I find this interesting. What I wonder about is whether some losses are pathological in themselves, and whether putting the emphasis on how that person responds is appropriate. I have also treated someone who had traumatically lost a daughter two years earlier. At the time, my own daughter was young. Even now, as a parent, it seems to me the loss of a child is wrong, unexpected, unacceptable, and can only be imagined to cause pathological suffering. Maybe it doesn't matter what the label is, but there are some losses from which people cannot return to baseline.
I think some losses are *pathological within a given context*. Loss of a child, especially a small child, used to be absolutely run of the mill part of life (something like 20% of children died before reaching 5 yo in 1900, for example), and while OBVIOUSLY it could be traumatic and even if not traumatic, extremely sad, it was also NORMAL. So there was both an expectation that it might happen, and societal/cultural ways to handle it. And nowadays it's indeed unexpected, very rare and thus, perhaps necessarily, metabolised socially and processed individually very differently -- as wrong and unacceptable -- the vast majority of mothers never have to face this kind of loss.
And I think this applies to other cases too. My partner died unexpectedly and suddenly in his early 50s and while the shock of it led to (pretty spectacular and still not gone 6 years on) trauma response on my side, the grief itself was "normal" (in the sense of not being pathological). But I also think that living in a community where relatively many men die in middle age (remote, physical labour, booze, dangerous work at sea etc) made the grief easier to socially process, even tho he wasn't a fisherman. As the undertaker said to me "people here still understand death", and what he meant I think was "death that's not at 83 of degenerative conditions of old age".
I do think that response matters *in a given cultural context* --we would likely all see certain deaths as "justifying" heavier or longer grief and conversely, certain reactions that would feel like ENTIRELY REASONABLE to a death of a child, suicide of a close friend or a loss of a spouse at 30yo would seem "excessive" to a loss of a 90 year old parent. Yet all of those could progress to some kind of acceptance or adjustment and as the OP states, it's the *stuckness in prolonged suffering (and to some extent dysfunction tho I personally hate that argument)* that matters.
To your point of pathological within a given context, the NYT today has an article about a 20-yo young man who visited the ER twice and died due to medical error:
The parents are described as still acutely grieving and angry two years later, and are suing for wrongful death.
I agree that context with loss is crucial, and am sorry for your own loss. So many things contribute to context: death of a twin might mean more than that of a much older sibling, preventable loss is much harder than say loss that is anticipated or unavoidable. The larger question you raise is whether many of our DSM diagnoses are culturally and temporally specific.
I do respect your and Awais' contention that, no matter the loss, a lack of some degree of adjustment may constitute "disorder."
Thanks for this post, Awais. Grief is so awful! And it is so misunderstood by scientists who try to make it more consistent than it is.
I spent three years getting funding and recruiting grief expert collaborators to analyze of one of the best prospective studies of grief ever conducted in hopes of understanding how low mood is useful. (the CLOC study https://www.icpsr.umich.edu/web/ICPSR/studies/3370)
I concluded that there is no way to define "normal" grief, its variations are manifold. A third of our subjects had little or no grief; in contrast to my hypothesis, most of them seemed to have good relationships and stable lives. A third had regular grief with all its variations in symptoms and sequence. A third had a harder time and longer symptoms, but still lots of variation. The best predictor was previous low mood and depression. We found no evidence that delayed grief led to bad outcomes, and what I was taught in psychiatry residency-that prolonged grief was a product of an ambivalent relationship-was just plain wrong. Surviving spouses with ambivalent relationships had less grief than others.
As for evolution and grief, I remain uncertain if it is an adaptation or an epiphenomenon of attachment and the broader capacity for sadness. More work is needed.
Absolutely agree. Spent much of my career working to help people with prolonged grief who desperately wanted help. It exists but not everyone seeks assistance. People find ways through it. My personal experience after losing my father needed therapy.
I have such strong feelings of grief (of any variety) being labeled “disordered.” My daughter died almost 10 years ago and the first 8 years following were excruciating. I am doing better now but why do we have such firm beliefs that grief needs to look a certain way? I did seek treatment and my first psychiatrist told me that while it was tragic that my daughter died, this sort of thing happens every day and I needed to move on. If we’re going to medicalize my grief then I think we can also say her “treatment” was malpractice. Of course, I’m being facetious but it illustrates my frustration. I don’t pretend to know what “normal” looks like after this kind of loss. I am skeptical of the medical community that thinks it has better answers.
Strong feelings are understandable given the topic! I've had them myself. I don't think we are obliged to look at grief a certain way. I have mixed feelings about what your psychiatrist told me, but I am also not your physician and don't know the clinical details, so I don't know how I would've responded, but I do think many psychiatrists also dismiss or ignore the clinical framing of grief. I imagine you do agree that certain forms of grief can be maladaptive and destructive for the person? If so, I am curious what conceptualization and language you'd prefer for those cases.
