International Society for Traumatic Stress Studies

Is Prolonged Grief a Mental Disorder?

Posted 28 July 2013 in StressPoints by Birgit Wagner, PD, PhD

Grief reactions following the loss of a significant person are often associated with psychological and functional impairment. These reactions involve a set of expected negative symptoms, such as strong yearning, sadness and separation distress. Still, despite of the negative set of emotions, bereavement is a normal, non-pathological phenomenon. While in most cases intensive grief reactions abate after the first six months (Maciejewski, Zhang, Block, & Prigerson, 2007), in some cases grief can become severe and take the pathological form of prolonged grief. A number of studies have shown that prolonged grief is related to increased mortality and negative health outcomes (Stroebe, Schut, & Stroebe, 2007).

In the past years different workgroups have proposed a criteria set for the new DSM-5 (APA, 2013) as well as for the upcoming ICD-11 in 2015 (Horowitz et al., 1997; Prigerson et al., 2009). In parallel, a number of studies and comments have been published discussing the pros and cons of diagnostic criteria for prolonged grief (Bryant, 2012; Corruble, Falissard, & Gorwood, 2011; Friedman, 2012). Throughout the discussion between scientists and mental health professionals a number of questions have arisen regarding the specific diagnostic criteria for prolonged grief (Wagner & Maercker, 2010).

First of all, is grief a mental disorder? How can normal grief be defined within different cultural and durational differences in bereavement reactions among individuals and different bereaved subgroups (e.g. loss of a spouse, parental loss, traumatic losses)?

A number of studies have shown that depression and prolonged grief are distinct diagnostic criteria (Boelen, van de Schoot, van den Hout, de Keijser, & van den Bout, 2010; Boelen & van den Bout, 2005). However, inconclusive findings were found for normal bereavement and bereavement related depression (Fox & Jones, 2013; Zisook & Kendler, 2007; Zisook, Shear, & Kendler, 2007). In the older editions of the DSM-III-R (APA, 1987) and the DSM-IV (APA, 1994) the criteria for major depression had included an exclusion criterion of two months for diagnosing depression if the depressive symptoms could be accounted for by bereavement.

In the new DSM-5 (APA, 2013) this exclusion criterion has been eliminated. Reasons for this were that other major life-stressors (e.g. divorce, unemployment) were also not exclusionary reasons for the diagnosis of depression. The elimination of the exclusion criteria in the DSM-5 has major implications for psychiatrists and psychologists. Now, bereaved people who fulfil the symptom set of depression can be diagnosed already two weeks after the loss with a mental disorder. The danger of medicalize and over-diagnose a normal human reaction has been seen as critical and causes an ethical dilemma. Further, the DSM-5 does not recognize intensive prolonged grieving, which can impair bereaved people in the long-term.

Still, the inclusion of prolonged grief disorder with clinical diagnostic criteria in the next ICD-11 is open. The traumatic stress workgroup of the ICD-11 have proposed diagnostic criteria, which proposes prolonged grief disorder as an distinct disorder from depression and PTSD (Maercker et al., 2013). The proposed criteria are based on the criteria of Prigerson et al. (2009). The grief-related symptoms include separation distress (e.g. yearning and strong longing for the deceased), cognitive, emotional and behavioural symptoms (e.g. emotional numbness, avoidance of the reality of the loss). These symptoms must persist for at least 6 months after the bereavement and must be associated with functional impairment.

Still, even though the distinctiveness of the diagnostic criteria from other mental disorders has been shown, there remains some scepticism and critical discussion concerning the validity of diagnostic criteria for prolonged grief (Wakefield, 2013), and it is difficult to find a consensus with regard to the difference between pathological and normal grief reactions, specifically in subgroups such as the bereaved parents, whose normal grief reaction might last for years after the death of their child. In a Swedish population-based sample 26 percent of bereaved parents reported that they had not worked through their grief at 4 to 9 years after the death of their children and 23 percent said that they had worked through their grief in some ways.

