Prolonged Grief

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

Richard A. Bryant


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

In This Article

Consequences of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Decision

What is the impact of DSM-5's reluctance to recognize prolonged grief? This can be answered in two ways. From a clinical perspective, it runs the risk of patients who do suffer prolonged grief being incorrectly diagnosed with depression – or not identified at all. In the context of widespread use of medication with antidepressant[26] and its apparent lack of utility for prolonged grief patients, there is a concern that too many patients with prolonged grief may be prescribed antidepressant medication to manage grief reactions. This possibility may be compounded by DSM-5's controversial decision to remove the bereavement 'exclusion' from the diagnosis of major depressive episode, thereby possibly encouraging premature depression diagnoses to be made in the wake of bereavement.[27,28] Many of these patients may be deprived of receiving targeted psychotherapeutic interventions for prolonged grief that have been validated in robust trials.[22]

The other potential impact may be on research agendas. There is little doubt that validation of a condition via diagnostic recognition facilitates research questions, funding, and outcomes. Time will tell how this development impacts on the progression of prolonged grief research. At this stage, it is unlikely that the DSM-5 decision will impact on research agendas. The empirical basis for research into risk factors, trajectories, biological and cognitive studies, and treatment trials is increasing steadily. Whether DSM-5 recognizes the disorder, or even how it diagnoses it in the Appendix, will probably not significantly impact on how the field approaches the condition. For example, recent analytic approaches have gone beyond diagnostic boundaries and explored the trajectories of grief responses by using latent growth mixture modeling. This approach classifies homogenous groups in a population to identify classes of individual variation over time; instead of assuming that all respondents belong to a homogenous population, latent growth mixture modeling maps heterogeneous patterns of response, which allows different trajectories to be mapped over time. One study of 301 widowed persons assessed at 6, 18, and 48 months after the death documented four distinct trajectories: resilient (66%), chronic grief (9%), chronic depression (15%), and improved depression (10%).[29] Supporting this finding was another study that also found four trajectories following bereavement, with a distinct group following a chronic grief course.[30] These studies underscore that there is a minority of bereaved people, who comprise approximately 10% of the studied group, who is persistently endorsing grief symptoms.[30] It is apparent that regardless of the DSM-5 decision, longitudinal data attest to the conclusion that this subset is experiencing ongoing distress.

On the basis of the increased evidence of a proportion of bereaved people with persistent and disabling grief, there has been a surge in recent years on processes that moderate this persistent reaction. Research has focused on biological, cognitive, and social processes. From a biological perspective, there is much evidence that bereavement triggers general stress responses;[31] despite this, there is relatively little evidence on stress response indices in those with prolonged grief. One study found that individuals with prolonged grief have a flatter decline in diurnal cortisol levels than nonprolonged grief individuals.[32] One neuroimaging study has found greater activation of the nucleus accumbens in response to photographs of the deceased – this network is implicated in reward and approach tendencies, which is clearly central to the experiences of those with prolonged grief.[33] In one of the only studies that addresses the specificity of arousal response in prolonged grief, it was found that during a discussion of the deceased, heart rate was negatively associated with prolonged grief severity and positively associated with posttraumatic stress disorder severity.[16]

There is also increasing evidence of dysfunctional cognitive processes in prolonged grief. Individuals with prolonged grief display attentional biases to death reminders,[34] disproportionate retrieval of loss-related memories,[35] difficulty imaging the future with the deceased,[36] impairments in social problem-solving,[37] impaired forward-focus coping strategies,[38] and maladaptive appraisals about the loss and one's capacity to cope with the future without the deceased.[39] These factors all attest to the utility of applying experimental paradigms to understanding the underpinning of prolonged grief, and reflect that this research is progressing in a productive direction despite the lack of diagnostic recognition.