Prolonged grief disorder
Prolonged grief disorder, also known as complicated grief, traumatic grief, and persistent complex bereavement disorder, is a mental disorder consisting of a distinct set of symptoms following the death of a family member or close friend. While grief is a natural and normal response to painful or traumatic events or losses, people with PGD are preoccupied by grief and feelings of loss to the point of clinically significant distress and impairment, which can manifest in a variety of symptoms including depression, emotional pain, emotional numbness, loneliness, identity disturbance and difficulty in managing interpersonal relationships. Difficulty accepting the loss is also common, which can present as rumination about the death, a strong desire for reunion with the departed, or disbelief that the death occurred. PGD is estimated to be experienced by about 10 percent of bereaved survivors, although rates vary substantially depending on populations sampled and definitions used.
In March 2022, PGD was added as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. PGD is also in the eleventh revision of the International Classification of Diseases. To meet diagnosis, symptoms must occur frequently and be present for at least 6–12 months.
Signs and symptoms
PGD behavioral symptoms include:- Elevated rates of suicidal ideation and attempts
- Functional impairment
- High treatment-seeking behaviors
- Adverse health behaviors
- Reduced quality of life in adults and in children
- Cancer
- Immunological dysfunction
- Hypertension
- Cardiac events
Grief is a common response to bereavement, occurring in a variety of severities and durations, however only a minority of cases of grief meet the severity and duration criteria to merit diagnosis of PGD; it is considered when an individual's ability to function and level of distress over the loss is extreme and persistent. People with PGD can experience a chronic aching and yearning for the dear departed, feel that they are not the same person anymore, become emotionally disconnected from others, or lack the desire to "move on". Although normal grief remains with the bereaved person far into the future, its ability to disrupt the survivor's life is believed to dissipate with time.
Since the 1990s, studies have demonstrated the validity of distinguishing PGD from mental disorders with similar symptom clusters, specifically major depressive disorder and post-traumatic stress disorder. Validity has also been demonstrated for the DSM-5-TR criteria.
Diagnosis
Both DSM-5-TR or the ICD-11 are manuals that describe the diagnostic criteria for prolonged grief disorder. As early as 2009, diagnostic criteria for PGD were proposed and later revised. However, Section IIwhich contains officially recognized diagnosesof the DSM-5 did not include PGD; it was only added later in the DSM-5-TR. The DSM-5 however includes persistent complex bereavement disorder as a proposed diagnosis in Section III. The ICD-11 was published in 2022 and also included PGD. Compared to the DSM-5-TR criteria, the ICD-11 allows for a shorter duration of grief responses in adults before diagnosing prolonged grief disorder.DSM-5-TR
Prolonged grief disorder in the DSM-5-TR is classified as a "trauma and stressor-related disorder". The diagnosis is given when someone experiences intense and persistent grief following the death of a close person. Key symptoms include intense longing or preoccupation with the deceased, along with additional signs such as disturbances in the sense of identity, difficulty accepting the death, intense emotional pain or numbness, feeling very lonely, and finding that life is meaningless. The symptoms must cause significant distress or impairment, exceed cultural expectations for grief, and not be better explained by another mental or medical condition.According to psychologist Holly Prigerson, an editor on the trauma and stressor-related disorder section of the DSM-5-TR, strong and ongoing longing for the deceased is a key symptom of prolonged grief, but it is not a feature of depression or any other disorder in the DSM.
ICD-11
Prolonged grief disorder in the ICD-11 is diagnosed when a person experiences ongoing and intense grief after the death of someone close. Core symptoms include strong longing or preoccupation with the deceased, combined with emotional pain such as sadness, guilt, anger, or numbness. The grief must last longer than culturally expected and cause significant disruption to daily life. Additional signs include difficulty coping without the deceased, problems recalling positive memories, social withdrawal, and increased substance use or suicidal thoughts. The diagnosis should reflect the individual's cultural norms and not be confused with normal bereavement or other mental health conditions like depression or PTSD. Children and older adults may show grief differently depending on developmental stages.Assessment tools
Multiple assessment tools specifically for grief related to bereavement have been developed. The Brief Grief Questionnaire, the 13-item Prolonged Grief-13-R and the 19 item Inventory for Prolonged Grief are screening tools which may suggest the presence of a prolonged grief disorder, with further interview and grief history inventory required to establish a diagnosis. The Inventory of Complicated Grief is validated to assess grief symptoms and remains widely used today. According to a 2020 systematic review, there were eleven assessment tools, three of which are designed for clinical interviews. The Traumatic Grief Inventory Self-Report was the only assessment tool found to have empirical evidence supporting use as a diagnostic tool.Causes
No specific causes guarantee onset of PGD. Known risk factors include one-time incidents along with chronic conditions and neurological abnormalities. One-time incidents include:- The death was due to a violent method, such as homicide or suicide
- The death occurred in a hospital
- Miscarriage
- Lack of preparation for death, or high levels of anticipatory grief
- Childhood separation anxiety
- Controlling parents
- Parental abuse or death
- Close kinship relationship to the deceased
- Insecure attachment styles
- Emotional dependency
- Emotional closeness to the deceased before death
These risk factors and clinical correlates have been largely shown to relate to PGD symptoms and not symptoms of major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder.
Management
Treatment is strongly recommended for prolonged grief disorder. The first line treatment is Grief Focused Psychotherapy. Specifically, Prolonged Grief Therapy has the best evidence of effectiveness. Other cognitive-behavioural therapies have also been developed and shown effectiveness in reducing symptoms of PGD, PTSD and depressive symptoms in bereaved suffering from PGD. Antidepressants may be combined with grief focused therapy when one is having symptoms of concomitant depression, including co-existing major depression. However, medications as a sole therapy for grief related symptoms has not been shown to be helpful and is not recommended.A combination of relational and cognitive-behavioral interventions have shown evidence for efficacy when treating individuals who have lost loved ones to suicide. Exposure therapy has mixed evidence and in some cases intensifies symptoms, suggesting effectiveness does not vary significantly compared to non-exposure therapies especially with comorbid PTSD. Group therapy has mixed evidence, and has been shown to be less helpful when compared to other treatments.