I find this interesting. What I wonder about is whether some losses are pathological in themselves, and whether putting the emphasis on how that person responds is appropriate. I have also treated someone who had traumatically lost a daughter two years earlier. At the time, my own daughter was young. Even now, as a parent, it seems to me the loss of a child is wrong, unexpected, unacceptable, and can only be imagined to cause pathological suffering. Maybe it doesn't matter what the label is, but there are some losses from which people cannot return to baseline.
I think some losses are *pathological within a given context*. Loss of a child, especially a small child, used to be absolutely run of the mill part of life (something like 20% of children died before reaching 5 yo in 1900, for example), and while OBVIOUSLY it could be traumatic and even if not traumatic, extremely sad, it was also NORMAL. So there was both an expectation that it might happen, and societal/cultural ways to handle it. And nowadays it's indeed unexpected, very rare and thus, perhaps necessarily, metabolised socially and processed individually very differently -- as wrong and unacceptable -- the vast majority of mothers never have to face this kind of loss.
And I think this applies to other cases too. My partner died unexpectedly and suddenly in his early 50s and while the shock of it led to (pretty spectacular and still not gone 6 years on) trauma response on my side, the grief itself was "normal" (in the sense of not being pathological). But I also think that living in a community where relatively many men die in middle age (remote, physical labour, booze, dangerous work at sea etc) made the grief easier to socially process, even tho he wasn't a fisherman. As the undertaker said to me "people here still understand death", and what he meant I think was "death that's not at 83 of degenerative conditions of old age".
I do think that response matters *in a given cultural context* --we would likely all see certain deaths as "justifying" heavier or longer grief and conversely, certain reactions that would feel like ENTIRELY REASONABLE to a death of a child, suicide of a close friend or a loss of a spouse at 30yo would seem "excessive" to a loss of a 90 year old parent. Yet all of those could progress to some kind of acceptance or adjustment and as the OP states, it's the *stuckness in prolonged suffering (and to some extent dysfunction tho I personally hate that argument)* that matters.
To your point of pathological within a given context, the NYT today has an article about a 20-yo young man who visited the ER twice and died due to medical error:
https://www.nytimes.com/2025/10/05/well/sam-terblanche-virus-death-columbia.html?searchResultPosition=2
The parents are described as still acutely grieving and angry two years later, and are suing for wrongful death.
I agree that context with loss is crucial, and am sorry for your own loss. So many things contribute to context: death of a twin might mean more than that of a much older sibling, preventable loss is much harder than say loss that is anticipated or unavoidable. The larger question you raise is whether many of our DSM diagnoses are culturally and temporally specific.
I do respect your and Awais' contention that, no matter the loss, a lack of some degree of adjustment may constitute "disorder."
Thanks for this post, Awais. Grief is so awful! And it is so misunderstood by scientists who try to make it more consistent than it is.
I spent three years getting funding and recruiting grief expert collaborators to analyze of one of the best prospective studies of grief ever conducted in hopes of understanding how low mood is useful. (the CLOC study https://www.icpsr.umich.edu/web/ICPSR/studies/3370)
I concluded that there is no way to define "normal" grief, its variations are manifold. A third of our subjects had little or no grief; in contrast to my hypothesis, most of them seemed to have good relationships and stable lives. A third had regular grief with all its variations in symptoms and sequence. A third had a harder time and longer symptoms, but still lots of variation. The best predictor was previous low mood and depression. We found no evidence that delayed grief led to bad outcomes, and what I was taught in psychiatry residency-that prolonged grief was a product of an ambivalent relationship-was just plain wrong. Surviving spouses with ambivalent relationships had less grief than others.
As for evolution and grief, I remain uncertain if it is an adaptation or an epiphenomenon of attachment and the broader capacity for sadness. More work is needed.
Details available at https://www.randolphnesse.com/articles/grief
Absolutely agree. Spent much of my career working to help people with prolonged grief who desperately wanted help. It exists but not everyone seeks assistance. People find ways through it. My personal experience after losing my father needed therapy.
I have such strong feelings of grief (of any variety) being labeled “disordered.” My daughter died almost 10 years ago and the first 8 years following were excruciating. I am doing better now but why do we have such firm beliefs that grief needs to look a certain way? I did seek treatment and my first psychiatrist told me that while it was tragic that my daughter died, this sort of thing happens every day and I needed to move on. If we’re going to medicalize my grief then I think we can also say her “treatment” was malpractice. Of course, I’m being facetious but it illustrates my frustration. I don’t pretend to know what “normal” looks like after this kind of loss. I am skeptical of the medical community that thinks it has better answers.
Strong feelings are understandable given the topic! I've had them myself. I don't think we are obliged to look at grief a certain way. I have mixed feelings about what your psychiatrist told me, but I am also not your physician and don't know the clinical details, so I don't know how I would've responded, but I do think many psychiatrists also dismiss or ignore the clinical framing of grief. I imagine you do agree that certain forms of grief can be maladaptive and destructive for the person? If so, I am curious what conceptualization and language you'd prefer for those cases.