Prolonged grief disorder
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Prolonged grief disorder (PGD) refers to a syndrome consisting of a distinct set of symptoms following the death of a loved one. PGD is experienced by about 10 percent of bereaved survivors, though rates vary depending on the circumstances. The affected person is incapacitated by grief, so focused on the loss that it is difficult to care about much else. He or she often ruminates about the death and longs for a reunion with the departed, while feeling unsure of his or her own identity and place in the world. The victim will develop a flat and dull outlook on life, feeling that the future holds no prospect of joy, satisfaction or pleasure. The bereaved person who suffers from PGD feels devalued and in constant turmoil, with an inability to adjust to (if not a frank protest against) life without the beloved.
|Prolonged grief disorder|
PGD is defined by its symptoms, duration and intensity. The symptoms are intense yearning for the person, identity confusion, difficulty accepting the loss, bitterness, emotional numbness, inability to trust others and the feeling of being trapped in grief. These are present every day, causing significant distress and functional impairment, and remaining intense, frequent, and disabling for six months or more after the death.
PGD symptoms have been associated with:
- Elevated rates of suicidal ideation and attempts
- Immunological dysfunction
- Cardiac events
- Functional impairment
- Adverse health behaviors
- Reduced quality of life in adults and in children
- Increased health service use and sick leave
Known risk factors include one-time and ongoing events and conditions:
- Childhood separation anxiety
- Controlling parents
- Parental abuse or death
- Close kinship relationship to the deceased (e.g., parents)
- Insecure attachment styles
- Emotional dependency
- Lack of preparation for death
- Death in hospital
- No shortened rapid eye movement (REM) latency
- Activation of the nucleus accumbens
These risk factors and clinical correlates have been shown to relate to PGD symptoms and not symptoms of major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD).
Factor analytic studies have determined that the symptoms of PGD form a unitary construct that is separate from symptoms of bereavement-related depression and anxiety. Extensive research has been conducted to identify and isolate the symptoms that constitute PGD and distinguish it from diagnostic "nearest neighbors" such as Major Depressive Disorder or Posttraumatic Stress Disorder. These analyses integrate clinical insights with rigorous empirical analysis to determine the set of symptoms that best indicate which bereaved survivors will be at risk of long term dysfunction and distress (e.g., suicidality, alcohol abuse, disability days, sleep impairment, quality of life impairment, high blood pressure, hospitalizations for serious medical events such as heart attacks).
Prigerson et al. proposed diagnostic criteria for PGD for inclusion in the DSM-5 and ICD-11.
Grief is a normal response to bereavement. Researchers have found that 10–20% of people experience a prolonged response to bereavement that impacts functioning and has adverse long-term effects on health.
Prolonged grief is considered when an individual's ability to function and level of distress over the loss is extreme and persistent. People with PGD feel "stuck" in their grief, experience a chronic aching and yearning for the dear departed, feel that they are not the same person anymore (e.g., unsure of their identity, loss of a sense of self and self-worth), become emotionally disconnected from others, and lack the desire to "move on" (sometimes feeling that doing so would be betraying the person who is now deceased).
The unique symptom profile and course of PGD requires targeted treatment. Randomized control trials (RCT) have proven tricyclic antidepressants alone or together with interpersonal psychotherapy ineffective in reducing PGD symptoms, while psychotherapy designed specifically for PGD has been proven to be beneficial. Preliminary results of an online, self-management intervention to prevent PGD in recently bereaved individuals, in a study called "HEAL" (Healthy Experiences After Loss), are very promising. A larger randomized controlled trial is being planned.
The DSM-IV and ICD-10 do not distinguish between normal and prolonged grief. Based on numerous findings of maladaptive effects of prolonged grief, diagnostic criteria for PGD have been proposed for inclusion in the DSM-5 and ICD-11. In 2018, the WHO included PGD in the ICD-11 and it is currently the only official diagnosis for PGD. The APA is investigating adding PGD in the DSM-5-TR (text revision).
