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March 23, 2022

The DSM-5 adds a new diagnosis: Prolonged grief disorder

Daily Briefing

    After a years-long debate within the mental health field, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) now includes "prolonged grief disorder" as an official diagnosis.

    3 ways to help your team navigate grief in crisis

    'Prolonged grief disorder' as a diagnosis

    Prolonged grief disorder was added to the DSM-5 for people who are still grieving one year after experiencing a loss, unable to return to everyday activities. It is expected to apply to around 4% of bereaved people.

    The inclusion of prolonged grief disorder in the DSM-5 means that clinicians will now be able to bill insurance companies for treating patients diagnosed with the condition. It will also likely prompt funding for research into treatments and set off competition for FDA approval of these treatments, the New York Times reports.

    The new diagnosis can be traced back to research from the 1990s. Holly Prigerson, a psychiatric epidemiologist, gathered data on the effectiveness of depression treatments in a group of elderly patients, the Times reports.

    While many of the patients were responding to the antidepressant medications, Prigerson noticed that their grief—measured by a set of standardized questions—remained high despite their positive response to depression treatments. However, many psychiatrists seemed uninterested in her findings at the time.

    "Grief is normal," Prigerson recalled being told by other psychiatrists. "We're psychiatrists, and we don't worry about grief. We worry about depression and anxiety." In response, Prigerson asked, "Well, how do you know that's not a problem?"

    As Prigerson continued to gather data, she concluded that signs of intense grief, including "yearning and pining and craving," differed from depression. In addition, she determined that these symptoms were predicative of negative outcomes, including high blood pressure and suicidal ideation.

    Among most of Prigerson's patients, symptoms of grief peaked within six months of loss. However, there was a group of outliers who remained "stuck and miserable," and continued to struggle with mood, day-to-day functioning, and sleep over an extended period of time.

    Commentary

    In 2010, the American Psychiatric Association (APA) proposed expanding the definition of depression to encompass bereaved individuals—a move that resulted in backlash from experts arguing that mental health professionals were overdiagnosing and overmedicating their patients.

    Although many experts agree that they could reasonably identify prolonged grief disorder six months after a loss or bereavement, Prigerson said the APA "begged and pleaded" to define the disorder more conservatively at one year to avoid public backlash.

    APA's concern was that the public was "going to be outraged, because everyone feels because they still feel some grief — even if it's their grandmother at six months, they are still missing them," she added. "It just seems like you're pathologizing love."

    Joanne Cacciatore, an associate professor of social work at Arizona State University who has published widely on grief, is concerned that drug companies will try to persuade the public that they need medical treatment to emerge from mourning.

    "When someone who is a quote-unquote expert tells us we are disordered and we are feeling very vulnerable and feeling overwhelmed, we no longer trust ourselves and our emotions. To me, that is an incredibly dangerous move, and short sighted," she said.

    However, the new diagnosis creates an opportunity for tailored treatments for intensely grieving individuals, the Times reports. 

    "It's sort of an official blessing in the world," said Kenneth Kendler, a professor of psychiatry at Virginia Commonwealth University. "If we were on the planetary committee of the American Astronomical Society deciding what is a planet or not — this one's in, and Pluto we kicked out."

    According to M. Katherine Shear, a psychiatry professor at Columbia University, who developed a 16-week program of psychotherapy that relies on exposure techniques to help trauma victims, it is difficult to predict what treatments could emerge for the disorder.

    If the diagnosis becomes common in the mental health field, it is likely to popularize Shear's treatment, according to the Times. In addition, there could be a range of new treatments that target the disorder, including drug treatments and online interventions.

    "I don't really have any idea, because I don't know when the last time there was a really brand-new diagnosis," Shear said.

    "I really am in favor of anything that helps people, honestly," she added.

    Ultimately, the inclusion of the disorder in the DSM-5 "mean[s] that mental health clinicians and patients and families alike share an understanding of what normal grief looks like and what might indicate a long-term problem," said APA CEO Saul Levin. (Reed, Axios, 3/21; Barry, New York Times, 3/18)

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