these changes prove to be final remains to be seen; the whole area is one of shifting linguistic sand but what’s in DSM-5-TR reflects current thinking and the entire text of the Gender Dysphoria chapter has also been updated based on a review of the literature.

Also expected was the restructuring (again) of the diagnostic criteria of Autism, reflecting the view that Autism seems to be over diagnosed, a problem inherent in spectrum conditions.  Less anticipated was the creation of Unspecified Mood Disorder (UMD) which, ominously, does sound like the criminal charge of “unspecified offences” used in the justice systems of places like the DPRK (North Korea) but which seems to have been coined to permit clinicians some flexibility so that patients presenting with irritability, agitation and sadness (and for whom some diagnosis is clearly appropriate), don’t have to be labeled as “bipolar unspecified” or “depressive disorder unspecified’, both stigmatizing conditions, the presence of which in a medical record may have implications which last a lifetime.  It’s thus a legitimate diagnosis (which really is important to patients) to be applied until a more specific disorder is found but does raise two interesting technical points: (1) can any emo not be diagnosed UMD and (2) should all emos be diagnosed UMD?