Prolonged grief disorder

PGD behavioral symptoms include: • Elevated rates of suicidal ideation and attempts • Functional impairment • High treatment-seeking behaviors • Adverse health behaviors and in children • Cancer Bereaved persons often feel a need to understand why their loved one died by suicide, particularly if a message was not left behind by the deceased. Grief is a common response to bereavement, occurring in a variety of severities and durations, however only a minority of cases of grief meet the severity and duration criteria to merit diagnosis of PGD; it is considered when an individual's ability to function and level of distress over the loss is extreme and persistent. People with PGD can experience a chronic aching and yearning for the dear departed, feel that they are not the same person anymore (identity disturbance), become emotionally disconnected from others, or lack the desire to "move on" (in some cases feeling that doing so would be betraying the person who is now deceased). ==Diagnosis==

Both DSM-5-TR or the ICD-11 are manuals that describe the diagnostic criteria for prolonged grief disorder. As early as 2009, diagnostic criteria for PGD were proposed and later revised. as a proposed diagnosis in Section III. According to psychologist Holly Prigerson, an editor on the trauma and stressor-related disorder section of the DSM-5-TR, strong and ongoing longing for the deceased is a key symptom of prolonged grief, but it is not a feature of depression or any other disorder in the DSM. ICD-11 Prolonged grief disorder in the ICD-11 is diagnosed when a person experiences ongoing and intense grief after the death of someone close. Core symptoms include strong longing or preoccupation with the deceased, combined with emotional pain such as sadness, guilt, anger, or numbness. The grief must last longer than culturally expected and cause significant disruption to daily life. Additional signs include difficulty coping without the deceased, problems recalling positive memories, social withdrawal, and increased substance use or suicidal thoughts. The diagnosis should reflect the individual's cultural norms and not be confused with normal bereavement or other mental health conditions like depression or PTSD. Children and older adults may show grief differently depending on developmental stages. Assessment tools Multiple assessment tools specifically for grief related to bereavement have been developed. The Brief Grief Questionnaire, the 13-item Prolonged Grief-13-R and the 19 item Inventory for Prolonged Grief are screening tools which may suggest the presence of a prolonged grief disorder, with further interview and grief history inventory required to establish a diagnosis. The Inventory of Complicated Grief (developed in 1995) is validated to assess grief symptoms and remains widely used today. According to a 2020 systematic review, there were eleven assessment tools, three of which are designed for clinical interviews. was the only assessment tool found to have empirical evidence supporting use as a diagnostic tool. ==Causes==

No specific causes guarantee onset of PGD. Known risk factors include one-time incidents along with chronic conditions and neurological abnormalities. One-time incidents include: • The death was due to a violent method, such as homicide or suicide • Miscarriage • Lack of preparation for death, or high levels of anticipatory grief • Controlling parents • Parental abuse or death (other than that of the bereaved death) • Close kinship relationship to the deceased (e.g., parents) • Insecure attachment styles • Emotional dependency • Emotional closeness to the deceased before death PGD may be associated with activation of the nucleus accumbens. These risk factors and clinical correlates have been largely shown to relate to PGD symptoms and not symptoms of major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. ==Management==

Treatment is strongly recommended for prolonged grief disorder. Specifically, Prolonged Grief Therapy has the best evidence of effectiveness. Antidepressants may be combined with grief focused therapy when one is having symptoms of concomitant depression, including co-existing major depression. A combination of relational and cognitive-behavioral interventions have shown evidence for efficacy when treating individuals who have lost loved ones to suicide. Recent research has investigated bereavement care as a preventative method to improve grief outcomes and reduce grief disorders in familial cancer caregivers. Bereavement care involves providing support for the family at an initial cancer diagnosis, implementing palliative care early on in the disease trajectory. However, this was not associated with one's health status at the 4 month follow up assessment. Research has shown that CBT is more successful than supportive counseling in reducing PGD symptoms. Additionally, a 2005 study developed Complicated Grief Treatment (CGT), which integrates psychoeducation with CBT techniques. The study demonstrated that individuals receiving CGT experienced greater and faster symptom reduction compared to those undergoing interpersonal therapy (IPT).''' Support groups have been shown to help improve global well being in those who lost a patient to cancer and in improving life satisfaction. A 2005 intervention, called "The Parent Guidance Program," included six therapy sessions for families with children from ages 7-17 years. The program included six therapy sessions during the cancer patient's terminal phase and six sessions after the death of the patient, including family meetings. The main aim of this intervention was to help the child's adjustment to the loss of the parent with a cancer diagnosis by aiming to increase the surviving parent's competency in providing support for the children. This 2005 intervention displayed a small effect size in improving children's anxiety levels. ==Epidemiology==