The proposed diagnostic criteria were the result of statistical analysis of a set of criteria agreed upon by a panel of experts. The analyses produced criteria that were the most accurate markers of bereaved individuals suffering from painful, persistent, destructive PGD. The criteria for PGD have been validated and dozens of studies both internationally and domestically are being conducted, and published, that validate the PGD criteria in other cultures, kinship relationships to the deceased and causes of death (e.g., earthquakes, tsunami, war, genocide, fires, bombings, palliative and acute care settings).
Recognizing prolonged grief as a disorder would allow it to be better understood, detected, studied and treated. Insurance companies would also be more likely reimburse its care. On the other hand, inclusion of PGD in the DSM-5 and ICD-11 may be misunderstood as the medicalization of grief, reducing its dignity, turning love into pathology and implying that survivors should quickly forget and "get over" the loss. Bereaved persons may be insulted by having their distress labeled as a mental disorder. While this stigmatization would not be the intent, it might be an unintended consequence. In spite of this concern, studies have shown that nearly all bereaved individuals who met the criteria for PGD were receptive to treatment and their families relieved to know they had a recognizable syndrome. In addition, a recent study found that labeling PGD symptoms with a grief-specific diagnosis does not produce public stigma.
Difference from normal griefEdit
Although extremely painful, grief is the normal process of accommodating to a new life without the deceased loved one. Most bereaved survivors manage to get through the worst of their grief and continue to function and find meaning in life. Normal grief differs from PGD in that it is not as intense, persistent, disabling and life-altering and is not experienced as a severe threat to the survivor's identity, sense of self-worth, feeling of security, safety or hopes for future happiness. Although normal grief remains with the bereaved person far into the future, its ability to disrupt the survivor's life dissipates with time.
- Davis M, Feyer P, Ortner P, Zimmermann C (2011). Supportive Oncology. Philadelphia, PA: Elsevier Saunders. p. 628. ISBN 978-1-4377-1015-1.
- Frances, A. (2012, February 28). When Good Grief Goes Bad. The Huffington Post. Retrieved from http://www.huffingtonpost.com/allen-frances/grief-depression_b_1301050.html
- Prigerson HG, Bridge J, Maciejewski PK, Beery LC, Rosenheck RA, Jacobs SC, et al. (December 1999). "Influence of traumatic grief on suicidal ideation among young adults". The American Journal of Psychiatry. 156 (12): 1994–5. doi:10.1176/ajp.156.12.1994 (inactive 2020-09-01). PMID 10588419.CS1 maint: DOI inactive as of September 2020 (link)
- Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear MK, Day N, et al. (May 1997). "Traumatic grief as a risk factor for mental and physical morbidity". The American Journal of Psychiatry. 154 (5): 616–23. doi:10.1176/ajp.154.5.616. PMID 9137115.
- Irwin M, Daniels M, Weiner H (1987). "Immune and neuroendocrine changes during bereavement". Psychiatr Clin North Am. 10 (3): 449–465. doi:10.1016/S0193-953X(18)30554-9. PMID 3317313.
- Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, et al. (August 2009). Brayne C (ed.). "Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11". PLOS Medicine. 6 (8): e1000121. doi:10.1371/journal.pmed.1000121. PMC 2711304. PMID 19652695.
- Prigerson HG, Frank E, Kasl SV, Reynolds CF, Anderson B, Zubenko GS, et al. (January 1995). "Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses". The American Journal of Psychiatry. 152 (1): 22–30. CiteSeerX 10.1.1.466.8151. doi:10.1176/ajp.152.1.22. PMID 7802116.
- Latham AE, Prigerson HG (2004). "Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality". Suicide & Life-Threatening Behavior. 34 (4): 350–62. doi:10.1521/suli.34.4.350.53737. PMC 1459278. PMID 15585457.
