Opinion

Prolonged Grief Disorder Diagnostic Criteria—

VIEWPOINT
Helping Those With Maladaptive Grief Responses

Holly G. Prigerson, The American Psychiatric Association’s DSM-5-TR tent with a diagnosis of PGD and an indication for fur-
PhD presents new diagnostic criteria for prolonged grief ther evaluation and treatment (Figure).
Department of disorder (PGD).1 They provide timely and important Prolonged grief disorder can also be successfully
Medicine,
guidance for clinical practice and research given the treated, as shown in 3 separate randomized clinical trials
Weill Cornell Medicine,
New York, New York. enormous death toll from the COVID-19 pandemic comparing a 16-session PGD-targeted therapy vs treat-
both in the US and globally, complicated by the disrup- ment efficacious for major depression.3-5 Among a total
M. Katherine Shear, tion of clinical practice, social support for those dying, of 641 participants, the overall prolonged grief disorder
MD and for the bereaved left behind. Because of the pan- therapy (PGDT) response rate, as indicated by a rating
Center for Prolonged
demic, the absolute number of PGD cases is likely to in- of 2 or 1 (ie, “much improved” or “very much improved”)
Grief, Columbia
University School of crease and the 7% to 10% prevalence rate among of be- on the Clinical Global Impression Scale, was 71% vs 44%
Social Work, reaved people may rise.2 Thus, it is vital that clinicians for depression treatment using interpersonal psycho-
New York, New York; be knowledgeable about grief reactions, know how to therapy3,4 or citalopram.5 Participants were aged 20 to
and Department of
Psychiatry, Vagelos distinguish normal from pathological manifestations of 93 years, bereaved of a range of losses by natural and
College of Physicians grief, and be aware of proven treatments for it. by violent causes. Most had already received grief coun-
and Surgeons, The DSM-5-TR criteria for PGD require that distress- seling and/or mental health treatment. The largest of the
Columbia University,
ing symptoms of grief continue for at least 12 months fol- 3 randomized clinical trials, HEAL (Healing Emotions
New York, New York.
lowing the loss of a close attachment and that the grief After Loss5), found no difference between citalopram
Charles F. Reynolds III, response is characterized by intense longing/yearning and placebo in the resolution of PGD symptoms, in con-
MD for the deceased person and/or preoccupation with trast with the markedly better response rates to PGDT
University of Pittsburgh thoughts and memories of the lost person to a clinically than to no PGDT. Importantly, the combination of cit-
School of Medicine,
significant (ie, impairing) degree, nearly every day for at alopram and PGDT resulted in better resolution of de-
Department of
Psychiatry, Western least the past month. Furthermore, as a result of the pressive symptoms compared with PGDT and placebo,
Psychiatric Hospital, death, at least 3 of the following 8 symptoms have been though combined treatment led to no better resolu-
Pittsburgh, experienced to a clinically significant degree: (1) feeling tion of PGD symptoms than PGDT alone. Other similar
Pennsylvania.
as though a part of oneself has died, (2) a marked sense therapy approaches in single trials, most using cogni-
of disbelief about the death, (3) avoidance of remind- tive behavioral therapy methods, have also been tested
ers that the person has died (often coupled with in- and have demonstrated efficacy.6,7
tense searching for things reminiscent of the deceased The central premise of PGDT is that loss triggers
person and/or evidence that they are still alive, such as acute grief and a natural adaptive process by which grief
mistaking others for the person who died), (4) intense is transformed and integrated. A further premise is that
emotional pain (anger, bitterness, sorrow) related to the persistence and predominance of early grief coping re-
death, (5) difficulty with reintegration into life after the sponses (eg, protest, self-blame, anger, counterfactual
death, (6) emotional numbness (particularly with re- thinking, and avoidance) derail this process. The objec-
spect to an emotional connection to others), (7) feeling tive of PGDT is to facilitate adaptation and address these
that life is meaningless as a result of the death, and (8) derailing symptoms. Adapting to loss involves learning
intense loneliness as a result of the death. The burden to (1) accept the new reality, including the finality of the
of these symptoms causes clinically significant distress loss, a change in the relationship to the deceased, other
or impairment in social, occupational, or other impor- changes in the world, and the permanence of grief, and
tant areas of functioning. The duration and severity of (2) restore the capacity for well-being, including a sense
the bereavement reaction clearly exceeds social, cul- of autonomy, competence, and relatedness. The 7
tural, or religious norms for the individual’s culture and themes, or healing milestones, that PGDT is organized
context. Additionally, the symptoms are not better ex- around are introduced sequentially with core procedures
plained by major depressive disorder, posttraumatic for each: (1) understanding and accepting grief, (2) man-
stress disorder, or attributable to the physiological aging grief emotions—both painful and positive (grief
Corresponding
Author: Charles F. effects of a substance (eg, medication or alcohol) or to monitoring and psychoeducation), (3) seeing a promis-
Reynolds III, MD, another medical condition. ing future (aspirational goals), (4) strengthening rela-
University of Pittsburgh The performance characteristics of the PGD diag- tionships (inviting a significant other to join a session),
School of Medicine,
Department of
nostic criteria and the PG-13-Revised (PG-13-R) scale (5) narrating the story of the death (imaginal revisit-
Psychiatry, Western have been extensively researched by Prigerson et al.1 ing), (6) living with reminders (situational revisiting), and
Psychiatric Hospital, The PG-13-R is a useful self-report measure of the syn- (7) connecting with memories (imaginal conversation).
3811 O’Hara St,
drome that can be used to screen for the diagnosis and In summary, PGD is a serious mental disorder that
Pittsburgh, PA 15261
(cfreynoldsiii@gmail. estimate its severity; it maps onto DSM-5-TR diagnostic puts the patient at risk for intense distress, poor physi-
com). criteria, and a summary score of 30 or greater is consis- cal health, shortened life expectancy, and suicide.1,6

