When does grief become pathological?
According to Sidney Zisook of the Department of Psychiatry, UCLA, it is important to recognize that, while each individual grief process is unique, there is a form of grief that is disabling and interferes with functions of daily living and overall quality of life. This prolonged, complicated grief response tends to be chronic and persistent in the absence of targeted interventions, and may even be life-threatening.2
It is for these reasons that Jerome Wakefield of New York University argues in favor of the need for a reclassification of prolonged grief in the DSM-5. In particular, he believes there needs to be a reconsideration of the empirical and conceptual arguments for complicated grief disorder. The proposed diagnostic criteria, should Prolonged Grief Disorder (PGD) be included in the DSM-5, resulted from panel discussions between numerous experts. These criteria, however, fail to discriminate the disorder from intense ‘normal’ grief and are likely to yield massive false-positive diagnoses.3
To arrive at an accurate classification of PGD, more research is needed that focuses on delineation of syndromes that comprise ‘pathological grief’.4 Holly Prigerson, Associate Professor of Psychiatry at Harvard Medical School, conducted one such study with 306 respondents at 7 months after they had been widowed.5 She found that a diagnosis of PGD could be considered if the symptoms of separation distress including loneliness and yearning, and of traumatic distress syndromes including anger, futility and numbness, were scored as mostly true.
Manifestations of PGD
Individuals with PGD exhibit the same signs as the individuals during a ‘normal’ grieving process, but the symptoms are more prolonged, debilitating, and intense. There may be a numbness and detachment to the extent that a person cannot participate in normal activities. The person may have suicidal thoughts, and there may also be an inability to accept the death, so s/he will hold onto reminders of the loved one – keeping everything in place as it was when they ‘left.’ A deep sense of guilt plagues the person as s/he asks her self/him self, “Am I responsible?” or “What could I have done to prevent this?” This individual’s identity has been disturbed and s/he may have trouble finding new avenues in which to progress towards identity growth and finding a redefined self-worth.
A person experiencing pathological grief will not be able to perform normal day-to-day tasks and this can lead to further health problems. Indeed, Prigerson reports that PGD symptoms can result in some of the following: cancer, hypertension, immune system dysfunction, cardiac events, functional impairments, adverse health behaviors, reduced quality of life, suicide attempts, and hospitalization.6 These severe consequences of losing a loved one are the result of experiencing a mild form of traumatic stress injury. The traumatic stress of losing a loved one can, without intervention, progress into Acute Stress Disorder or even Posttraumatic Stress Disorder, particularly if the death has been a violent or unexpected one.
Interventions for PGD
In the absence of diagnostic criteria for PGD, many sufferers are diagnosed with Major Depressive Disorder (MDD) and are treated with antidepressants.7 While this might benefit the patient,8 there is a scarcity of evidence to support this notion because of the lack of official diagnostic criteria. Although people are encouraged to ‘let go’ of a loved one in ‘normal’ grief, inner relationships with the deceased person may continue throughout a person’s life. Indeed, the adoption of the Continuing Bonds Perspective emphasizes grief and mourning as a lifelong developmental process that serves to maintain a continuing bond with the deceased.9
It was Dennis Klass, Phyllis Silverman, and Steven Nickman, in their 1996 book, Continuing Bonds – New Understandings of Grief, who felt that bonds through dreams, visiting the grave, or maintaining rituals helped people maintain equilibrium. This approach could be beneficial and should be explored for treating PGD; however, more data is required to determine its efficacy.
A study conducted at the University of Michigan showed that, around a year after a significant loss, people were better able to make sense of the death, but benefit-finding took longer – between 13 to 18 months.10 People who find it difficult to adjust are at higher risk of their grief becoming pathological, especially those without a strong belief system or those who fail to make sense of their loss. To overcome bereavement, there needs to be some benefit, although people may find this hard to find initially –,a sense of greater independence or resilience, for example, or a more compassionate approach to life, and strengthened ties with family and friends.
Assisting patients to clarify the shifts they are experiencing in their own identity and concepts has been found helpful in the treatment of PGD.11 A 2007 study compared Supportive Counseling with 2 different types of Cognitive-Behavioral Therapy (CBT), namely Exposure Therapy and Cognitive Restructuring.12 The researchers found that CBT was more effective as a PGD intervention than supportive counseling. They also recommended a combination program, with 6 weeks of exposure therapy, followed by 6 weeks of cognitive restructuring. This was found to be the most effective combination of the CBT options.
There is a wealth of research supporting the value of grief counseling, provided that clinicians undertake careful assessment before initiating a tailored intervention program. Since grief is a different experience for each individual, effective grief support should offer a range of alternatives, including, but not limited to, online support, bibliotherapy, individual counseling, group support, community support, rituals, and psycho-educational programs.13
Increasing the evidence-base
Taken together, PGD is a condition that is commonly encountered by psychology practitioners, and benefit from receiving diagnostic status would be great. Treatment approaches require solutions that are tailored to each person and circumstance and, in the lack of further guidance provided by diagnostic criteria, treatment options need to be explored and documented in order to increase the evidence base.
1. Bonanno GA, Kaltman S. The varieties of grief experience. Clin Psychol Rev. 2001;21:705-734.
2. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington: American Psychiatric Publishing.
4. Stroebe M, van Son M, Stroebe W, et al. On the classification and diagnosis of pathological grief. Clin Psychol Rev. 2000; 20:57-75.
5. Prigerson HG, Shear MK, Jacobs SC, et al. Consensus criteria for traumatic grief. A preliminary empirical test. Brit J Psychiatry. 2009;174:67-73.
6. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6:e1000121.
7. Bryant RA. Prolonged grief: where to after Diagnostic and Statistical Manual of Mental Disorders. Curr Opin Psychiatr. 2014;27:21-26.
8. Hall C. Beyond Kubler-Ross: recent developments in our understanding of grief and bereavement. InPsych: The Bulletin of the Australian Psychological Society Ltd. 2011;33:8.
9. Malkinson R. Cognitive-Behavioral Grief Therapy: The ABC Model of Rational-Emotion Behavior Therapy. Psihologijske Teme. 2010;19:289-305.
10. Davis CG, Nolen-Hoeksema S, Larson J. Making sense of loss and benefiting from the experience: two construals of meaning. J Pers Soc Psychol. 1998;75:561.
11. Neimeyer RA, Burke LA, Mackay MM, van Dyke Stringer JG. Grief therapy and the reconstruction of meaning: From principles to practice. J Contemp Psychotherapy. 2010;40:73-83.
12. Boelen PA, de Keijser J, van den Hout MA, van den Bout J. Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psych. 2007;75:277.
13. Humphrey KM. Counseling strategies for loss and grief. 2009. Alexandria, VA: American Counseling Association.