- Jacobsen J, Vanderwerker L, Block S, Friedlander R, MacIejewski P, Prigerson H (2006). "Depression and demoralization as distinct syndromes: Preliminary data from a cohort of advanced cancer patients". Indian Journal of Palliative Care. 12: 8–15. doi:10.4103/0973-1075.25913.
- Silverman GK, Jacobs SC, Kasl SV, Shear MK, Maciejewski PK, Noaghiul FS, Prigerson HG (July 2000). "Quality of life impairments associated with diagnostic criteria for traumatic grief". Psychological Medicine. 30 (4): 857–62. doi:10.1017/S0033291799002524. PMID 11037094.
- Lannen PK, Wolfe J, Prigerson HG, Onelov E, Kreicbergs UC (December 2008). "Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later". Journal of Clinical Oncology. 26 (36): 5870–6. doi:10.1200/JCO.2007.14.6738. PMC 2645112. PMID 19029425.
- Kersting A, Wagner B (June 2012). "Complicated grief after perinatal loss". Dialogues in Clinical Neuroscience. 14 (2): 187–94. PMC 3384447. PMID 22754291.
- Vanderwerker LC, Jacobs SC, Parkes CM, Prigerson HG (February 2006). "An exploration of associations between separation anxiety in childhood and complicated grief in later life". The Journal of Nervous and Mental Disease. 194 (2): 121–3. doi:10.1097/01.nmd.0000198146.28182.d5. PMID 16477190. S2CID 8995920.
- Johnson JG, Zhang B, Greer JA, Prigerson HG (January 2007). "Parental control, partner dependency, and complicated grief among widowed adults in the community". The Journal of Nervous and Mental Disease. 195 (1): 26–30. doi:10.1097/01.nmd.0000252009.45915.b2. PMID 17220736. S2CID 45358849.
- Silverman GK, Johnson JG, Prigerson HG (2001). "Preliminary explorations of the effects of prior trauma and loss on risk for psychiatric disorders in recently widowed people". The Israel Journal of Psychiatry and Related Sciences. 38 (3–4): 202–15. PMID 11725418.
- Mitchell AM, Kim Y, Prigerson HG, Mortimer-Stephens M (2004). "Complicated grief in survivors of suicide". Crisis. 25 (1): 12–8. doi:10.1027/0227-5910.25.1.12. PMID 15384652.
- Cleiren M, Diekstra RF, Kerkhof AJ, van der Wal J (1994). "Mode of death and kinship in bereavement: focusing on "who" rather than "how"". Crisis. 15 (1): 22–36. PMID 8062585.
- van Doorn C, Kasl SV, Beery LC, Jacobs SC, Prigerson HG (September 1998). "The influence of marital quality and attachment styles on traumatic grief and depressive symptoms". The Journal of Nervous and Mental Disease. 186 (9): 566–73. doi:10.1097/00005053-199809000-00008. PMID 9741563.
- Johnson JG, Vanderwerker LC, Bornstein RF, Zhang B, Prigerson HG (2006). "Development and Validation of an Instrument for the Assessment of Dependency Among Bereaved Persons". Journal of Psychopathology and Behavioral Assessment. 28 (4): 261–70. doi:10.1007/s10862-005-9016-3. S2CID 144070054.
- Barry LC, Kasl SV, Prigerson HG (2002). "Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death". The American Journal of Geriatric Psychiatry. 10 (4): 447–57. doi:10.1176/appi.ajgp.10.4.447. PMID 12095904.
- Hebert RS, Dang Q, Schulz R (June 2006). "Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: findings from the REACH study". Journal of Palliative Medicine. 9 (3): 683–93. doi:10.1089/jpm.2006.9.683. PMID 16752974.
- Wright AA, Keating NL, Balboni TA, Matulonis UA, Block SD, Prigerson HG (October 2010). "Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health". Journal of Clinical Oncology. 28 (29): 4457–64. doi:10.1200/JCO.2009.26.3863. PMC 2988637. PMID 20837950.
