Prolonged grief disorder

Essential (Required) Features:

• History of bereavement following the death of a partner, parent, child, or other person close to the bereaved.
• A persistent and pervasive grief response characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain. This may be manifested by experiences such as sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to experience positive mood, emotional numbness, and difficulty in engaging with social or other activities.
• The pervasive grief response has persisted for an atypically long period of time following the loss, markedly exceeding expected social, cultural or religious norms for the individual’s culture and context. Grief responses lasting for less than 6 months, and for longer periods in some cultural contexts, should not be regarded as meeting this requirement.
• The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Persistent preoccupation may focus on the circumstances of the death or manifest as behaviours such as the preservation of all of the deceased person’s belongings exactly as they were before their death. The individual may alternate between excessive preoccupation and avoidance of reminders of the deceased.
• Other features of Prolonged Grief Disorder may include problems coping without the loved one, difficulties in recalling positive memories of the deceased, difficulty trusting others, social withdrawal, and the feeling that life is meaningless.
• Increased tobacco, alcohol, and other substance use, as well as increased suicidal ideation and behaviour may be present.

Boundary with Normality (Threshold):

• An individual experiencing a grief reaction that is within a normative period given their cultural and religious context is considered to be experiencing normal bereavement and should not be assigned a diagnosis of Prolonged Grief Disorder. It is often important to consider whether other people who share the bereaved person’s cultural or religious perspective (e.g., family, friends, community) regard the response to the loss or duration of the reaction as abnormal.
• Children and adolescents may respond to the loss of a primary attachment figure (e.g., a parent or caregiver) with an intense and sustained grief response (e.g., greater in intensity, symptomatology, duration) because of the role these individuals play in the child’s life. Pre-school age children commonly have difficulty accepting the loss. Aspects of the grief response may be retriggered at various points during the individual’s development, for example as new needs arise that would normally be supplied by the parent or caregiver. Generally, these reactions should be regarded as normal and the diagnosis of Prolonged Grief Disorder should be assigned with caution to children and adolescents in this situation.

Developmental Presentations:

• Prolonged Grief Disorder can occur at all ages, but the grief response can differ depending on the age and developmental stage and thus on age-specific concepts of death.
• Children often do not explicitly describe the experience of longing for the deceased or persistent preoccupation with the death of a loved one. These symptoms may be more likely to manifest behaviourally such as in play or in other behaviours involving themes of separation or death. Other behavioural expressions of longing can include waiting for the deceased person to return or returning to places where they last saw the deceased. Some children may develop a fearful preoccupation that others may die, magical thinking, as well as separation anxiety centering on worries about their caregivers’ welfare and safety.
• In younger children, intense sadness or emotional pain may emerge intermittently with seemingly appropriate moods. Anger related to the loss may be exhibited in children and adolescents as irritability, protest behaviour, tantrums, oppositional behaviour or conduct problems.
• Various contextual factors can influence symptoms related to the death of a loved one in children. For example, delayed onset or worsening of symptoms may occur in response to a change to a child or adolescent’s social environment, degree of coping of parents or caregivers with the loss, and family communication.
• In older adults, Prolonged Grief Disorder may manifest as enduring depression with the feeling one has lost a part of one’s self and accentuated feelings of emptiness. Feelings of being stunned and dazed over the loss are common. A preoccupation with somatic complaints is often found to be the primary sign of distress at this developmental stage.

Culture-Related Features:

• Cultural practices vary with regard to appropriate emotional expressions of bereavement, rituals and practices for managing the grieving process, modes of commemorating the deceased, concepts of an afterlife, stigma associated with certain types of death (e.g., suicide), or situations that may be especially traumatic (e.g., death of a child). This variation may contribute to the likelihood of experiencing prolonged grief reactions, and the range of symptoms and clinical presentations.
• Cultural groups vary regarding the normative duration of grief reactions. Among some groups, prescribed grief reactions may last for one year or even be postponed until the first anniversary. Among others, rituals or ceremonies are expected to prompt negative emotions related to loss, and formal grieving periods are relatively short. It is often important to consider whether other people who share the bereaved person’s cultural or religious perspective (e.g., family, friends, community) regard the response to the loss or duration of the reaction as abnormal.
• In some cultural or religious traditions, death is not seen as the cessation of life, but as an important transition to another form of existence. Such cultural beliefs may focus on karma, rebirth, heaven/hell, purgatory, or other transitions into the afterlife. Prolonged grief may be caused by concern about the status of the deceased in the afterlife. Culturally specific rituals and yearly celebrations may aim to assure the auspicious spiritual status of the deceased. Prolonged grief may be associated with concern about the status of the deceased in the afterlife.
• Encounters with the deceased may vary greatly across cultures. For example, in some societies, any waking encounter with the deceased is considered abnormal. By contrast, it is common in many Southern European and Latin American societies to receive visitations from deceased relatives soon after their death, which may be comforting to the bereaved. Other groups (e.g., some American Indians) may encounter the deceased in dreams, with a variety of interpretations. Among Cambodians, for example, having dreams of the deceased may be highly upsetting, indicating that rebirth has not occurred.

Sex- and/or Gender-Related Featuress:

• Prolonged Grief Disorder is more prevalent in females.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Post-Traumatic Stress Disorder: Similar to Post-Traumatic Stress Disorder, Prolonged Grief Disorder may occur in individuals who experience bereavement as a result of the death of a loved one occurring in traumatic circumstances. In Prolonged Grief Disorder the person may be preoccupied with memories of the circumstances surrounding the death but unlike Post-Traumatic Stress Disorder does not re-experience them as occurring again in the here and now.
• Boundary with Depressive Episode: Some common symptoms of Prolonged Grief Disorder are similar to those observed in a Depressive Episode (e.g., sadness, loss of interest in activities, social withdrawal, feelings of guilt, suicidal ideation). However, Prolonged Grief Disorder is differentiated from Depressive Episode because symptoms are specifically focused on the loss of the loved one, whereas depressive thoughts and emotional reactions typically encompass multiple areas of life. Further, other common symptoms of Prolonged Grief Disorder (e.g., difficulty accepting the loss, feeling angry about the loss, feeling as though a part of the individual has died) are not characteristic of a Depressive Episode. The timing of the onset of the symptoms in relation to the loss and whether there is a prior history of Depressive or Bipolar Disorder are important to consider in making this distinction. However, Prolonged Grief Disorder and Mood Disorders can co-occur, and both should be diagnosed if the full diagnostic requirements for each are met.