Download PROLONGED GRIEF DISORDER IN THE DSM-V - trauma-ptsd

Prolonged Grief Disorder
Running head: STANDARDIZED DIAGNOSTIC CRITERIA FOR PGD
A Rationale for Creating Standardized Diagnostic Criteria
for Prolonged Grief Disorder
Laurie A. Burke
University of Memphis
1
Prolonged Grief Disorder
2
Although loss and grief are ubiquitous human experiences, Prolonged Grief Disorder
(PGD; Boelen & Prigerson, 2007), formally called Complicated Grief (CG), stands apart as a
serious psychiatric condition that mental health professionals struggle to distinguish and
diagnose correctly (Shear, Frank, Houck & Reynolds, 2005). Fundamentally, PGD is an
event-related, relationship-based attachment disorder with symptoms so severe that if left
untreated it can cause long-term psychological disequilibrium and distress.
Research clearly demonstrates that PGD occurs in approximately 15% of the
bereaved population, has a distinctly adverse trajectory, and consists of a specific cluster of
symptoms (Horowitz et al., 1997; Parkes, 2007; Prigerson et al., 1995; Prigerson et al., 1999;
Prigerson & Maciejewski, 2006). According to the proposed diagnostic criteria these
symptoms must continue at a marked intensity for at least six months from the point of their
first appearance (Boelen & Prigerson, 2007) and include separation anguish in the form of
invasive thought patterns and powerful pining to be reconnected with the deceased.
Furthermore, PGD is distinguished by difficulty accepting the loss, confusion about one’s
role in life, avoidance of reminders of the loved one, inability to trust others, bitterness or
anger surrounding the loss, difficulty moving on, numbness and shock, and a sense that life is
meaningless (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 1995; Prigerson et al.,
1999). Moreover, this profoundly debilitating response to loss has potentially life-threatening
consequences. Most notably, individuals diagnosed with PGD have a statistically higher
propensity toward suicidality (Latham & Prigerson, 2004) as well as cancer, heart disease,
and sleep disturbances than those with a more normative grief response (Prigerson, Bierhals,
et al., 1997).
Prolonged Grief Disorder
3
Inclusion of PGD in the Diagnostic and Statistical Manual of Mental Disorders-Fifth
Edition (DSM-V) is warranted primarily because the current options for capturing
uncharacteristic responses to bereavement in the DSM-IV-TR (text revision; American
Psychiatric Association, 2000) are inadequate (Lichtenthal, Cruess, & Prigerson, 2004;
Prigerson, Shear, et al., 1997). Although PGD shares symptoms with other psychiatric
disorders such as emotional numbing (posttraumatic stress disorder; PTSD) and a diminished
sense of self (major depressive disorder; MDD), PGD sufferers would be overlooked or
“forced” into an inappropriate diagnostic category if they were assessed using only
psychiatric disorders that are presently listed in the DSM-IV-TR (American Psychiatric
Association). Typically, a protracted and incapacitating reaction to loss is classified as MDD
(Prigerson et al., 1999) or PTSD because of symptom overlap (Shear, Jackson, Essock,
Donahue, & Felton, 2006). While both MDD and PTSD have some symptoms that overlap
with PGD, the new diagnosis will be helpful in describing the cardinal features of the
pathological grief experience, namely the intense feeling of emotional detachment and
relational severance that comes from the death-related dissolution of a core attachment
(Neimeyer, 2008; Prigerson et al., 1997). With PGD, regardless of the quantity or quality of
one’s social network, the primary sense is that the individual is alone in life based on the
death of a primary attachment figure (Stroebe, Stroebe, Abakoumkin, & Schut, 1996).
That a traumatic event can create an environment conducive to a complicated and
elongated grief response has been decidedly determined. Researchers have demonstrated that
loss resulting from violent death (homicide, suicide, or fatal accident) substantially increases
one’s susceptibility to a pathological grief outcome (Currier, Holland, Coleman, & Neimeyer,
Prolonged Grief Disorder
4
2007; Hardison, Neimeyer, & Lichstein, 2005); and likewise, childhood trauma is associated
with increased risk for PGD following adulthood loss (Silverman, Johnson, & Prigerson,
2001). The trauma incurred through experiencing the sudden, untimely, and violent death of
a loved one can develop into PTSD (Bonnano & Kaltman, 1999; Green, 2000) and then into
a lengthy and disordered grief reaction (Neimeyer, 2002).