- McDermott OD, Prigerson HG, Reynolds CF, Houck PR, Dew MA, Hall M, et al. (March 1997). "Sleep in the wake of complicated grief symptoms: an exploratory study". Biological Psychiatry. 41 (6): 710–6. doi:10.1016/S0006-3223(96)00118-7. PMID 9066995. S2CID 22306103.
- O'Connor MF, Wellisch DK, Stanton AL, Eisenberger NI, Irwin MR, Lieberman MD (August 2008). "Craving love? Enduring grief activates brain's reward center". NeuroImage. 42 (2): 969–72. doi:10.1016/j.neuroimage.2008.04.256. PMC 2553561. PMID 18559294.
- Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, et al. (November 1995). "Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss". Psychiatry Research. 59 (1–2): 65–79. doi:10.1016/0165-1781(95)02757-2. PMID 8771222. S2CID 34298459.
- Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear MK, Newsom JT, Jacobs S (November 1996). "Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study". The American Journal of Psychiatry. 153 (11): 1484–6. doi:10.1176/ajp.153.11.1484. PMID 8890686.
- Prigerson HG, Shear MK, Jacobs SC, Reynolds CF, Maciejewski PK, Davidson JR, et al. (January 1999). "Consensus criteria for traumatic grief. A preliminary empirical test". The British Journal of Psychiatry. 174: 67–73. doi:10.1192/bjp.174.1.67. PMID 10211154.
- Simon NM, Wall MM, Keshaviah A, Dryman MT, LeBlanc NJ, Shear MK (February 2011). "Informing the symptom profile of complicated grief". Depression and Anxiety. 28 (2): 118–26. doi:10.1002/da.20775. PMC 3079952. PMID 21284064.
- Boelen PA, van den Bout J (November 2005). "Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study". The American Journal of Psychiatry. 162 (11): 2175–7. doi:10.1176/appi.ajp.162.11.2175. PMID 16263861.
- Boelen PA, van den Bout J, de Keijser J (July 2003). "Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: a replication study with bereaved mental health care patients" (PDF). The American Journal of Psychiatry. 160 (7): 1339–41. doi:10.1176/appi.ajp.160.7.1339. PMID 12832252.
- Maciejewski PK, Zhang B, Block SD, Prigerson HG (February 2007). "An empirical examination of the stage theory of grief". JAMA. 297 (7): 716–23. doi:10.1001/jama.297.7.716. PMID 17312291.
- Melhem NM, Moritz G, Walker M, Shear MK, Brent D (April 2007). "Phenomenology and correlates of complicated grief in children and adolescents". Journal of the American Academy of Child and Adolescent Psychiatry. 46 (4): 493–499. doi:10.1097/chi.0b013e31803062a9. PMID 17420684.
- Prigerson HG, Vanderwerker LC, Maciejewski PK (2008). "A case for inclusion of prolonged grief disorder in DSM-5". In Stroebe MS, Hansson RO, Schut H, et al. (eds.). Handbook of Bereavement Research and Practice: Advances in Theory and intervention. Washington, DC: American Psychological Association. pp. 165–86. ISBN 978-1-4338-0351-2.
- Reynolds CF, Miller MD, Pasternak RE, Frank E, Perel JM, Cornes C, et al. (February 1999). "Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy". The American Journal of Psychiatry. 156 (2): 202–8. doi:10.1176/ajp.156.2.202 (inactive 2020-09-01). PMID 9989555.CS1 maint: DOI inactive as of September 2020 (link)
- Jacobs SC, Nelson JC, Zisook S (September 1987). "Treating depressions of bereavement with antidepressants. A pilot study". The Psychiatric Clinics of North America. 10 (3): 501–10. doi:10.1016/S0193-953X(18)30557-4. PMID 3684751.
- Pasternak RE, Reynolds CF, Schlernitzauer M, Hoch CC, Buysse DJ, Houck PR, Perel JM (July 1991). "Acute open-trial nortriptyline therapy of bereavement-related depression in late life". The Journal of Clinical Psychiatry. 52 (7): 307–10. PMID 2071562.