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 Opinion Viewpoint

Figure. Prolonged Grief Disorder (PG-13 Revised)

1. Have you lost someone significant to you? Yes No

2. How many months has it been since your significant other died? Months

For each item below, please indicate how you currently feel

Since the death, or as a result of the death... Not at all Slightly Somewhat Quite a bit Overwhelmingly

3. Do you feel yourself longing or yearning for

the person who died?

4. Do you have trouble doing the things you

normally do because you are thinking so much
about the person who died?

5. Do you feel confused about your role in life or

feel like you don’t know who you are anymore
(ie, feeling like that a part of you has died)?

6. Do you have trouble believing that the person

who died is really gone?

7. Do you avoid reminders that the person who

died is really gone?

8. Do you feel emotional pain (eg, anger,

bitterness, sorrow) related to the death?

9. Do you feel that you have trouble re-engaging

in life (eg, problems engaging with friends,
pursuing interests, planning for the future)?

10. Do you feel emotionally numb or detached

from others?

11. Do you feel that life is meaningless without

the person who died?

12. Do you feel alone or lonely without

the deceased?

13. Have the symptoms above caused significant impairment in Reproduced from Prigerson et al1
social, occupational, or other important areas of functioning? Yes No with permission from the World
Psychiatric Association.

Among PGD clinical trial participants, PGD has often lasted for years, tutorial on how to make a differential diagnosis can be found online.8
even after patients have received treatments proven effective for The PGD diagnostic criteria and the PG-13-R provide useful tools for
other bereavement-related mental disorders (eg, depression). Thus, bridging science and service. In addition, a PGD therapy tutorial, de-
clinicians should learn how to accurately assess, to accurately and veloped at the Center for Prolonged Grief at the Columbia School
differentially diagnose, and to offer or refer patients for treatment. of Social Work, is available to learn how this therapy has been done
Weill Cornell Medicine’s Center for Research on End-of-Life Care’s and can be found online (https://prolongedgrief.columbia.edu).9

ARTICLE INFORMATION REFERENCES JAMA Psychiatry. 2016;73(7):685-694. doi:10.1001/

Published Online: February 2, 2022. 1. Prigerson HG, Boelen PA, Xu J, Smith KV, jamapsychiatry.2016.0892
doi:10.1001/jamapsychiatry.2021.4201 Maciejewski PK. Validation of the new DSM-5-TR 6. Prigerson HG, Kakarala S, Gang J,
Conflict of Interest Disclosures: Dr Shear reported criteria for prolonged grief disorder and the Maciejewski PK. History and status of prolonged
grants from the National Institute of Mental Health PG-13-revised (PG-13-R) scale. World Psychiatry. grief disorder as a psychiatric diagnosis. Annu Rev
Small Business Technology Transfer program and 2021;20(1):96-106. doi:10.1002/wps.20823 Clin Psychol. 2021;17:109-126. doi:10.1146/annurev-
the US Department of Defense outside the 2. Lundorff M, Holmgren H, Zachariae R, clinpsy-081219-093600
submitted work. No other disclosures were Farver-Vestergaard I, O’Connor M. Prevalence of 7. Shear MK. Clinical practice. N Engl J Med. 2015;372
reported. prolonged grief disorder in adult bereavement. (2):153-160. doi:10.1056/NEJMcp1315618
Additional Contributions: We thank Stephen J Affect Disord. 2017;212:138-149. doi:10.1016/j.jad. 8. Weill Cornell Medicine Center for Research on
Cozza, MD (Uniformed Services University of the 2017.01.030 End-of-Life Care. Resources for clinicians. Accessed
Health Sciences), Paul K. Maciejewski, PhD (Weill 3. Shear K, Frank E, Houck PR, Reynolds CF III. December 28, 2021. https://endoflife.weill.cornell.
Cornell Medicine), Christine Mauro, PhD (Mailman Treatment of complicated grief. JAMA. 2005;293 edu/grief-resources/resources-clinicians
School of Public Health, Columbia University), (21):2601-2608. doi:10.1001/jama.293.21.2601 9. The Center for Prolonged Grief; Columbia
Naomi Simon, MD (New York University Grossman 4. Shear MK, Wang Y, Skritskaya N, Duan N, University School of Social Work. Overview.
School of Medicine), Natalia Skritskaya, PhD Mauro C, Ghesquiere A. Treatment of complicated Accessed December 28, 2021. https://
(School of Social Work, Columbia University), grief in elderly persons. JAMA Psychiatry. 2014;71 prolongedgrief.columbia.edu
and Sidney Zisook, MD (University of California, (11):1287-1295. doi:10.1001/jamapsychiatry.2014.1242
San Diego), for their contributions to the science of
PGD and for their review of this article. 5. Shear MK, Reynolds CF III, Simon NM, et al.
Optimizing treatment of complicated grief.

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