Medicalizing Grief: A Response to Cheng and Shen

To the Editor: We believe the case report by Cheng and Shen¹ to be an example of how normal and understandably painful reactions to traumatic grief are cast into the likeness of illness. The subject is a middle-aged woman whose fiancé’s death is described as a “terrible shock,” obviously an unexpected and traumatic loss for her.

The article opens with some “stage-setting” that gives the impression of her reaction to his death as a disease. It refers to the DSM’s definition of catatonia as if there were some medical evidence that catatonia is a disease in the sense that diabetes is a disease, with identifiable bodily pathology that causes it. With catatonia, this is not the case. The term is merely a label used to define a particular kind of human behavior that expresses the person’s inner experiences, not a pathological condition. The authors note that “…catatonia…is associated with many psychiatric and medical conditions,” give percentages of the “causes” (without any evidence to support the cause), and go on to present a case of a person who, “…developed an emergent catatonia in a major depressive episode with psychotic features….” Such use of language further gives the impression that it is a pathological condition itself. It would be just as accurate to say, “In the face of extreme angst, people can shut down, becoming immobile and resistant to changes in movement and posture in an attempt to escape from the distress.” This description would not make it sound like an illness; rather, it would sound like what it actually is. The coup de grâce is, “…catatonia was improved by injectable” valium and olanzapine. Incidentally, it strains credulity that the authors (and presumably the treating physicians) knew the olanzapine affected both the catatonia and psychotic depression, whereas valium affected only catatonia and mirtazapine affected only the psychotic depression. After all, the catatonia and psychotic depression are “in” the same person. Also incidentally, her so-called “psychosis” consisted of “guilty delusion.” The literature is replete with evidence that such feelings are common, particularly in traumatic grief.^2,3 In addition, while the pharmacologic treatment is credited for its efficacy, in fact, this simply cannot be discerned in this case study. Merely the passage of time has been shown, in conjugal bereavement, to itself remedy psychiatric sequelae.

Finally, all biological laboratory tests verified no physiological pathology. Nonetheless, the authors refer to the “neurobiology of psychotic depression and that of catatonic syndromes,” noting that pharmacology and electroconvulsive treatment may be used to “treat” catatonia.

This approach to “treating” traumatic grief violates the inviolable: a person’s basic human right to experience extreme shock, angst, despair, and, yes, even catatonia in the face of such loss. This woman’s reaction to the untimely death of her fiancé is likely to be influenced by many things, including her culture, social support, and the shockingly sudden circumstances under which her fiancé died, none of which are illumined in the article. How much more appropriate would it have been for her community to support her, give her space to fall silent to a world where such trauma can occur, and slowly regain her equilibrium? The most dangerous approach to bereavement seems to be one that medicalizes what it means to be human and to love deeply. This is reason for us all to be deeply concerned. We implore clinicians—and communities—to do better for the bereaved, particularly those bereaved under traumatic circumstances.

Potential conflicts of interest:

None reported.

Funding/support:

None reported.