Of particular interest to traumatologists is that protracted, persistent, and recalcitrant
PTSD symptoms following trauma-related deaths might include symptoms that are better
described by a PGD diagnosis. However, presently there is no bona fide provision within the
field for diagnosis or treatment of PGD. The advantage of a DSM-V diagnosis for PGD is
twofold. For clinicians, it affords more options for clinical assessment and treatment for their
traumatically bereaved clients. For bereaved individuals, it promises validation of the
“protracted misery” following the sense of violation found in the traumatic death of a loved
one (Parkes, 2007, p. 141). The absence of PGD in the diagnostic nomenclature is one factor
that causes alienation and disenfranchisement in this population. In fact, in a study of 135
grievers, 96% believed that an identifiable diagnosis would reduce their sense of
misunderstanding and marginalization by others (Prigerson & Maciejewski, 2006).
Shear (2008) developed a version of the Structured Clinical Interview for
complicated grief (SCI-CG) and a specific psychotherapy treatment designed to ameliorate
the symptoms of complicated grief—complicated grief treatment (CGT; Shear, Frank,
Houck, & Reynolds, 2005). For this population, CGT was found superior to interpersonal
psychotherapy (IPT; used successfully for depression) in treating PGD. CGT addresses the
inability to accept the loss through use of a technique similar to prolonged exposure (PE;
used successfully for PTSD), called revisiting, in which the bereaved repeats and tape-
Prolonged Grief Disorder
5
records the story of the death in an effort to face aspects of the event that prevent acceptance.
Simultaneously, the therapist assists the client in recognizing the areas of avoidance that keep
the individual from living fully in the present and making plans for the future.
Having a recognizable diagnosis for chronic, problematic bereavement will allow for
the orderly investigation of the relationship between PGD and other related phenomena. Our
overall understanding of PGD has been hampered due to the lack of agreed-upon
terminology; thus, inclusion of PGD will encourage convergence on a common set of terms
and criteria to better organize and advance the field. Undoubtedly, research examining the
correlation between trauma distress and PGD is needed (Bonanno et al., 2007). For example,
are trauma patients with subsyndromal PTSD symptoms predisposed to PGD? Do sufferers
of non-death traumatic losses experience PGD at the same rate and degree as those with
death-related traumatic losses? What role does negative social support play in the
establishment and perpetuation of PGD (Wisley & Shear, 2007)? A diagnosis for PGD will
encourage and permit more rigorous research addressing these questions.
As in the battle for PTSD’s inclusion in the DSM, which included the need to
demonstrate prevalence across cultures (Monson & Friedman, 2006), the proposed addition
of PGD faces similar struggles as a non-normative outcome of bereavement. Although most
people eventually are able to face the future without their loved one, even making some sense
of the event, a substantial portion of bereaved persons exhibit a pathological reaction to loss.
The inclusion of PGD in the DSM-V will help to further the development of research, to
delineate the predictors and course of pathological grief, and to develop adequate treatments.
Conversely, without official recognition in the DSM-V, those emotionally debilitated by
traumatic losses are left to suffer needlessly and indefinitely.
Prolonged Grief Disorder
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (text revision). Washington, DC: Author.
Boelen, P.A., & Prigerson, H.G. (2007). The influence of symptoms of prolonged grief
disorder, depression, and anxiety on quality of life among bereaved adults: A
prospective study. European Arch. Psychiatry Clinical Neuroscience, 257, 444-452.
Bonnano, G. & Kaltman, S. (1999). Toward an integrative perspective on bereavement.
Psychological Bulletin, 126(6), 760-776.
Bonnano, G. A., Neria, Y., Mancini, A., Coifman, K., Litz, B., Insel, G. (2007). Is there
more to complicated grief than depression and posttraumatic stress disorder? A test
of incremental validity. Journal of Abnormal Psychology, 116(2). 342-351.
Currier, J. M., Holland, J. M., Coleman, R. A., & Neimeyer, R. A. (2007). Bereavement
following violent death: An assault on life and meaning. In R. Stevenson & G. Cox
(Eds.) Perspectives on violence and violent death (pp. 175-200). Amityville, NY:
Baywood.
Green, B. (2000). Traumatic loss: Conceptual and empirical links between trauma and
bereavement. Journals of Personal and Interpersonal Loss, 5(1), 1-17.
Hardison, H.G., Neimeyer, R.A., & Lichstein, K.L. (2005). Insomnia and complicated grief
symptoms in bereaved college students. Behavioral Sleep Medicine, 3, 99-111.
Horowitz, M.J., Siegel, B., Hole, A., Bonanno, G.A. Milbrath, C., & Stinson, C.H. (1997).
Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry,
154(7), 904-910.