- Shear K, Frank E, Houck PR, Reynolds CF (June 2005). "Treatment of complicated grief: a randomized controlled trial". JAMA. 293 (21): 2601–8. doi:10.1001/jama.293.21.2601. PMC 5953417. PMID 15928281.
- Boelen PA, de Keijser J, van den Hout MA, van den Bout J (April 2007). "Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling". Journal of Consulting and Clinical Psychology. 75 (2): 277–84. doi:10.1037/0022-006X.75.2.277. PMID 17469885.
- Clinical trial number NCT00598884 for "Effectiveness of an Internet-Based Self-Management Program in Treating Prolonged Grief Disorder" at ClinicalTrials.gov
- Boelen, Paul; Lenferink, Lonneke (2020). "Comparison of six proposed diagnostic criteria sets for disturbed grief". Psychiatry Research. 285. doi:10.1016/j.psychres.2020.112786.
- American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington: American Psychiatric Press. ISBN 978-0-89042-062-1.[page needed]
- National Center for Health Statistics (2009) International Classification of Diseases, Tenth Revision (ICD-10).; Available at: CDC. Accessed 12 July 2012.
- Boelen PA, Prigerson HG (October 2012). "Commentary on the inclusion of persistent complex bereavement-related disorder in DSM-5". Death Studies. 36 (9): 771–94. doi:10.1080/07481187.2012.706982. PMID 24563927. S2CID 44547916.
- Kilikelly, Clare; Zhou, Ningning; Merzhvynska, Mariia; Stelzer, Eva-Maria; Dotschung, Tenzin; Rohner, Stefan; Sun, Lea Han; Maercker, Andreas (2020). "Development of the International Prolonged Grief Disorder Scale for the ICD-11: measurement of core symptoms and culture items adapted for Chinese and German-speaking samples". Journal of Affective Disorders. doi:10.1016/j.jad.2020.08.057.
- O'Connor, Maja; Larsen, Lene; Joensen, Biretha; Boelen, Paul; Maccallum, Fiona; Komischke-Konnerup, Katrine; Bryant, Richard (2020). "Valid ICD-11 PGD Scales and Structured Clinical Interviews Needed". Frontiers in Psychology. 11. doi:10.3389/fpsyg.2020.01120.
- Kokou-Kpolou, Cyrille; Cénat, Jude; Noorishad, Pari-Gole; Park, Sunyoung; Bacqué, Marie-Frédérique (2020). "A comparison of prevalence and risk factor profiles of prolonged grief disorder among French and Togolese bereaved adults". Social Psychiatry and Psychiatric Epidemiology. 55: 757–764. doi:10.1007/s00127-020-01840-w.
- Rodríguez Villar S, Sánchez Casado M, Prigerson HG, Mesa García S, Rodríguez Villar M, Hortigüela Martín VA, et al. (June 2012). "Prolonged grief disorder in the next of kin of adult patients who die during or after admission to intensive care". Chest. 141 (6): 1635–1636. doi:10.1378/chest.11-3099. PMID 22670028.
- Morina N, von Lersner U, Prigerson HG (2011). Laks J (ed.). "War and bereavement: consequences for mental and physical distress". PLOS ONE. 6 (7): e22140. Bibcode:2011PLoSO...622140M. doi:10.1371/journal.pone.0022140. PMC 3134481. PMID 21765944.
- Johnson JG, First MB, Block S, Vanderwerker LC, Zivin K, Zhang B, Prigerson HG (September 2009). "Stigmatization and receptivity to mental health services among recently bereaved adults". Death Studies. 33 (8): 691–711. doi:10.1080/07481180903070392. PMC 2834798. PMID 19697482.
- Gonschor, Judith; Eisma, Maarten; Barke, Antonia; Doering, Bettina (2020). "Public stigma towards prolonged grief disorder: Does diagnostic labeling matter?". PLoS ONE. 15 (9). doi:10.1371/journal.pone.0237021.