Is prolonged grief disorder an important addition to the DSM-5-TR?
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In the article titled “Is DSM-5-TR Worth Buying?,” Allen Frances, MD, argued that the new DSM-5-TR category of prolonged grief disorder (PGD) mislabels grief as a psychiatric disorder, “stigmatizes the grievers, exposes them to unneeded psychiatric medication, and insults the dignity of their loss.” In response, I want first to acknowledge that colleagues who are worried about the diagnosis are making some important points but overemphasize the potential negative consequences and neglect to name the positive ones.
PGD occurs when something interferes with adapting to the loss of a loved one.1,2 It is analogous to a wound complication that interferes with healing. Clinically, PGD is characterized by persistence—often for years—of acute grief, accompanied by maladaptive thoughts, dysfunctional behaviors (particularly avoidance coping), and inability to effectively regulate emotions. The persistence and predominance of early grief coping responses, such as counter-factual thinking, self-blame, and avoidance, derails the process of adaptation—that is, of learning to accept the finality of the loss, and to envision a life of meaning and fulfillment in the absence of the loved one. The suffering, anguish, and disablement of PDG are profound and enduring.
Accurate diagnosis matters because there is a specific psychotherapy—prolonged grief disorder therapy (PGDT)—proven to be highly effective in 3 NIMH-sponsored randomized controlled trials involving 641 participants aged 20 to 93 (70% to 80% effective).3-5 PGDT enables acceptance of the finality of the loss, assists with the restoration of meaning and purpose, and facilitates a continuing bond with the loved one. PGDT is organized around 7 themes or healing milestones: (1) accepting the finality of the loss, (2) restoring the capacity for well-being, (3) seeing a promising future, (4) strengthening relationships, (5) narrating the story of the death (imaginal revisiting), (6) living with reminders (situational revisiting), and (7) connecting with memories (imaginal conversations). A PGDT tutorial to learn how this therapy has been done can be found online (https//:prolongedgrief.columbia.edu).6
In essence, PGD is a serious mental disorder that puts the griever at risk for intense distress, poor physical health, shortened life expectancy, and suicide.2 Failure to diagnose PGD denies the patient access to a highly effective and specific psychotherapy.
We know that acute grief is a cold, dark, lonely place. In contrast to what the commentary noted, my view and that of my collaborators1,2 is that grief per se is not the problem. Indeed, grief is normally an adaptive process and, as Frances noted, does not have a fixed expiration date. Rather, in PGD, the grieving process has become derailed, necessitating intervention not in the form of psychiatric medication (as suggested in the commentary), but rather via a brief, specific psychotherapy which teaches the griever new coping strategies, addressing the challenge of warming things up, turning on lights, and opening doors to the outside world. Doing so not only does not stigmatize patients (contrary to the assertion), but rather honors their loss by helping them to integrate that loss into their lives—transforming and restoring lives of purpose and meaning.
Dr Reynolds is Distinguished Professor of psychiatry and UPMC Endowed Professor in geriatric psychiatry emeritus at the University of Pittsburgh School of Medicine. He is also an editor for the American Journal of Geriatric Psychiatry.
Acknowledgment: The author would like to thank Ronald W. Pies, MD for his comments on a draft of this article.
1. Prigerson HG, Shear MK, Reynolds CF III. Prolonged grief disorder diagnostic criteria: helping those with maladaptive grief responses. JAMA Psychiatry. February 2, 2022. Online ahead of print.
2. Prigerson HG, Kakarala S, Gang J, Maciejewski PK. History and status of prolonged grief disorder as a psychiatric diagnosis. Annu Rev Clin Psychol. 2021;179:109-126.
3. Shear MK, Frank E, Houck PR, Reynolds CF III. Treatment of complicated grief: a randomized controlled trial. JAMA.2005;293(21):2601-2608.
4. Shear MK, Wang Y, Skritskaya N, et al. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry. 2014;71(11):1287-1295.
5. Shear MK, Reynolds CF, Simon N, et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry. 2016;73(7):684-694.
6. The Center for Prolonged Grief; Columbia University School of Social Work. Overview. Accessed March 29, 2022. https://prolongedgrief.columbia.edu/professionals/complicated-grief-professionals/overview/