This Month in Psychopharmacology

Prolonged Grief Disorder Diagnostic Criteria in DSM-5-TR

New diagnostic criteria for prolonged grief disorder (PGD) have been presented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). PGD not only places patients at risk for intense distress, but also poor physical health, shortened life expectancy, and suicide. The estimated prevalence of PGD is likely to increase beyond previous estimates of 9.8% due to the death toll of the COVID-19 pandemic. Therefore, it is critical that clinicians be knowledgeable about grief reactions, including pathological manifestations of grief, and how to treat them. DSM-5-TR criteria for PGD require distressing symptoms of grief to continue for at least 12 months following the death of a close attachment. The grief response must be characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to an impairing degree nearly every day for at least the past month. Three of eight symptoms must be experienced to a clinically significant degree for a PGD diagnosis (see Table 1).

Table 1. Prolonged Grief Disorder Symptoms
1 Feeling as though a part of oneself has died
2 A marked sense of disbelief about the death
3 Avoidance of reminders that the person has died (often coupled with intense searching for things reminiscent of the deceased person and/or evidence that they are still alive, such as mistaking others for the person who died)
4 Intense emotional pain (anger, bitterness, sorrow) related to the death
5 Difficulty with reintegration into life after the death
6 Emotional numbness (particularly with respect to an emotional connection to others)
7 Feeling that life is meaningless as a result of the death
8 Intense loneliness as a result of the death

The PG-13-Revised (PG-13-R) scale is a useful self-report measure of PGD that can be used to screen for diagnosis and estimate its severity. A summary score of 30 or greater is consistent with a diagnosis of PGD, indicating further evaluation and treatment. An effective treatment for PGD includes prolonged grief disorder therapy (PGDT). The goals of PGDT are to 1) facilitate adaptation through which grief is transformed and integrated and 2) address any derailing symptoms of the early grief coping response (i.e., protest, self-blame, anger, counterfactual thinking, and avoidance). Adapting to loss involves accepting the new reality and restoring the capacity for well-being. See Table 2 for healing milestones of PGDT.

Table 2. Healing Milestones of Prolonged Grief Disorder Therapy
1 Understanding and accepting grief
2 Managing grief emotions—both painful and positive (grief monitoring and psychoeducation)
3 Seeing a promising future (aspirational goals)
4 Strengthening relationships (inviting a significant other to join a session)
5 Narrating the story of the death (imaginal revisiting)
6 Living with reminders (situational revisiting)
7 Connecting with memories (imaginal conversation)


Prigerson HG et al. JAMA Psychiatry 2022; Epub ahead of print. Abstract

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