Joy, Guilt, Anger, Love (19 page)

The question then arises: is the biology behind the symptoms different in the two circumstances? A few researchers are trying to identify symptomatic and biological factors that could justify the creation of a new dedicated category named
prolonged grief disorder
(PGD) or
complicated grief
(CG), thus differentiating normal grief from a form of unresolved grief which deteriorates into an incapacitating condition that parallels severe cases of depression.
²¹

All in all, the proposal comes with the best of intentions. Doctors have no specific interest or desire to increase the toll of psychiatric disorders in the world by over-diagnosing them. The world prevalence of major depression currently stands at approximately 10 per cent of the population.
²²
That means that one in ten individuals that you see walking on the street may be depressed. In the United States, approximately 2.5 million deaths occur every year.
²³
If, on average, each death leaves four or five bereaved survivors, then about ten million people each year could potentially be diagnosed with PGD. The main argument in favour of the introduction of prolonged grief disorder is that it would become legitimate for doctors to detect it and treat it swiftly to avoid the onset of a much more complicated illness (and as a practical consequence, especially in the US, insurance companies would be more likely to reimburse its care).

The change made in the new DSM edition inevitably bears unwanted consequences. Leading psychiatrist Allen Frances, who was also the chair of the task-force behind DSM-IV, has several times warned against the creation of a new category for grief.
²⁴
Establishing boundaries of duration to distinguish normal grieving from a form of grieving that demands special attention and dedicated treatment is bound to generate a large number of false positives. Nobody can really tell what a normal duration of grief ought to be. Two weeks is definitely too short a time to conclude a season of sorrow for the death of a loved one. Most of the people whom I have seen cope with grief take much longer than that. And there doesn’t seem to be empirical evidence proving that all those who take longer than two weeks to recover from the gripping symptoms of grief will end up being incapacitated by the loss. Depending on the life circumstances of the bereaved – health, work and financial conditions, past experiences of grief and other difficult life experiences – the individual variation in the duration of grief is enormous, just as is the variation of symptoms in depressions not caused by the actual loss of a loved one.
²⁵

Grief is also articulated by factors such as culture. Different mourning rituals and traditions encourage different lengths of seasons of grief which, in response to the disorienting experience of loss, help the bereaved by providing guidance and structure on how to cope with it. If I told Nonna that her grieving season might be mistaken for something abnormal, she would probably take offence. Speaking of somebody grieving more or less intensely creates a hierarchy of emotions that undermines their value. The categorization of grief would turn it into a commodity.

The writer Julian Barnes once said that mourning ‘hurts as much as it is worth’.
²⁶
Mourning is painful, but it is necessary in order to deal with the loss. Indeed, the most dangerous, perhaps unintended, consequence of this move is that normal grief, an entirely expected reaction to loss, may be wrongly branded an unwanted problem. A new category for grief is just a label. But with its introduction would come millions of patients who, before the label existed, would not have been considered candidates for medical attention.

By any other name . . .

In 1953, only a year after the publication of the first edition of the DSM, another very important volume made its debut in the world. It was the posthumous publication of a charming, mysterious and out of the ordinary Austrian philosopher who taught at the University of Cambridge.
²⁷
The book in question is
Philosophical Investigations
and the philosopher Ludwig Wittgenstein (1889–1951). The Austrian thinker was obsessed with language. For Wittgenstein, language is the staple of our social lives, but also underlies most misunderstandings and disagreements.

Wittgenstein was firmly convinced that the meaning of words is not an inflexible correspondence between an arbitrary string of letters and an object or entity in the world. On the contrary, words assume meaning according to the use which we make of them in the outer world. Wittgenstein called the use we make of words their public aspect and believed it had more influence than the private one. For him, the grammar of a language was not about how to put together a sentence correctly, minding rules of syntax and orthography, but about the set of rules or customs attached to the use and meaning of a word. He adopted the term language games to describe everyday social contexts in which words were employed for particular purposes and according to particular rules.

His most famous example is indeed the word
game
. We have board-games, card-games, ball-games, Olympic games, war-games, etc. All such words have ‘game’ in common, but they all actually mean something different.

The practice of psychiatric diagnosis consists exactly in associating a name with a list of symptoms, a set of behavioural patterns that are supposed to give meaning to a disease. In turn, each diagnostic term implies the existence of some disease entity, which we know conceals a complex biological scaffolding, the structure of which, however, we are only starting to comprehend. This is true of depression – in all the various designations in which it has appeared over time. The proposed new category of prolonged grief disorder therefore purports to correspond to something specific, distinguishable both from major depression and from what would be ‘normal’ grief.

Wittgenstein was neither a medical doctor nor a scientist, but had an interest in psychiatry. The language problems Wittgenstein formulated for everyday words hold true for the categories of the DSM, which, in one way or another, enter the everyday language of doctors, researchers and patients alike, and even the language of the media and public discourse. Major depression, bipolar disorder and all the other categories pervade everyday talk and work as terms by which individuals define themselves and their condition. Knowledge of the existence of a diagnosis, a name for a mental illness, as well as a biological description, is often a comforting discovery for patients, one that erases a sense of self-blame for being ill.

