The psychopathological characteristics of prolonged grief

Grief is a normal human response to the death of a loved one that may vary among individuals and in the way it manifests itself across cultures. Whereas the majority of bereaved people adjust adequately to the loss, a small but noteworthy proportion of individuals may experience a prolongation of the symptoms of acute grief well beyond the period when these have commonly abated. This syndrome, characterised by prolonged psychological distress in relation to bereavement, has been termed prolonged grief (PG) and shows distinct psychopathological features compared with other stress-related mental disorders. Accurately diagnosing PG in the context of difficult bereavement is an ongoing challenge to clinicians and researchers and many have called for improving the identification of PG and its treatment. PG has been recognised as a predictor of negative outcomes, such as substantial impairment in work and social functioning, reduction of quality of life, risk for mental disorders and suicidality, and physical health problems. This article discusses the main clinical features of PG, the determinants associated with the severity of PG symptoms, the risk factors that may predispose an individual to develop PG and the efficacy of different preventive and treatment approaches, including psychopharmacological and psychotherapeutic interventions

Validation of the new DSM‐5‐TR criteria for prolonged grief disorder and the PG‐13‐Revised (PG‐13‐R) scale

Although the concept of pathological grief dates back at least as far as Freud’s “Mourning and Melancholia”, there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) – an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption – can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. We tested the validity of the new DSM criteria for PGD and of an adapted version of our PG-13 scale, the PG-13-Revised (PG-13-R), designed to map onto these criteria, using data from investigations conducted at Yale University (N=270), Utrecht University (N=163) and Oxford University (N=239). Baseline assessments were performed at 12-24 months post-loss; follow-up assessments took place 5.3-12.0 months later. Results indicated that the PG-13-R grief symptoms represent a unidimensional construct, with high degrees of internal consistency (Cronbach's alpha = 0.83, 0.90 and 0.93, for Yale, Utrecht and Oxford, respectively). The DSM PGD diagnosis was distinct from post-traumatic stress disorder (phi=0.12), major depressive disorder (phi=0.25) and generalized anxiety disorder (phi=0.26) at baseline. Temporal stability was remarkable for this diagnosis (r=0.86, p<0.001). Kappa agreement between a PG-13-R threshold symptom summary score of 30 and the DSM symptom criterion for PGD was 0.70-0.89 across the datasets. Both the DSM PGD diagnosis and the PG-13-R symptom summary score at baseline were significantly associated (p<0.05) with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline and at follow-up, in the Yale, Utrecht and Oxford datasets. Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses

Validation of the new DSM‐5‐TR criteria for prolonged grief disorder and the PG‐13‐Revised (PG‐13‐R) scale

Although the concept of pathological grief dates back at least as far as Freud’s “Mourning and Melancholia”, there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) – an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption – can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. We tested the validity of the new DSM criteria for PGD and of an adapted version of our PG-13 scale, the PG-13-Revised (PG-13-R), designed to map onto these criteria, using data from investigations conducted at Yale University (N=270), Utrecht University (N=163) and Oxford University (N=239). Baseline assessments were performed at 12-24 months post-loss; follow-up assessments took place 5.3-12.0 months later. Results indicated that the PG-13-R grief symptoms represent a unidimensional construct, with high degrees of internal consistency (Cronbach's alpha = 0.83, 0.90 and 0.93, for Yale, Utrecht and Oxford, respectively). The DSM PGD diagnosis was distinct from post-traumatic stress disorder (phi=0.12), major depressive disorder (phi=0.25) and generalized anxiety disorder (phi=0.26) at baseline. Temporal stability was remarkable for this diagnosis (r=0.86, p<0.001). Kappa agreement between a PG-13-R threshold symptom summary score of 30 and the DSM symptom criterion for PGD was 0.70-0.89 across the datasets. Both the DSM PGD diagnosis and the PG-13-R symptom summary score at baseline were significantly associated (p<0.05) with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline and at follow-up, in the Yale, Utrecht and Oxford datasets. Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses

Narrative reconstruction therapy for prolonged grief disorder—rationale and case study

Background: Prolonged grief disorder (PGD) is a potentially disabling condition affecting approximately 10% of bereaved people. It has been suggested that the impaired integration of the loss memory, as expressed in recurrent memories of the loss and disorganization of memory, is involved in the development of PGD. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD) in an integrative therapy module, and consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative and an elaboration of the personal significance of that memory for the bereaved, has been shown to be effective in the treatment of intrusion symptoms. Objective: In light of findings that cognitive behavior therapy (CBT), including cognitive restructuring and exposure, is effective in the treatment of PGD, we suggest the implementation of a somewhat novel therapy module, NR, for the treatment of intrusive phenomena in bereaved patients. Method: The rationale for the implementation of NR for PGD and a case study of the treatment of a woman suffering from PGD after the death of her father are presented. Therapy took place in a university outpatient training clinic. Results: Evaluations conducted before and after treatment and at a 3-month follow-up demonstrated the effectiveness of NR in reducing symptoms of PGD and depression. The analysis of spontaneous narratives recorded before and after treatment showed an increased organization of the narratives. Conclusions: This case report demonstrates an adaptation of NR for the treatment of PGD. The results provide preliminary support for the effectiveness of NR for PGD. The significance of the study and its limitations are discussed