Prolonged Grief Disorder, a Second Look

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March 18, 2022: The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revision (DSM-5-TR) was released.

Throngs of psychology professionals the world over once again lose their minds, outraged at yet another diagnosis allegedly pathologizing normal human experiences: prolonged grief disorder (PGD).

The New York Times responded with an article, “How Long Should it Take to Grieve? Psychiatry Has Come Up With an Answer,” that pits two grief experts’ polarizing views. Twitter erupted with professional debates, and the American Psychiatric Association (APA) ran for cover while the dust settles. Some of us pulled up a chair, curiously entertained by the ensuing carnage.

Let's Be Objective

People need things to argue about, and it’s no different in the psychology community. Premenstrual dysphoric disorder was going to pathologize the menstrual cycle; disruptive mood dysregulation disorder was pathologizing temper tantrums, etc.

Once the dust settled, upon closer examination, many came to understand these were clearly directed towards outliers who have significantly pervasive experiences that are much more complicated than the common mood shifts during a menstrual cycle or the garden variety temper tantrum. Sure, some remained adamant about these diagnoses' alleged damages, but others found relief in recognizing their or their loved ones' unique plight.

The contention with PGD is that grief is a normal experience, so how can you tell someone experiencing it that they are sick? It is not ironic that PGD gets considered “pathologizing a normal human experience,” but no one ever blinked at applying a major depression or adjustment disorder diagnosis to people whose affective disposition is rooted in grief. Doesn't application of a diagnosis of any sort imply pathology?

With PGD, it's estimated that it affects around 7-10 percent of bereaved individuals (e.g., Maccallum & Bryant, 2019; Karkarala et al., 2020). That's ultimately a pretty small number and hardly a blanket statement about grief that will pathologize a normal experience.

Putting It Into Perspective

It's often heard that money is the root of all evil, but it would be hard to exist without it; the issue is more related to how the money is used. The same goes for diagnoses. They’re necessary and helpful when used correctly. Instead of immediately criticizing a diagnosis, perhaps consider that the problem may be more related to how the diagnosis is applied. Is it possible that honing diagnostic skills, as discussed in "Tips for Accurate Diagnosing: One Symptom Isn't Enough," could be what keeps PGD from contaminating the perception of normal grief?

To put things into perspective, anxiety, depression, and insomnia are also normal human experiences, but no one is calling for the de-recognition of major depressive disorder, generalized anxiety, or primary insomnia.

I once heard a talk by the late pioneering psychologist Albert Ellis at one of his famous Friday Night sessions. He said, “Depression and anxiety are like the common cold; everyone gets it to one degree or another. It’s just that some people have it to greater or lesser degrees or more or less often.”

Ellis' description leads us to the basis for all psychiatric diagnoses. On one end of the spectrum, anxiety, grief, insomnia, etc., are fleeting, normal hiccups in our well-being, and we continue to function fairly well despite. On the other, when the intensity and frequency of such things continuously elevate, and there is persistent, reduced capacity for the person's level of normal, optimal functioning, it's hard to deny it has reached pathological levels, leading to formal recognition as a diagnosis which conceptualizes the experience thus.

Critics of diagnoses often fail to pay attention to the fact that the APA (and other diagnosis-sanctioning bodies like the International Classification of Disease [ICD]) recognize in their material that many conditions are normal human experiences. However, they clearly state that it only becomes diagnosable if it becomes pervasive.

This means it’s in excess of what’s generally expected and maintains a pattern of significantly impairing a person’s ability to optimally function at home, school, or in social or occupational arenas, creating disorder and thus requiring recognition for specific intervention. It’s normal, for example, to feel blue, not sleep well, and want to be left alone when something upsetting occurs. If, however, this goes on for weeks and the person starts to not maintain hygiene, begins thinking about death, and loses their appetite, it’s abnormal and concerning, and thus called a major depressive episode in recognition of the gravity of the matter.

Grief Essential Reads

Conversations With Patients Who Have Died

We Heal From Grief in Relationship

The Real Problem

Where problems with over-pathologizing tend to be encountered is when providers arbitrarily apply a diagnosis based on its name or one chief symptom. This issue was recognized almost 125 years ago when Emil Kraepelin, the father of modern psychiatric disorder classification methods, wrote, “A single symptom unto itself never justifies a diagnosis, no matter how representative it may be”(Spitzer et al., 2002).

Source: Daria Rudyk/Pexels

Regarding PGD, the issue will most likely be that careless providers will contribute to some pathologizing of the normal human experience of grief when PGD is reflexively applied to anyone who seeks therapy for grief. The fact that some may do this doesn't warrant de-recognition of the matter.

Some people just need to process a death and move on; they’re not spinning their wheels for extensive periods trying to gain traction once more, like the example in "Beyond Grief." Others are, and that’s what PGD recognizes.

PGD Intervention Considerations

Considering the identity and existential crises inherent in people with PGD, it’s easy to see it’s different from garden variety depression. As such, it deserves its own study because it will require unique intervention. PGD is essentially noting that it’s not only important to understand the person is depressed but also to understand the unique conflicts that must be navigated. This new diagnostic category will invite clinicians to study the uniquities and better prepare.

For example, many people with PGD have a disrupted sense of identity without the deceased. They struggle to integrate socially without the person and thus isolate, which further stirs the grief; and there is not only sadness, but bitterness, or all-consuming emotional numbness, perhaps even to the point of dissociation so painful is the loss (DSM-5-TR).

Some Prozac and cognitive therapy likely won’t cut it, especially when it has been recognized that PGD has a lot in common with one of the most complicated conditions of all: PTSD (e.g., Maercker & Lalor, 2012). In fact, some researchers like Maccallum and Bryant (2019) noted that PGD seems to respond more favorably to more trauma-focused interventions than depression-focused ones.

While anyone familiar with existential psychotherapy will know that life and death are the bread and butter of the approach, it will be interesting to see how existentialism, which is more akin to analysis than it is to the often-favored cognitive-behavioral therapy (CBT) approaches, might be integrated into CBT as pointed interventions are trialed.

Further, research has been going on for years regarding the effects of grief on the body. It is not only a matter of the brain, but it seems that there are frequently concurrent physical problems that develop alongside the depression in the prolonged aggrieved that leads to morbidity (e.g., Fagundes et al., 2019; O'Connor, 2019). Therefore, it may also become important to immediately integrate physiological examination/intervention in those identified with PDG because there is a high correlation between physical comorbidities and mortality.

Ultimately, PGD does not simply apply a pathological label to grief and is beneficial to clinically recognize for more accurate intervention.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.