Prolonged Grief Disorder – New DSM-5 Diagnosis is Distinct from Major Depression Disorder

What’s happening – People who suffer a close loss typically experience grief but, in some cases, that grief can be extreme and persistent. When bereavement symptoms exceed cultural expectations, the situation can warrant a separate diagnosis and a specific treatment plan that differs from that used for major depressive disorder (MDD). This distinction led the American Psychiatric Association to recommend the addition of a formal diagnosis of Prolonged Grief Disorder (PGD) to the DSM-5. This action – now approved – follows a move by the WHO to include similar criteria in the ICD-11 (set to become effective in January 2022).

According to the association, the DSM-5 included a category of “persistent complex bereavement disorder (PCBD)” for further study. PGD will replace that category. Why make this change now? “It will encourage the identification of patients who might previously have been ignored or misdiagnosed, and for whom is there specific, evidence-based treatment,” Paul S. Appelbaum, MD, chair of the DSM Steering Committee and Dollard Professor of Psychiatry, Medicine, & Law at Columbia University, told Psycom Pro. The change also “represents the first new disorder added to the DSM since DSM-5 in 2013, using a new process that allows the field to propose changes to the DSM and provide the evidence to support them,” he said.

The details – See the American Psychiatric Association’s announcement about the DSM-5 addition of prolonged grief disorder – and its six core criteria – as well as an overview of the ICD-11’s diagnostic criteria for PGD.

Why it’s complicated – The Center for Complicated Grief estimates that 20% of people receiving mental health treatment have unrecognized PGD and that it is most often confused with depression. COVID-19 may be further complicating clinical assessments. Many people experiencing a loss (whether the death of a loved one, the loss of a job, etc) during the pandemic are not getting a chance to find closure or to grieve in the traditional way with family and friends, or to access proper help. Some could be at increased risk of experiencing more severe and prolonged symptoms due to already increased depression, worry, and fear.

The perspectives –

  • Some people fear a PGD diagnosis – sometimes called complicated grief – could be stigmatizing for patients. A study published in PLoS One attempts to dispute this concern.
  • A team of psychologists in The Netherlands sent a letter to the editor on the American Psychiatric Association’s proposal to add PGD to the DSM-5, describing it as a “welcome step” but also offering concerns over some of the criteria.
  • An International Social Work paper stresses the importance of training social workers to support the families of people who are critically ill during COVID to help prepare them for death and to help them better handle the bereavement process.
  • A Palliative Medicine paper identifies the fact that caregivers with poorer physical and mental health before a loved one’s death are more likely to experience prolonged grief disorder.
  • Tidsskr Nor Legeforen – aka the Journal of the Norwegian Medical Association – discusses the distinct differences between depression and prolonged grief disorder.
  • The American Psychological Association shares its take on complicated grief.

The conversation

  • @psmhttc (Pacific Southwest MHTTC) shares: “Dr. Shear announces that Prolonged Grief Disorder (PGD) is *NOW* officially recognized by the DSM 5. HUGE for all of us to be able to recognize, treat, and support people who are experiencing deep grief and in need.”
  • @mattwardio (The Disruptors podcast host) shares a Science News Frontiers post that “Recovery from grief is a slow, difficult process for families of terrorist attacks. People who lose loved ones to terrorism are at a particularly high risk of developing Prolonged Grief Disorder, a condition characterized by severe, persistent…”
  • @GHS (Global Health Strategies) shares a Statnews piece on how prolonged grief syndrome “will become a major public health concern” once the pandemic ends.
  • Columbia Psychologist @DrJeffCohen tweets that underlying interpersonal issues could be the result of complicated grief.

In practice – Diagnosing grief can be challenging as it is often masked by depression, anxiety, or even somatic disorders like ED or vaginismus. As a result, clinicians sometimes miss the signs. Grief expert Edy Nathan, LCSWR, shares how to identify grief and talk about loss with clients.

New Factors to Consider for Suicide Risk in People with Borderline Personality Disorder

What’s happening – Among patients with borderline personality disorder (BPD), the rate of suicide attempts is high. Yet, while this ill-fated relationship has long been recognized, many clinicians struggle with how to effectively address the ongoing threat.

The results of a 10-year longitude study recently published in JAMA Psychiatry may shed some light. Researchers identified independent characteristics among people with BPD that were associated with suicide attempts, including feelings of emptiness, identity disturbances, and going to great lengths to avoid feeling abandoned. This is an interesting development considering that, up until now, it was believed that affective instability and impulsivity in people with BPD were the elements more closely tied to suicide risk.