Dyregrov and colleagues (2003) found in 78 percent of the parents who lost their child through suicide, accident or sudden infant death 18 months after the loss still had intense grief reactions. In a Dutch study 50 percent of the fathers and 75 percent of the mothers received a diagnosis of prolonged grief according the cut-off score of the Inventory of Complicated Grief (Prigerson et al., 1995) 20-months after the loss of their child. Prolonged grief reactions in samples of bereaved parents are so highly prevalent that intensive and long-term grieving seems to be rather the normal than the abnormal case. The criteria proposal for prolonged grief still lacks recognition of distinct bereaved subgroups. The validation of the criteria has been originally tested in a field trial of the Yale Bereavement Study, a study which only included elderly widowed persons.

The high prevalence rates among bereaved parents and the normative long-term psychological impact show that applying norms based on conjugal bereavement processes might not be equally valid for other groups of bereavement (Thieleman & Cacciatore, 2013). It is acknowledged that the ICD-11 for general reasons of clinical utility and simplicity for its worldwide use does not include subtypes of any of its new formulations of mental disorder diagnoses.

In conclusion, the inclusion of prolonged grief disorder in the next ICD-11 would have a far-reaching impact, and there are a number of good arguments for a new diagnostic category. No doubt, diagnostic criteria could be helpful for the identification of bereaved individuals who are suffering long-term pathological grief reactions. However, at this point of research the inclusion of prolonged grief as an entity may still need further validation among the different subgroups of bereaved people.

References

Boelen, P. A., van de Schoot, R., van den Hout, M. A., de Keijser, J., & van den Bout, J. (2010). Prolonged Grief Disorder, depression, and posttraumatic stress disorder are distinguishable syndromes. Journal of affective disorders, 125(1-3), 374–378. doi:10.1016/j.jad.2010.01.076.

Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study. The American journal of psychiatry, 162(11), 2175–2177. doi:10.1176/appi.ajp.162.11.2175.

Bryant, R. A. (2012). Grief as a psychiatric disorder. The British journal of psychiatry: the journal of mental science, 201(1), 9–10. doi:10.1192/bjp.bp.111.102889.

Corruble, E., Falissard, B., & Gorwood, P. (2011). Is DSM-IV bereavement exclusion for major depression relevant to treatment response? A case-control, prospective study. The Journal of clinical psychiatry, 72(7), 898–902. doi:10.4088/JCP.09m05681blu.

Fox, J., & Jones, K. D. (2013). DSM-5 and Bereavement: The Loss of Normal Grief? Journal of Counseling & Development, 91(1), 113–119.

Friedman, R. A. (2012). Grief, depression, and the DSM-5. The New England journal of medicine, 366(20), 1855–1857. doi:10.1056/NEJMp1201794.

Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath, C., & Stinson, C. H. (1997). Diagnostic criteria for complicated grief disorder. The American journal of psychiatry, 154(7), 904–910.

Maciejewski, P. K., Zhang, B., Block, S. D., & Prigerson, H. G. (2007). An empirical examination of the stage theory of grief. JAMA: the journal of the American Medical Association, 297(7), 716–723. doi:10.1001/jama.297.7.716.

Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., Reed, G. M., Ommeren, M. van, Saxena, S. (2013). Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11. Lancet. doi:10.1016/S0140-6736(12)62191-6.

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Neimeyer, R. A. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.

Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. Lancet, 370(9603), 1960–1973. doi:10.1016/S0140-6736(07)61816-9.

Thieleman, K., & Cacciatore, J. (2013). When a Child Dies: A Critical Analysis of Grief-Related Controversies in DSM-V. Research on Social Work Practice. Retrieved from http://rsw.sagepub.com/content/early/2013/01/27/1049731512474695.abstract.

Wagner, B., & Maercker, A. (2010). The diagnosis of complicated grief as a mental disorder: A critical appraisal. Psychologica Belgica, 50(1-2), 1–2.

Wakefield, J. C. (2013). Is complicated/prolonged grief a disorder? Complicated Grief: Scientific Foundations for Health Care Professionals, 99.

Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression? Psychological medicine, 37(6), 779–794. doi:10.1017/S0033291707009865.

Zisook, S., Shear, K., & Kendler, K. S. (2007). Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry: Official journal of the World Psychiatric Association (WPA), 6(2), 102–107.

About the Author

Birgit Wagner, PD, PhD, is a member of the Department of Psychosomatic Medicine and Psychotherapy at the University of Leipzig in Germany.