Although the impact of Wittgenstein’s work and legacy hasbeen greatest on logic and the philosophy of language in general, the contribution of his thoughts to the field of emotions was far from marginal. We need to take a step back and examine it.

As I have emphasized several times in this book, one of the current prevailing concepts in research on emotion is the distinction between emotions and feelings. This distinction is often used to clarify that emotions are spontaneous bodily reactions to events and circumstances, and feelings are internal, subjective and private states, fruit of introspection and awareness of those emotional states, and hence not accessible to others. As a consequence, those around us can only deduce what we feel, and achieve an approximate interpretation of our internal states. So far, so good.

Wittgenstein recognized and endorsed the idea that emotions are immediate visible manifestations.
²⁸
‘Don’t think, but look!’ he urged, implying that the bodily expression of an emotion communicates much more than can a description of it and needs little learning or interpretation.
²⁹
Behaviour and what was observable to the naked eye mattered to him a great deal and he acknowledged the power of our bodies to effectively communicate emotions to each other: ‘Grief, one would like to say, is personified in the face. This is essential to what we call “emotion”.’
³⁰
Facial, vocal and other bodily expressions were all valid manifestations of emotion, while language was a secondary, yet determining attribute. If you leaf through Wittgenstein’s works, you will find some pages adorned with drawings he made to allude to emo-
tional expressions and to aid his arguments – among them the following passage:

If I were a good draughtsman, I could convey an innumerable number of expressions by four strokes –

[ . . . ] Doing this, our descriptions would be much more flexible and various than they are as expressed by adjectives.
³¹

In fact, they are not dissimilar to today’s emoticons.
³²

What Wittgenstein didn’t believe was that introspection could reliably extrapolate the essence of mental states. In Wittgenstein’s philosophical grammar, the terms we use to denote emotions such as grief are not direct correspondences to our inner states. He didn’t mean that we can’t build inner feelings or that introspection doesn’t work. We certainly do have subjective experiences of our emotions. However, Wittgenstein thought that we do not learn how to identify our emotions solely through the inner experience, but through the language we use to describe them – in addition to our expressions. Just as in the case of the word ‘game’, without a public set of criteria to describe emotions, there would be no way to understand what we mean by them, let alone judge what others are feeling. The way we describe emotions depends on the available public language of emotions and also on the situation as well as the historical context in which they arise.

My grief is not yours

It is ironic that the two publications were issued at pretty much the same time: the American Psychiatric Association’s manual that prescribed the language and categories by which mental pathologies and, by extension, emotions such as grief were to be labelled, and Wittgenstein’s reflections on the impact that language and words have on the way we understand our lives and interact with each other. Wittgenstein did not live long enough to witness the publication of the DSM, or to marvel at the scientific advances of the second half of the twentieth century. He had no knowledge of the structure of DNA – the publication reporting its discovery was issued two years after Wittgenstein’s death – or of the roles we attribute today to the amygdala, the prefrontal cortex and neurotransmitters such as norepinephrine and serotonin. Serotonin had been isolated in 1933, but it was only after the philosopher’s death that it was associated with emotional states.

Wittgenstein, however, must have had his own notion and experience of grief. It doesn’t matter too much whether Wittgenstein believed in the existence of indefinable inner feelings and in the explicative power of introspection. After all, as yet nobody knows the exact composition of these inner feelings and consciousness, or for that matter how we can measure them. And not everyone agrees that such feelings ever will be measured with exactitude. If Wittgenstein were still alive today, sixty years after the publication of the Investigations, it would be fascinating to ask his opinion on the current state of psychiatry and on the most recent neuroscience developments. Would he show curiosity at the whole neuroscience enterprise? He would probably be puzzled by and perhaps cringe at the very idea of defining a single diagnostic category – prolonged grief disorder – to encompass the wide and complex spectrum of emotional state that we label grief. He would also probably have doubts on what really lies behind that name.

Research in psychiatric neuroscience is heading towards the identification of biomarkers. These are measurable biological values that work as proof of some distinct change in the body. For instance, high levels of gonadotropin in a woman’s urine are the biomarker of her pregnancy. Insulin level is a good indicator of whether someone has diabetes. In the case of mental illness, biomarkers would indicate dysfunction in the neurochemistry of mental states, thereby facilitating the diagnosis and the treatment choice for depression or complicated grief. Over the decades of neurological and molecular research on depression biomarkers have varied widely. To take some examples: levels of cortisol – the hormone involved in an organism’s stress response – appear to be higher in depressed individuals, especially during the early hours of the day; certain alterations in brain morphology or changes in brain activity, detectable through brain-imaging techniques, have been shown to indicate depression;
³³
depressed patients have also been found in general to have decreased blood flow in the frontal part of the brain. Researchers and the authors of DSM-V are eager to pinpoint as many reliable and precise biomarkers as possible and include them as diagnostic criteria.
³⁴
This search is an exciting undertaking, because it leans towards a refinement in diagnosis. However, it is also an extremely challenging one because of the vast diversity within any one psychiatric disorder, both at the level of symptoms and at the level of the biology underlying them. There are so many variables involved and it is unlikely that one biological measure could suffice for a diagnosis.