The findings call attention to the need for mental health professionals to use the new factors to screen for people who could be considering suicide. This adjusted assessment may also enable therapists to design more effective interventions for patients.

Why it’s complicated – In individuals with BPD, suicide risk can often be chronic – meaning multiple attempts are made. Complicating matters is that many experts believe that addressing suicide risk can actually worsen the problem. This poses challenges for therapists in determining how best to respond.

The details – Read the full study by Yen et al in JAMA Psychiatry.

The perspectives –

  • Research appearing in Frontiers in Psychiatry demonstrates that people with co-existing BPD and depression may be at increased risk of suicidal behavior.
  • A paper published in Medicina explores how interventions to address suicide in people with BPD are rarely successful and recommends that therapists focus on improving the patient’s quality of life instead.
  • A smaller study (n=125) shared in Psychiatry Investigation supports a connection between BPD and impulsivity, maladaptive defense style, and suicidal risk.

The conversation—

  • @emergmedottawa (EM Ottawa) tweets: “After a potentially lethal toxic ingestion a patient tells you that she does not want to live, and does not consent to any treatment, What do you do in this scenario Dr. @ER_Beamer reviews ….”
  • @bpdvideo (A BPD support group) shared an older study: “McLean Hospital Study of Adult Development (MSAD) involved 290 women treated there for BPD. They found that after 6 yrs, 75% of the women no longer met criteria for BPD diagnosis and after 10 years 93% no longer met the criteria. Yes, most people do get better.”
  • @JClinPsychiatry stated: “#Borderline personality disorder is associated with increased #suicidality, but less is known about other forms of premature #death. Learn how #BPD relates to mortality @ what risk factors can be targeted to prevent premature deaths in BPD…”

In practice – A related summary from the 2020 AACAP virtual meeting explores risk factors for mental illness among children and teens and provides clinical guidance for developing early interventions.

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Spirituality and Mental Health Back in the News During Pandemic

What’s happening – While links between spirituality and mental health have been studied for years, a new report following close to 500 participants in Brazil identifies an important link between religious beliefs and better mental health outcomes. This news may be particularly useful for therapy sessions this winter season – and beyond – as COVID-19 infection rates soar and people forego traditional celebrations – including religious ceremonies – with extended family and friends.

Specifically, researchers discovered that engaging in private religious activities, religious attendance, and spiritual growth led to reduced levels of worry and fear. In addition, spiritual growth seemed to reduce people’s sadness.

The details – Read the full study by Lucchetti et al in the International Journal of Social Psychiatry.

Why it’s complicated – Encouraging clients to explore their spirituality in the face of ongoing difficulties may help them stay well this winter. Yet, some therapists shy away from talking about religion, which means an important level of resilience may be left untapped. (See our related trivia question: should therapists talk about religion?)

The perspectives –

  • A study in Affective, & Behavioral Neuroscience found that people who feel more of a connection with God report an enhanced sense of control. Interestingly, the researchers looked at focal brain lesions in participants and noted that those with damage to the ventromedial prefrontal cortex (vmPFC) – an area associated with emotionally meaningful religious experiences and sense of control – had a stronger religious bent and associated feelings of control than their counterparts.
  • Quality of Life Research reported on a study conducted in Korea that discovered a connection between physical health status and symptoms of depression.
  • Research published in the Journal of Nervous and Mental Disease looking at psychiatric outpatients in Canada found that those with stronger religious and spiritual beliefs had improved coping skills, and less attachment insecurity, less severe depression, and less social anxiety than their counterparts.

The conversation –

  • @TrudeauPhD refers to PEW research in which: “24% of U.S. adults said that their #faith has become stronger because of #Covid_19. The science of how #religion is used to cope with major life stressors and #trajuma. #prayer #coping #Mentalhealth @WSJ”
  • @SyneDrum (The Health Syndrome) tweets: “What helped people and communities cope during Covid? Fascinating insights on the resources people have drawn on: arts and creativity; family and friends; religion, philosophy and meaning; greenspace and nature” and points to the whatworkswellbeing collective

 In practice – Julie Kolzet, PhD, shares how therapists can help clients, and themselves, find new sources of meaning this year.


Last Updated: Apr 20, 2021