Running head: PROLONGED GRIEF DISORDER IN THE DSM-V



Running head: Standardized Diagnostic Criteria for PGD

A Rationale for Creating Standardized Diagnostic Criteria

for Prolonged Grief Disorder

Laurie A. Burke

University of Memphis

Although loss and grief are ubiquitous human experiences, Prolonged Grief Disorder (PGD; Boelen & Prigerson, 2007), formally called Complicated Grief (CG), stands apart as a serious psychiatric condition that mental health professionals struggle to distinguish and diagnose correctly (Shear, Frank, Houck & Reynolds, 2005). Fundamentally, PGD is an event-related, relationship-based attachment disorder with symptoms so severe that if left untreated it can cause long-term psychological disequilibrium and distress.

Research clearly demonstrates that PGD occurs in approximately 15% of the bereaved population, has a distinctly adverse trajectory, and consists of a specific cluster of symptoms (Horowitz et al., 1997; Parkes, 2007; Prigerson et al., 1995; Prigerson et al., 1999; Prigerson & Maciejewski, 2006). According to the proposed diagnostic criteria these symptoms must continue at a marked intensity for at least six months from the point of their first appearance (Boelen & Prigerson, 2007) and include separation anguish in the form of invasive thought patterns and powerful pining to be reconnected with the deceased. Furthermore, PGD is distinguished by difficulty accepting the loss, confusion about one’s role in life, avoidance of reminders of the loved one, inability to trust others, bitterness or anger surrounding the loss, difficulty moving on, numbness and shock, and a sense that life is meaningless (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 1995; Prigerson et al., 1999). Moreover, this profoundly debilitating response to loss has potentially life-threatening consequences. Most notably, individuals diagnosed with PGD have a statistically higher propensity toward suicidality (Latham & Prigerson, 2004) as well as cancer, heart disease, and sleep disturbances than those with a more normative grief response (Prigerson, Bierhals, et al., 1997).

Inclusion of PGD in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) is warranted primarily because the current options for capturing uncharacteristic responses to bereavement in the DSM-IV-TR (text revision; American Psychiatric Association, 2000) are inadequate (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson, Shear, et al., 1997). Although PGD shares symptoms with other psychiatric disorders such as emotional numbing (posttraumatic stress disorder; PTSD) and a diminished sense of self (major depressive disorder; MDD), PGD sufferers would be overlooked or “forced” into an inappropriate diagnostic category if they were assessed using only psychiatric disorders that are presently listed in the DSM-IV-TR (American Psychiatric Association). Typically, a protracted and incapacitating reaction to loss is classified as MDD (Prigerson et al., 1999) or PTSD because of symptom overlap (Shear, Jackson, Essock, Donahue, & Felton, 2006). While both MDD and PTSD have some symptoms that overlap with PGD, the new diagnosis will be helpful in describing the cardinal features of the pathological grief experience, namely the intense feeling of emotional detachment and relational severance that comes from the death-related dissolution of a core attachment (Neimeyer, 2008; Prigerson et al., 1997). With PGD, regardless of the quantity or quality of one’s social network, the primary sense is that the individual is alone in life based on the death of a primary attachment figure (Stroebe, Stroebe, Abakoumkin, & Schut, 1996).

That a traumatic event can create an environment conducive to a complicated and elongated grief response has been decidedly determined. Researchers have demonstrated that loss resulting from violent death (homicide, suicide, or fatal accident) substantially increases one’s susceptibility to a pathological grief outcome (Currier, Holland, Coleman, & Neimeyer, 2007; Hardison, Neimeyer, & Lichstein, 2005); and likewise, childhood trauma is associated with increased risk for PGD following adulthood loss (Silverman, Johnson, & Prigerson, 2001). The trauma incurred through experiencing the sudden, untimely, and violent death of a loved one can develop into PTSD (Bonnano & Kaltman, 1999; Green, 2000) and then into a lengthy and disordered grief reaction (Neimeyer, 2002).

Of particular interest to traumatologists is that protracted, persistent, and recalcitrant PTSD symptoms following trauma-related deaths might include symptoms that are better described by a PGD diagnosis. However, presently there is no bona fide provision within the field for diagnosis or treatment of PGD. The advantage of a DSM-V diagnosis for PGD is twofold. For clinicians, it affords more options for clinical assessment and treatment for their traumatically bereaved clients. For bereaved individuals, it promises validation of the “protracted misery” following the sense of violation found in the traumatic death of a loved one (Parkes, 2007, p. 141). The absence of PGD in the diagnostic nomenclature is one factor that causes alienation and disenfranchisement in this population. In fact, in a study of 135 grievers, 96% believed that an identifiable diagnosis would reduce their sense of misunderstanding and marginalization by others (Prigerson & Maciejewski, 2006).

Shear (2008) developed a version of the Structured Clinical Interview for complicated grief (SCI-CG) and a specific psychotherapy treatment designed to ameliorate the symptoms of complicated grief—complicated grief treatment (CGT; Shear, Frank, Houck, & Reynolds, 2005). For this population, CGT was found superior to interpersonal psychotherapy (IPT; used successfully for depression) in treating PGD. CGT addresses the inability to accept the loss through use of a technique similar to prolonged exposure (PE; used successfully for PTSD), called revisiting, in which the bereaved repeats and tape-records the story of the death in an effort to face aspects of the event that prevent acceptance. Simultaneously, the therapist assists the client in recognizing the areas of avoidance that keep the individual from living fully in the present and making plans for the future.

Having a recognizable diagnosis for chronic, problematic bereavement will allow for the orderly investigation of the relationship between PGD and other related phenomena. Our overall understanding of PGD has been hampered due to the lack of agreed-upon terminology; thus, inclusion of PGD will encourage convergence on a common set of terms and criteria to better organize and advance the field. Undoubtedly, research examining the correlation between trauma distress and PGD is needed (Bonanno et al., 2007). For example, are trauma patients with subsyndromal PTSD symptoms predisposed to PGD? Do sufferers of non-death traumatic losses experience PGD at the same rate and degree as those with death-related traumatic losses? What role does negative social support play in the establishment and perpetuation of PGD (Wisley & Shear, 2007)? A diagnosis for PGD will encourage and permit more rigorous research addressing these questions.

As in the battle for PTSD’s inclusion in the DSM, which included the need to demonstrate prevalence across cultures (Monson & Friedman, 2006), the proposed addition of PGD faces similar struggles as a non-normative outcome of bereavement. Although most people eventually are able to face the future without their loved one, even making some sense of the event, a substantial portion of bereaved persons exhibit a pathological reaction to loss. The inclusion of PGD in the DSM-V will help to further the development of research, to delineate the predictors and course of pathological grief, and to develop adequate treatments. Conversely, without official recognition in the DSM-V, those emotionally debilitated by traumatic losses are left to suffer needlessly and indefinitely.

References

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