A Revised Perspective on "Prolonged Grief Disorder"

William G. Hoy

Baylor University

On April 6, the American Psychiatric Association posted a potential revision to the DSM-5 (Diagnostic & Statistical Manual of Mental Disorders) that is a consensus diagnostic criteria for dealing with persons experiencing grief that seems never to "progress." Herein is one of the great challenges of systematizing such a complex process, a fact I and many others have been pointing out in the context of this debate for a couple of decades now.

First, we have a burgeoning scientific basis to substantiate the reality that some individuals (7% of all bereaved persons is the current favored estimate) somehow get "stuck" in their grief. But clinicians do not need data to know this fact; we see it in the countless individuals in our practices who express just such sentiments. In the words of my colleague and friend, Dale Larson, it really boils down to two questions: Are you having trouble with your grief? Would you like some help with that?

Second, the issue becomes more clouded when we ask questions about "how long" and "to what intensity" is "normal grief?" If we believe that bereavement fundamentally reshapes our lives and that we do not so much "recover" as we do "integrate" the loss, how exactly do we make sense of the notion something could be "prolonged?" Yet, there is a collective sense--whether for the bereaved mom or the widowed husband or the child orphaned in mid-life--that at some point, one begins to function again in the work and social world in socially-sanctioned ways. As a society, we are patient with the bereaved parent's tears a few weeks after the death of a child but is it reasonable to expect constant tearfulness and inability to talk of anything except that child six years after his death?

So to those questions, researchers have continually studied and then debated the conclusions of varied ways to categorize such loss. Now, perhaps we have the first glimmer of a consensus; the major research groups working on these issues have collaborated on a consensus criteria and have proposed it in the continual revision process for the DSM.

For non-clinicians who might not understand the significance of this, let me explain. The DSM (and its counterpart in medicine, the ICD or International Classification of Disease) lays out the consensus criteria on which any health care professional should rely in diagnosing a patient with, say, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, or Major Depressive Disorder. There has really never been a serviceable diagnostic criteria for complicated bereavement, leaving many therapists to refer to this complex grief as adjustment disorders or depression. The World Health Organization recently accepted the following criteria into its coming release of the ICD and now the American Psychiatric Association, publisher of the DSM is considering the same.

Here is the proposed criteria along with a link to the APA's website where its context is more fully explained:

Proposed Diagnostic Criteria: Prolonged Grief Disorder

1. The death of a person close to the bereaved at least 12 months previously.
2. Since the death, there has been a grief response characterized by intense yearning/longing for the deceased person or a preoccupation with thoughts or memories of the deceased person. This response has been present to a clinically significant degree nearly every day for at least the last month.
3. As a result of the death, at least 3 of the following symptoms have been experienced to a clinically significant degree, nearly every day, for at least the last month:
   1. Identity disruption (e.g., feeling as though part of oneself has died)
   2. Marked sense of disbelief about the death
   3. Avoidance of reminders that the person is dead
   4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
   5. Difficulty moving on with life (e.g., problems engaging with friends, pursuing interests, planning for the future)
   6. Emotional numbness
   7. Feeling that life is meaningless
   8. Intense loneliness (i.e., feeling alone or detached from others)
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. The duration of the bereavement reaction clearly exceeds expected social, cultural or religious norms for the individual's culture and context.
6. The symptoms are not better explained by another mental disorder

Over the next few weeks, anyone interested can comment on the proposed criteria. Concerned about the wording? Post your comment. Concerned that we are even adding such a diagnosis to the manual? Post your comment.  Like what you see and think we should move "full speed ahead?" Post your comment. The posting period ends on May 20.


Personally, I like this criteria better than anything I have seen yet. First, I like that the consensus criteria has pushed out the "adjustment period" to at least 12-months post-death. The early suggestions of six months was far too short in my clinical experience. I also like that we are making tracks to have a consensus criteria because that will help with such practical issues as insurance and Medicare reimbursement.

Second, there is always a dilemma in drawing lines where a "normal" process crosses the line to "abnormal." And while we long-sense quit using terms like "abnormal grief" and "pathological grief," isn't that really what the disorder-oriented criteria does? Like with all other issues, in the hands of the uninformed and worse, the ill-intentioned, this could be problematic. Moreover, it is not a sign of complicated grief or prolonged grief or whatever we end up calling it when a person still has occasional pangs of "missing you" years after the loss. This is especially acute for many bereaved individuals on  holidays and other special days.

Whether we are really "there" yet, or not, I do not know but I will be curious to see what the comments offer by way of thoughtful dialogue. What seems vital in this process, however, is that we are continuing to dialogue with each other about the best ways to support and intervene with those people who are continually struggling with accommodating their losses, often years after the experience. And if that is beneficial in providing better care to these suffering individuals, I applaud the effort.