Assessing and Treating Prolonged Grief Disorder

This article explores prolonged grief disorder, including definitions, symptoms, diagnostic criteria, and common treatment approaches.

Overview of grief

Grief is a normal and expected response to a loss, such as the death of a loved one or the loss of something significant, such as a pet, job, or financial loss. It can also result from other life changes, such as a medical diagnosis, the end of a significant relationship, or the loss of independence.

Grief can take many forms and can impact people in different ways, including emotional, physical, psychological, and spiritual reactions. Common emotional responses to loss include sadness, anger, guilt, and loneliness, while physical responses can include fatigue, difficulty sleeping, and changes in appetite. Psychological responses may involve a sense of numbness or disbelief, and can be accompanied by intrusive thoughts, memories, and images of the person or thing that has been lost. Spiritually, people may question their beliefs, feel abandoned by a higher power, or find comfort in their spiritual or religious practices.

There is no right or normal way to grieve, and individuals experience grief in their own unique way. Grief is highly personal, and can be influenced by individual differences, such as cultural background, age, and previous experiences with loss.

For many people, the grieving process involves several stages, including:

• Shock and disbelief,
• Yearning and searching,
• Disorganisation and depression, and finally,
• Reorganisation and resolution. 

However, it is important to note that this model is not necessarily linear and people may experience these stages in a different order or not experience some stages at all.

In working with individuals who are grieving, the role of the mental health clinician is to provide a supportive and empathetic environment. This may involve actively listening to the person’s experiences, helping them to express and process their emotions, and providing education about the grieving process and what to expect.

Additionally, it may be necessary to address any complicating factors, such as persistent grief or complicated bereavement, which can occur when grief does not resolve in a timely manner and significantly interferes with an individual’s daily functioning.

Mental health clinicians also need to be mindful of their own emotions and experiences when working with individuals who are grieving. Self-care strategies, such as debriefing with colleagues and seeking support when needed, can be helpful in preventing compassion fatigue and burnout.

In summary, grief is a complex and deeply personal experience that can impact people in a variety of ways. Mental health clinicians can play an important role in supporting individuals as they navigate this difficult time and work towards healing and resolution.

What is grief?

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revision (DSM-5-TR), persistent grief can now be classified as prolonged grief disorder (formerly called persistent complex bereavement disorder). The DSM-5 recognised that grief is a normal response to the loss of a loved one or significant object, and acknowledged that individuals may experience a range of emotions, such as sadness, anger, guilt, and disbelief. The latest iteration of the DSM, the DSM-5-TR, does not argue with those statements, but posits that when symptoms persist for longer than 12 months after the loss and significantly interfere with an individual’s daily functioning, the grief reaction is maladaptive.

The DSM-5-TR section for prolonged grief disorder (found in the chapter on trauma- and stressor-related disorders) includes six diagnostic criteria:

Criterion A

The death occurred at least 12 months ago (six months for children and adolescents).

Criterion B

Since the death or loss, there has been the development of a persistent grief response characterised by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month:

1. Intense and persistent yearning or longing for the deceased person or object
2. Preoccupation with thoughts or memories of the deceased person.

Criterion C

Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:

1. Identity disruption (feeling like part of oneself has died since the death)
2. Difficulty accepting the reality of the loss, including persistent disbelief or denial
3. Avoidance of reminders that the person is dead
4. Persistent intense emotions: feelings of anger or bitterness related to the loss, or feelings of guilt or self-blame for circumstances surrounding the loss
5. Difficulty reintegrating into one’s relationships and activities after the death
6. Emotional numbness as a result of the death
7. A profound sense of loneliness, emptiness, or meaninglessness of life since the loss
8. Intense loneliness as a result of the death.

Criterion D

The disturbance causes clinically significant distress or impairment, including difficulty sleeping, changes in appetite, or difficulty participating in previously enjoyed activities, including socially.

Criterion E

The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.

Criterion F

The symptoms are not better accounted for by another mental disorder, such as major depressive disorder, adjustment disorder with depressed mood, or substance-related and addictive disorders.

Note that these criteria should only be applied after the bereaved individual has had sufficient time to adjust to the loss; thus, the criteria should not be applied to an individual who has experienced a loss less than one year ago.

What are the symptoms of grief?

Grief can result in a range of emotional, physical, psychological, and behavioural symptoms. The specific symptoms an individual experiences will depend on a variety of factors, including the nature of the loss, their previous experiences with loss, and their individual coping styles.

