The addition of the diagnostic category prolonged grief disorder to DSM-5-TR is timely and important given the COVID-19 pandemic’s enormous death toll, wrote Holly Prigerson, Ph.D., of Weill Cornell Medicine and colleagues in a Viewpoint article published yesterday in JAMA Psychiatry. It is vital clinicians know how to identify pathological manifestations of grief and connect patients with proven treatments, notes Prigerson and her co-authors, psychiatrists Katherine Shear, M.D., of Columbia University and Charles F. Reynolds III, M.D., of the University of Pittsburgh Medical Center.
“[Prolonged grief disorder] is a serious mental disorder that puts the patient at risk for intense distress, poor physical health, shortened life expectancy, and suicide,” the authors wrote.
“The DSM-5-TR criteria for [prolonged grief disorder] require that distressing symptoms of grief continue for at least 12 months following the loss of a close attachment and that the grief response is characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to a clinically significant (i.e., impairing) degree, nearly every day for at least the past month,” the authors continued. Patients must also experience symptoms such as feeling as though a part of oneself has died, intense emotional pain, emotional numbness, or feeling that life is meaningless because of the death.
The PG-13 Revised scale—a 13-item questionnaire that asks patients about the length of time since their loved one’s death and their symptoms of grief—can help to determine the severity of grief. A score of 30 or higher on the PG-13 Revised scale is consistent with a prolonged grief disorder diagnosis and may indicate treatment is needed.
Several studies suggest that patients with prolonged grief disorder may respond better to targeted therapy than to other therapies used to treat major depression (including citalopram and interpersonal therapy). Among 641 participants experiencing complicated grief, 71% of those treated with prolonged grief disorder therapy reported improvement on the Clinical Global Impression Scale compared with 44% of those who received either interpersonal psychotherapy or citalopram, the authors wrote.
Prolonged grief disorder therapy works under the central premise that, for patients with prolonged grief disorder, the coping responses typical of early grief—such as self-blame, avoidance, and anger—derail the naturally adaptive process of transforming and integrating grief, according to the authors. Prolonged grief disorder therapy helps the patient learn to accept his or her new reality and restore a sense of autonomy and competence. It includes seven themes, “or healing milestones,” the authors wrote, that are introduced sequentially:
- Understanding and accepting grief
- Managing grief emotions
- Seeing a promising future
- Strengthening relationships
- Narrating the story of death
- Living with reminders
- Connecting with memories
“Because of the pandemic, the absolute number of [prolonged grief disorder] cases is likely to increase and the 7% to 10% prevalence rate among … bereaved people may rise,” they wrote. “[C]linicians should learn how to accurately assess, to accurately and differentially diagnose, and to offer or refer patients for treatment.”
For related information, see the Psychiatric News article “Pandemic Takes Toll on Those Who Grieve.”
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