Prolonged Grief

Where to After Diagnostic and Statistical Manual of Mental Disorders, 5th Edition?

Richard A. Bryant

Disclosures

Curr Opin Psychiatry. 2014;27(1):21-26. 

In This Article

Prolonged Grief in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

This accumulated evidence led to much discussion, and to a firm proposal of a new diagnosis in DSM-5: adjustment disorder related to bereavement. It was proposed as an adjustment disorder because it was regarded as an impairing reaction to a major life stressor. Despite the arguments for the diagnosis, it was ultimately decided by the DSM-5 decision-makers that the evidence was preliminary and did not warrant recognition as an independent diagnosis, even as a type of adjustment disorder. Instead, DSM-5 lists the curiously termed condition persistent complex bereavement disorder in the Appendix as 'condition for further study'. It is worth reflecting on the reluctance for prolonged grief to be recognized as a diagnosis. Unlike other psychological conditions, there is frequently much resistance to the notion that persistent grief responses should be diagnosed as a mental disorder because it risks medicalizing normative responses to a major loss. As grief is felt by nearly everyone at some stage, and its course can fluctuate over time, there is often a strong reaction to classify any grief reactions as pathological. This is a partially valid concern because psychiatry has certainly been guilty of overpathologizing normative states in the past.[24] Supporting this criticism is evidence of some persisting symptoms of grief in many bereaved individuals who are not suffering consistent impairment.[25] This concern was paramount for the DSM-5 committee, who went to lengths to safeguard against being too zealous in labeling bereaved people as suffering a disorder because they miss their loved one. In fact, the proposed text specifically noted that fluctuating symptoms are common for extended periods of time and do not necessarily reflect disorder.

The challenge for the diagnosis of prolonged grief is balancing the benefits of identifying those who are suffering persistent significant mental health problems following bereavement and not falsely labeling normative grief responses as pathological. This is a perennial problem with most psychiatric disorders. The reason this issue is so salient in prolonged grief is that most people will experience these reactions at some time in their lives, and so it is important to classify these reactions appropriately. DSM-5 took the approach of using symptom duration as the major safeguard – although most studies suggest that by 6 months one can discern grief reactions that are predictive of persistent problems, DSM-5 adopted a 12-month minimum requirement since the death to be particularly cautious. The finding that only 10% of bereaved people are typically classified as suffering prolonged grief provides some assurance that it is not excessively pathologizing responses. Nonetheless, DSM-5 decided to not proceed with the diagnosis lest it be guilty of introducing a diagnosis that would not find this appropriate balance.

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