Common emotional symptoms of grief include:

• Sadness
• Anger
• Guilt
• Anxiety
• Despair
• Loneliness
• Numbness

Physical symptoms can include:

• Fatigue
• Insomnia
• Changes in appetite
• Aches and pains
• Nausea
• Heart palpitations

Psychological symptoms may include:

• Difficulty concentrating
• Intrusive thoughts or memories
• Hallucinations or illusions
• Difficulty accepting the reality of the loss
• A sense of disbelief or denial

Behavioural symptoms can include:

• Withdrawal from others
• Difficulty participating in previously enjoyed activities
• Substance abuse
• Changes in eating or sleeping patterns
• Increased absenteeism from work or school

Remember: Grief is a highly personal experience and individuals may experience a range of symptoms, or none at all. Additionally, symptoms may wax and wane over time, and the course of grief can be unpredictable. Some people may experience relief from symptoms quickly, while others may experience symptoms for years after the loss.

How to diagnose prolonged grief disorder

In the past, grief was not typically diagnosed as a mental disorder because it is a normal response to the loss of a loved one or significant object. However, clinicians began to recognise that when grief persists over a much longer period than is normal for an individual’s culture or context and interferes with normal functioning, it is prohibiting the person from leading a fulfilling life. If there were to be a diagnosis, health provider funds in some jurisdictions could flow more easily to help the person. Thus, in the DSM-5-TR, grief persisting for more than a year may be diagnosed as prolonged grief disorder, as described above.

Diagnosis of prolonged grief disorder typically involves a comprehensive evaluation by a mental health professional, including a clinical interview, a review of symptoms and medical history, and a consideration of any other factors that may be contributing to the individual’s symptoms.

In order to be diagnosed with prolonged grief disorder, an individual must meet the criteria outlined in the DSM-5-TR, which we listed above. Note particularly that these criteria should only be applied after the bereaved individual has had sufficient time to adjust to the loss and the symptoms must not be better accounted for by other mental disorders, such as depressive, adjustment, or substance misuse disorders.

Additionally, it is important to consider cultural and religious factors that may influence an individual’s grieving process, as well as any comorbid medical or psychological conditions that may be contributing to their symptoms. A mental health professional can provide a thorough assessment and make a diagnosis based on the individual’s unique presentation.

Common treatment approaches for prolonged grief disorder

The treatment of prolonged grief disorder will vary depending on the individual and the nature of their loss. However, there are several common treatment options that can be effective in helping individuals manage their grief and move toward healing.

Some common treatments for grief include:

• Psychotherapy can be a valuable tool for individuals who are struggling with grief. Therapies that may be useful include cognitive-behavioural therapy (CBT), exposure therapy, and grief-focused therapy. Psychotherapy can help individuals process their emotions, develop coping skills, and work through any complicated feelings or thoughts related to their loss.
• Medication: In some cases, medication may be prescribed to manage symptoms such as anxiety or depression that can accompany grief. Antidepressants, antianxiety medications, or sleep aids may be used to manage symptoms, but should only be prescribed by a qualified healthcare provider.
• Support groups: Support groups can be a valuable resource for individuals who are grieving, as they provide a safe and supportive environment for individuals to share their feelings and experiences with others who are going through a similar process. Support groups can help individuals feel less isolated and can provide a sense of community and belonging.
• Creative expression: Creative activities such as writing, drawing, or painting can be a helpful way for individuals to express their emotions and process their grief. Creative expression can be especially helpful for individuals who may have difficulty verbalising their feelings.
• Mind-body techniques (somatic): Mind-body techniques such as yoga, meditation, or deep breathing can help individuals manage symptoms of stress and anxiety that can accompany grief. These techniques can help individuals develop a sense of calm and inner peace, and can be especially helpful for individuals who are having difficulty sleeping or concentrating.
• Physical activity: Regular physical activity can help individuals manage symptoms of stress and anxiety and improve overall physical and mental wellbeing. Exercise can help release endorphins, which can improve mood and provide a sense of accomplishment.

Because grief is such a highly individual experience, different individuals may respond differently to the various treatments. A mental health professional can help individuals determine the best treatment plan for their individual needs and goals.

Key takeaways

• Grief is a normal and expected response to a loss, such as the death of a loved one or the loss of something significant.
• Persistent grief may now be classified as prolonged grief disorder (formerly called persistent complex bereavement disorder) in the DSM-5 Text Revision.
• Symptoms of grief may include emotional, physical, psychological, and behavioural reactions.
• Mental health clinicians can provide a supportive and empathetic environment when working with individuals who are grieving.
• Treatment approaches for prolonged grief disorder may include psychotherapy, medication, support groups, creative expression, mind-body techniques, and physical activity.