Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Silver School of Social Work, New York University, New York, NY 10003, USA.
The Journal of nervous and mental disease (Impact Factor: 1.69). 06/2012; 200(6):499-511. DOI: 10.1097/NMD.0b013e3182482155
Source: PubMed


The proposed changes to DSM-5 will create new categories of mental disorder (referred to here generically as Prolonged Grief Disorder'' [PGD]) to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief (e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness). The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: (1) PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; (2) PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; (3) PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; (4) PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and (5) PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.

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    • "Persistent Complex Bereavement Disorder (PCBD) is a newly proposed (i.e., candidate) diagnosis included in the appendix of DSM-5 as an invitation for further study and exploration (American Psychiatric Association, 2012). Many facets of this proposed disorder —ranging from the risk of pathologizing " normal " grief reactions, to the minimum required duration of symptoms, to the specific nature of PCBD criteria, to the added value of PCBD above and beyond other grief-related constructs—have been the subject of considerable debate that continues to persist (e.g., Wakefield, 2012). "

    Full-text · Article · Jan 2014
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    • "family functioning, family support, level of general distress, and history of mood co-morbidity ) that have been found to be risk factor for CG in other studies (Chiu et al., 2010; Thomas et al., 2013; Fujisawa et al., 2010). Third, we applied only the ICG and the ICG structured interview, while the conceptualization and the criteria for what is now called Prolonged Grief disorder (Prigerson et al., 2009) are not completely overlapping with those of CG (Prigerson et al., 2008; Wakefield, 2012; Maercker and Lalor, 2012). Further research using more recent and specific criteria can add information about this issue. "
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    ABSTRACT: A number of studies have underlined a 10-20% prevalence of complicated grief (CG) among caregivers of cancer patients. The study aimed at examining the relationship between pre-loss criteria for CG and post-loss diagnosis of CG and at evaluating the validity and factor structure of a predictive tool, the Inventory of Complicated Grief (ICG), in order to identify the risk of developing CG in a sample of Italian caregivers. Sixty family members of terminally ill patients admitted to hospice and receiving a Palliative Prognostic Score (PaP) predictive 30 day survival time <30% completed the Pre-Death ICG (ICG-PL) (T0). Family members were met again 6 months after the death of their loved one (T1) and submitted to the interview for Complicated Grief (Post-loss interview-PLI). Caseness for CG was shown in 18.3% of caregivers at T1. ICG-PL score (T0) were higher among those who developed CG at T1 than non-cases. A cut off score ≥49 on the ICG-PL (AUC=0.98) maximized sensitivity (92%) and specificity (98%) on caseness at T1. Pre-loss criteria related to traumatic distress, separation distress and emotional symptoms in general were significantly related to a post-loss diagnosis of CG, while no effect was shown on duration of pre-loss distress. The use of short screening tools, like the ICG-PL, may help health care professionals to identify subjects at risk for CG.
    Full-text · Article · Dec 2013 · Journal of Affective Disorders
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    • "There are no studies to directly inform the likely impact of the PCBRD diagnosis on bereaved parents . However , others have noted that the proposed criteria are likely to capture many individuals with normal grief - related symptoms ( Boelen & Pri - gerson , 2012 ; Wakefield , 2012 ) . Additionally , there may be problems with applying even the more empirically validated criteria set for PGD proposed by Prigerson et al . "
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    ABSTRACT: The upcoming fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has incited vociferous debate among academics, clinicians, and the general public. Two contested changes are eliminating the bereavement exclusion from the major depressive disorder diagnosis and creating a new category for intense and prolonged grief called persistent complex bereavement-related disorder. This article critically analyzes research and debate regarding these two changes and considers the likely implications for bereaved parents and other traumatically bereaved groups, who may be especially vulnerable to consequences of the two proposed changes.
    Full-text · Dataset · Jan 2013
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