6
Prolonged Grief Disorder
Latham, A., & Prigerson, H. (2004). Suicidality and bereavement: Complicated grief as
psychiatric disorder presenting greatest risk for suicidality. Suicide Life Threat
Behavior, 34(4), 350-362.
Lichtenthal, W. G., Cruess, D.G., & Prigerson, H.G. (2004). A case for establishing
complicated grief as a distinct mental disorder in the DSM-V. Clinical Psychology
Review, 24, 637-662.
Monson, C., & Friedman, M. (2006). Back to the future of understanding trauma:
Implications of cognitive-behavioral therapies for trauma. In V. Follette & J. Ruzek,
(Eds.), Cognitive behavioral therapies for trauma (2nd ed.). (pp. 1-13). New York:
Guilford Press.
Neimeyer, R. A. (2002). Traumatic loss and the reconstruction of meaning. Journal of
Palliative Medicine, 5(6), 935-942.
Neimeyer, R. A. (2008). Prolonged grief disorder. In C. Bryant and D. Peck (Eds.),
Encyclopedia of death and the human experience. Thousand Oaks, CA: Sage.
Parkes, C., (2007). Complicated grief: The debate over a new DSM-V category. In Doka, K.
(Ed.), Living with grief: Before and after the death (pp. 139-152). Washington, DC:
Hospice Foundation of America.
Prigerson, H.G., Bierhals, A.J., Kasl, S.V., Reynolds, III, C.F., Shear, M.K. Day, N., et al.
(1997). Traumatic grief as a risk factor for mental and physical morbidity. American
Journal of Psychiatry, 154, 616-623.
Prigerson, H., Frank, E., Kasl, S., Reynolds, C., III, Anderson, B., Zubenko, G. et al. (1995).
Complicated grief and bereavement-related depression as distinct disorders:
Preliminary empirical validation in elderly bereaved spouses. American Journal of
Psychiatry, 152, 22-30.
7
Prolonged Grief Disorder
8
Prigerson, H., & Jacobs, S. (2001).Traumatic grief as a distinct disorder: A rationale,
consensus criteria, and a preliminary empirical test. In M.S. Stroebe, W. Stroebe, &
R.O. Hansson (Eds.) Handbook of Bereavement Research (pp. 613-645).
Washington, DC: American Psychological Association.
Prigerson, H., & Maciejewski, P. (2006) A call for sound empirical testing and evaluation of
criteria for complicated grief proposed for the DSM-V. Symposium on Complicated
Grief. Omega, 52(1), 16.
Prigerson, H. G., Shear, M. K., Frank, E., Beery, L.C., Silberman, R., Prigerson, J. et al.
(1997). Traumatic grief: A case for loss-induced trauma. American Journal of
Psychiatry, 154(7), 1003-1009.
Prigerson, H., Shear., M., Jacobs, S., Reynolds, C., III, Maciejewski, P., Davidson J. et al.
(1999). Consensus criteria for traumatic grief. British Journal of Psychiatry, 174,
67-73.
Rynearson, E.K. & Sinnema, C.S. (1999). Supportive group therapy for bereavement after
homicide. In D. Blake & B. Young (Eds.) Group treatments for post-traumatic stress
disorder (pp.137-147). Philadelphia, PA, US: Brunner/Mazel.
Shear, M.K. (2008). Structured clinical interview: Complicated grief. Manuscript in
preparation.
Shear, M.K., Frank, E., Houck, P.R., & Reynolds, C.F., III. (2005). Treatment of complicated
grief: A randomized controlled trial. JAMA, 293(11), 2601-2608.
Shear, M.K., Jackson, C.T., Essock, S.M., Donahue, S.A., & Felton, C.J. (2006) Screening
for complicated grief among Project Liberty service recipients 18 months after
September 11, 2001. Psychiatric Services, 57(9), 1291-1297.
Prolonged Grief Disorder
9
Silverman, G. K., Johnson, J.G., & Prigerson, H. G., (2001) Preliminary explorations of
the effects of prior trauma and loss on risk for psychiatric disorders in recently
widowed people. Israel Journal of Psychiatry and Related Sciences, 38(3-4), 202215
Stroebe, W., Stroebe, M., Abakoumkin, G., Schut, H. (1996). The role of loneliness and
social support in adjustment to loss: A test of attachment versus stress theory.
Journal of Personality and Social Psychology, 70(6), 1241-1249
Wisley, S., & Shear, M.K. (2007). Descriptions of social support in treatment narratives of
complicated grievers. Death Studies, 31, 801-819.