Can One and the Same Instance of Grief Be Both Normal and Disordered?

Abstract

Can One and the Same Instance of Grief Be Both Normal and Disordered? Jerome C. Wakefield (bio) Miriam solomon resuscitates a famous proposal of George Engel's (1961) to classify normal grief as a medical disorder. She has two main arguments justifying such a reclassification, one based on Engel's "wound analogy" and another a "Humpty Dumpty"-type argument that 'disorder' is a technical term that we can redefine any way we please. I consider them in turn. The Wound-Analogy Argument Solomon says: "I suggest that we allow a concept of "psychological injury" that is analogous to the concept of physical injury." Of course, we already have a whole chapter of the Diagnostic and Statistical Manual of Mental Disorders (DSM) devoted to psychological injuries in the form of "trauma- and stressor-related disorders" (this is where the new "prolonged grief disorder" category will go). Normal grief has never been among these disorders because it is considered a normal-range emotional response to loss rather than something going wrong with mental functioning. Solomon nevertheless wants to place normal grief under "disorder" to make treatment more accessible. Solomon's first strategy for migrating normal grief into the disorder category is to argue that grief is analogous to the healing of a physical injury, and the healing of a physical injury can be both normal and a disorder. She uses the example of an injured accident victim to argue her case: I would like to suggest that a condition can be both normal and disordered. In this context, "normal" is not the opposite of "disordered." To see how this is possible, consider a case of physical injury, such as a motor vehicle accident that leaves a driver, previously in good health, with several broken ribs. The driver needs medical treatment for both fractures and pain and has a disease/disorder that can easily be stated on health insurance forms. Yet the driver's response to the accident—pain and disability—is entirely normal, given their injury. … [I]t is normal to suffer broken bones in this accident. So, in the context of physical injury, "normal" includes the response of a healthy body to injury. I think there are three ways to interpret Solomon's wound-analogy argument that "a condition can be both normal and disordered." I will argue that all three are fallacious when considered in the medical context. [End Page 341] The first interpretation pivots on the premise that "it is normal to suffer broken bones in this accident" and "the driver's response to the accident—pain and disability—is entirely normal, given their injury." In this interpretation, the fractures that result from the accident and the disability that results from the fractures are clear disorders but are also normal. Given a sufficient amount of force on a bone, it will certainly fracture, and given certain fractures, the individual will certainly be disabled, ergo there are disorders that are normal. This argument is invalid in the medical context because it turns on an equivocation of the term 'normal' between the statistical frequencies given certain preconditions (e.g., "given their injuries") versus functional normality representing the range of outcomes consistent with biological design that are medically normal. Failure of a bone to be capable of performing its biologically designed function after being fractured is not medically normal, even if it is a statistically normal outcome under the circumstances. The equivocation here is a common confusion. For example, in influential articles defending changing the label "dependence" that was used in DSM-IV to refer to addiction (Hasin et al., 2013; O'Brien, Volkow, & Li, 2006), it was argued that it is "normal" when taking certain prescribed drugs to develop physiological dependence. Of course, it is indeed expectable for our brains to adjust in this way, but it is not functionally normal for an individual to require the drugs in question in order to function adequately (Wakefield, 2015b). Normality in the statistical sense is not the same as functional normality, and the functional sense is the one relevant to evaluating disorder versus nondisorder (Wakefield, 1992, 1999a, 1999b). The second interpretation is that "a condition can be both...