According to a 2017 meta-analysis, prevalence of prolonged grief is estimated to be 9.8%, although higher prevalence estimates, as high as 49%, are possible if the death was not due to natural causes. PGD is also more prevalent when the death is by a violent method such as homicide or suicide, with an estimated 70% of those with PGD in the study having been exposed to bereavement by a violent method. Conversely, PGD is less common in cases where the bereaved death was due to natural disasters. PGD has higher prevalence in women. PGD prevalence among bereaved cancer caregivers Losing a loved one to cancer can cause intense feelings of grief, as family members typically take on a caregiver role. Caregivers experience caregiver burden, due to the multifaceted role of caregiving, which can influence the level of grief experienced. Caregivers are often tasked with substantial unpaid care duties with many caregivers reporting feeling undertrained to provide extensive care. Stress that results from family caregivers of cancer patients have been shown to have negative impacts on psychological health, as poor psychological adjustments can lead to numerous mental health disorders. These disorders reported include anxiety and depression, as well as complicated grief or prolonged grief disorder. Families that were experiencing a loved one with neurological cancers also exhibited an increased number of prolonged grief disorder in comparison to other various cancer types. Research has also been assessed in familial caregivers who have experienced a loss of a loved one due to High-Grade Glioma, which has indicated that many experience extreme grief and report unmet needs in regards to their role as a caregiver. Pre-loss grief, refers to grief experienced before the loss of the patient, and has been associated with increased levels of PGD and increased depressive symptoms post-loss. Two review articles based in Europe, indicated that abnormal grief could be linked to decreased levels of preparedness for a family member's death. However, according to a meta-analysis conducted in 2024, which pooled prevalence rates among five studies from China and Japan, the prevalence rate of prolonged grief disorder was found to be 8.9%. This meta-analysis suggests that cultural practices regarding death in eastern countries may provide evidence for decreased PGD prevalence compared to western countries. In one cross-cultural comparison, Chinese bereaved parents reported increased views of feeling that life was "empty" in comparison to the sample of Swiss bereaved parents, with Swiss parents showing increased levels of grief-related preoccupation. Some cultures participate in religious mourning rituals, which has been researched as a preventative method in developing PGD. ==History ==

The DSM-IV and ICD-10 do not distinguish between normal and prolonged grief. Based on numerous findings of maladaptive effects of prolonged grief, diagnostic criteria for PGD have been proposed for inclusion in the DSM-5 and ICD-11. In 2018, the WHO included PGD in the ICD-11, and in March 2022 the American Psychiatric Association added PGD in the DSM-5-TR. The analyses produced criteria that were the most accurate markers of bereaved individuals with painful, persistent, destructive PGD. Traumatic grief or complicated grief was a term initially used to identify a complex syndrome in which an individual experiences a unique distress resulting from the simultaneous occurrence of psychological trauma and the loss of a loved one. Controversy Although evidence suggesting the validity of PGD has existed since 1995, This argument also underscored the urgent evidence that PGD has been associated with increased rates of other mental disorders, including PTSD, suicidality, and depression. In spite of this concern, studies have shown good accuracy for the ICD-11 and DSM-5-TR definitions, and that nearly all bereaved individuals who met the criteria for PGD were receptive to treatment and their families relieved to know they had a recognizable syndrome. In addition, a 2020 study found that labeling PGD symptoms with a grief-specific diagnosis does not produce additional public stigma beyond the stigma of these severe grief reactions alone. == References ==