The Nexus Between Grief and My Mental Illness
One of the most dominant questions of the last decade of my life has been whether there is any difference between the experience of grief and the experience of mental illness. As far back as 1918 Sigmund Freud considered this correlation between “mourning and melancholia” and more recently, there has been a heated debate whether grief should exclude someone from a diagnosis of major depressive disorder (MDD).
I strongly feel my experiences of grief manifested and then exacerbated my mental illnesses. In my 30s, I lost nine precious people and one dear cat in 10.5 years. During that time my major depressive disorder came to dominate the darkest period of my life, and eventually the lid that was tightly shut on my borderline personality disorder (BPD) burst open. To me, it is hard to untie and unravel the strands of really aching, devastating grief from the tendrils of my mental illnesses.
This very question became a heated debate between the writers of the Diagnostic Statistical Manual of Mental Health Disorders around the removal of the bereavement exclusion in the diagnostic criteria for major depressive disorder that had existed in the DSM-IV. This exclusion was for people who had lost someone up to two months prior, meaning they couldn’t be diagnosed before that two months period, with some exceptions for psychosis and other marked functional impairments. This was primarily to stop grief being pathologized or medicated.
The DSM-IV produced an illuminating table to differentiate normal bereavement from major depressive episode, which makes me reconsider whether grief and mental illness are the same thing. In this table, the main differences are primarily the waves of grief vs. the pervasive negative emotions/thoughts in depression, preserved self-esteem despite some regret/longing to the deceased relationship (grief) vs. self loathing and castigation (depression), sociable (grief) vs. withdrawn (depressed), thoughts of the death of the deceased (grief) vs. suicidal ideation (depressed) and depressed mood tied to reminders of the deceased (grief) vs. depressed mood detached from a deceased person (depression).
After heated debate, this exclusion was dropped for the DSM-V and replaced by a note that “responses to a significant loss (including a bereavement) may include a number of the diagnostic criteria for MDD including intense sadness, rumination on the loss, insomnia… and weight loss… which may resemble a depressive episode.” And the presence of a major depressive episode on top of the grief should be “carefully considered.” In the new edition it seems grief doesn’t have to always be disentangled from major depressive disorder.
I will detail the most devastating of my 10 losses to examine this relationship between bereavement and mental illness using the DSM-IV differential between the two phenomena as a guide.
Queen Gertrude: “One woe doth tread upon another’s heel, So fast they follow. Your sister’s drowned Laertes” (Act IV, Scene vii, Hamlet)
1st – My Mentor (November 20, 2009)
The first one cut the hardest. Even now my life is the result of that first loss. It was barely a month being back from a year living in Uganda and Ethiopia, inspired by this friend, when a phone call came. Our mutual friend said what everyone dreads to hear; our dearest friend and my life’s mentor and former teacher had died, “as we used to call it in the shadowlands” (C.S. Lewis — his favorite author).
The effect was instant, a defining before and after moment. I lay down on my bed winded and wounded and numbed by a powerful grief I had not experienced before, as if I had been stunned by the shock of falling onto an electric fence as I had sometimes done in my country childhood. The goodness and color had been stripped from the world. How could I go on without my guide, and what would even be the worth of doing so? No one else explained the world in a way that made perfect sense to me. Though we were never in a romantic relationship, the bond went into the very core of who I was.
Reading through my posts after his death, funeral and all the missed birthdays and anniversaries, I can see now how my grief was not in waves; it was pervasive, as depression is, and I felt empty and significantly lost the ability to experience pleasure.”I think of you every day without fail,” I posted a year after his death.
I tried to be sociable, but my heart was broken and withdrawn as in major depression. I wrote: “I think of you even when I’m pretending to do something else.” My self-esteem took a battering in that I didn’t know who I was if my friend wasn’t in the world, as in borderline personality disorder.
Still, my depressed thoughts had my friend as their object; they didn’t tend to detach as in a depressive disorder and there was no suicidal ideation. By March 2011 I was beginning to accept my life without my mentor, until the Japanese earthquake and Tsunami.
2nd – My Student (March 11, 2011)
One of my very first students when I became an English teacher to International Students was a delightful, young student from Northern Japan who had Asperger’s syndrome.
He was an awkward young man with a surprisingly thundering voice, which boomed a mechanical answer to every grammar question. He also had a fondness for discourse markers such as “Moreover, What is more, Besides and Hence,” which he would try to insert into his answers or even in regular conversation. He had a sweetness, a purity that many of the other students and teachers didn’t understand. But a group of young Japanese friends looked after him and he seemed to enjoy his time in Sydney. Five years after I taught him he invited me into his home in the Miyagi Prefecture countryside, a scene from Studio Ghibili animes. It was a moment, now suspended in time, I will never forget.
Just five months later, I watched with the rest of the world the devastation of the Tohoku earthquake and resulting tsunami. As I watched the first images I somehow knew. Though it would take another month before his and his mother’s body were identified and published in the newspaper as officially dead, in my heart I knew he had been obliterated.
This unique grief of such an innocent really made me question the existence of a loving God. Up until that point I had believed despite the world’s pain and suffering. But this time with my sweet, unguarded student it was personal.
It is clear this was grief in proportion to the horrific tragedy where thousands of lives were swept away, including my friend and student. The theological rupture around a benevolent God allowing such cruel suffering is common to such a mass tragedy. But in terms of grief becoming major depression I did feel the pervasive hopelessness and meaninglessness of Masa’s stolen life and manner of his demise. This lingered long after.
3rd – My Gran (November 22, 2014)
After my first two griefs, there were two others which were less complicated. So I will skip from the loss of one of my favorite students to the loss of my world’s favorite person, my grandmother.
There was nothing particularly tragic in the way she died aged 94. We had warning and her life had been long and full, and she was in no doubt as to how much I loved her. But the separation from someone who had brought such simple, unwavering support and comfort who could never be replicated was agony. And this is where my as yet undiagnosed borderline personality disorder turned up the intensity on the separation to unbearable levels. The separation from my most adored person in my life mirrored the abandonment I felt in my mental illness.
This abandonment, which had been building for a year through a tragic unrequited infatuation with a sensitive, but hopelessly straight housemate had finally overwhelmed me when he suddenly and casually announced he had found a better place to live. In that moment my BPD, which had been held with such effort underwater for so long, catapulted above the surface naked and writhing for everyone to see.
I wept. I self-harmed. I wanted to join my Gran on the other side, free from this pain. Instead, I ended up in hospital for the first time.
It is true I was going downhill for about a year before my Gran died and in that period I had premonitions of the separation/abandonment to come like a prophecy of death. So when I had lost both the object of my infatuation and my beloved grandmother they felt like the same grief. Each fueled and grew the other. A double howl into the abyss.
4. My Aunt (January 31, 2017)
Two years after my grandmother’s death I changed psychiatrists to one I knew immediately was a perfect fit. In our third session he diagnosed me with BPD and soon after began DBT, and both saved my life. I could see overwhelmingly this was not my fault and at last understood why I had felt so abandoned and such intense grief.
A few months after these life savers, my aunt experienced a brain aneurysm alone in her kitchen one scorching January day, dying a week later. This loss was such a complicated bereavement as my sister and I had been so close to her growing up. She was the wild, spunky, mercurial, truth-telling aunt everyone should have. But her life had also been ravaged by mental illness: bipolar disorder since her early 30s, and there were so many broken relationships which left powerful regret and sorrow after her death. I sometimes felt she was mentoring me to be her successor in bold creativity (also a teacher and a writer), a non-conformity, uncompromising honesty, but crucially in a troubled, disordered mind. I tried to sidestep this last legacy, but I never could entirely.
Though in the aftermath of her death I did some impulsive, reckless things very much in her honor, through my weekly DBT sessions I could grieve in a healthy way using techniques such as the acceptance/change dialectic of radical acceptance, and some emergency distress tolerance when the pain became too much. The constant support of my therapist, my DBT facilitators and group members helped me survive, grieve and in time heal.
Ultimately, this was a complicated, intense grief but mostly a grief nonetheless. One that responded well to the skills or therapy techniques designed to build a life worth living, especially around the acceptance of trauma or loss.
5. My Friend (October 2, 2018)
There was another traumatic grief after the loss of my aunt, another friend who dropped dead of an aneurysm aged only 41. A complex bereavement initially, but overall a grief proportionate to the loss.
6. My Neighbor (June 14, 2020)
This brings my story of grief and mental illness to the present day and to my two most recent losses of two very dear to my heart. First, my neighbor growing up who was an old-school gentleman and a gentle man. He died last month in his 80s after many near death experiences. I was overcome with grief the first week, but then I was able to go on — not overcome by a seductive darkness.
7. My Ramses (July 07, 2020)
Lastly, but no lesser a grief, the death of our wild, hilarious orange cat who was hit by a car one night a few weeks ago after my parents moved to a bigger town. My grief for him was also considerable; he filled me with joy and even an awe at this small tiger in our living room. But like Graham, this grief only overwhelmed for about a week. I feel I have accepted these losses and they will not reignite my mental illnesses.
Grief and/or Mental Illness?
If I go back to the DSM-IV’s differentiation between grief and major depressive disorder, I have to conclude that much of my grief of the last 10 years precipitated then blended into my mental illnesses. As if each death also ripped from my grasp a part of who I was, my joy and desire to go on.
However, it is crucial that when I did finally have a holistic diagnosis that made all pieces fit including the grief, and I began truly therapeutic therapy, the next losses I experienced I experienced as grief alone. These were bereavements which did not obliterate my self esteem, make me feel a pervasive bleakness, make me want to end all the pain by ending all things. These losses, as powerful as they were, did not detach from the people I lost. I can go on ready to live, but also to grieve.
In honor of all my departed 10.
Images via contributor