User acceptability of the diagnosis of prolonged grief disorder: How do professionals think about inclusion in ICD-11?

Prolonged grief reactions and help-seeking in bereaved adults during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted many care systems limiting bereaved people's ability to access social, community, and professional support. This study investigated help-seeking of people living with probable prolonged grief disorder (PGD) to identify challenges and facilitators of care, with the aim of informing bereavement practice and policy recommendations.

METHODS

Participants (N = 786; 96.3 % female, Mage = 54.51. SD = 11.64) who were 12 or more months post-bereavement completed an online survey indexing pandemic bereavement experiences, mental health and functional outcomes, and help-seeking experiences. Probable PGD was defined as a score ≥30 on the Prolonged Grief Scale 13-Revised (PG-13-R). Results were analyzed using univariate statistics for closed questions and content analysis for free-text responses.

RESULTS

Participants living with probable PGD (39.4 %) were more likely than others to: have sought help from professional or other structured grief supports (χ2(1) = 41.18, p < .001); have unmet bereavement needs (χ2(1) = 91.87, p < .001); and be living with significant functional impairment (t = -26.55, p < .001) and suicidal ideation (χ2(3) = 117.38, p < .001). Lack of provider availability and lack of relevant skills in working with grief and trauma were identified as challenges to care.

LIMITATIONS

The study used a convenience sample recruited online and so care is required before generalizing to less represented populations.

CONCLUSIONS

We identified both pandemic-specific and more general gaps within bereavement support systems. Our findings highlight a need to recognize care needs and elevate bereavement care within pandemic planning and health care systems more generally.

Understanding the complexity of suicide loss: PTSD, complex PTSD and prolonged grief disorder following suicide bereavement

Suicide-bereaved individuals are often confronted with profound grief reactions and have an increased risk for mental health disorders. Little is known about the development of complex post-traumatic stress disorder (CPTSD) following a loss by suicide. This paper aims to assess the prevalence of CPTSD, PTSD, prolonged grief disorder (PGD), and depression as well as to identify sociodemographic and loss-related factors regarding their development. A total of 161 suicide loss survivors (91.3% female) completed a questionnaire, which collected symptoms of grief (TGI-SR+), PTSD, CPTSD (ITQ), and depression (PHQ-D). In total, 12.4% met the diagnosis for CPTSD, 5.0% for PTSD. A total of 22.0% fulfilled the diagnosis for PGD. 41.6% showed at least moderate symptoms of depression. Pearson's correlation showed that time since loss was negatively associated with PG and PTSD symptoms, kinship to the deceased was associated with PG severity. The sample scored high on all disturbances in self-organization (DSO) symptom clusters typical for CPTSD. A focus on symptoms of CPTSD may be a necessary component in the care of survivors of suicide loss.

Prolonged Grief Disorder, but Not Death From COVID-19, Elicits Public Stigma: A Vignette-Based Experiment

We investigated the effects of cause of death (COVID-19 with an underlying medical condition vs. without) and prolonged grief disorder status (PGD present or absent) on participants' reported public stigma towards the bereaved. Participants (N = 304, 66% women; Mage = 39.39 years) were randomly assigned to read one of four vignettes describing a bereaved man. Participants completed stigma measures assessing negative attributions, desired social distance, and emotional reactions. Participants reported significantly stronger stigmatizing responses towards an individual with PGD (vs. without PGD) across all stigma measures. There was no significant difference in stigma based on cause of death; however, stigma was reported regardless of cause of death. There was no significant interaction between cause of death and PGD on stigma. This study supports the robust finding of public stigma being reported toward an individual with PGD, suggesting these individuals are at risk of public stigma and not receiving adequate bereavement support.

Public stigma toward prolonged grief and COVID-19 bereavement: A vignette-based experiment

We investigated the effects of cause of death and the presence of prolonged grief disorder (PGD) on eliciting public stigma toward the bereaved. Participants (N = 328, 76% female; Mage = 27.55 years) were randomly assigned to read one of four vignettes describing a bereaved man. Each vignette differed by his PGD status (PGD diagnosis or no PGD diagnosis) and his wife's cause of death (COVID-19 or brain hemorrhage). Participants completed public stigma measures assessing negative attributions, desired social distance, and emotional reactions. Bereavement with PGD (versus without PGD) elicited large and significantly stronger responses across all stigma measures. Both causes of death elicited public stigma. There was no interaction between cause of death and PGD on stigma. With increased PGD rates expected during the pandemic, the potential for public stigma and reduced social support for people bereaved via traumatic deaths and people with PGD requires mitigation.

[When the diagnosis came in … Bereavement care in Germany in 2020/2021: Where do we stand?]

BACKGROUND

In Germany, numerous health care providers work in the field of bereavement care. An epidemiological study of the field immediately after the introduction of the ICD-11 diagnosis "Prolonged Grief Disorder" (PGD) is pending.

METHODS

The second survey of the trend study, which is designed over a total of three measurement points at intervals of one decade each, explores whether and to what extent the field of bereavement care has evolved after the introduction of the grief-specific diagnosis PGD. For this purpose, providers of bereavement care at various organizational levels were asked to participate in an online survey. The survey was conducted from October 2020 to January 2021.

RESULTS

456 questionnaires were included in the study. Data analysis was descriptive. 80.5% of the participants have an additional grief-specific qualification, 59.4% base their work on a grief-specific concept. In view of the PGD diagnosis, only a few respondents have participated in a PGD-related advanced training. Most are afraid that the topic of grief will increasingly be subsumed in the medical-psychological-therapeutic field. An increase in bereavement research and the number and quality of continuing education is also expected.

DISCUSSION

Some positive trends in German bereavement care can be identified. However, there is a need for further development in the areas "designation of the activity", "diagnostics", and "intervention". Also, there is a need for training with regard to PGD.

CONCLUSION

After the introduction of PGD, the field of bereavement care in Germany turns out to be slightly different. The diagnosis is viewed skeptically.

Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies

Prolonged grief disorder has recently been added to the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders 5, Text Revision. This historical development is often presented as a linear process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. The present contribution provides an overview of work contradicting this dominant narrative. First, I show that the developmental history of prolonged grief disorder has been nonlinear and that this yields questions on generalizability and problems with measurement of the newest criteria sets. Second, I highlight an important gap in the validity evidence: the distinction of prolonged grief disorder from normal grief. Third, I discuss concerns relating to the societal effects of the inclusion of prolonged grief disorder in diagnostic handbooks, including the medicalization of grief, development and adverse effects of pharmacotherapy and stigmatization. A more realistic, balanced view on the history, validity and societal impact of prolonged grief disorder appears appropriate. I recommend stringent validation of assessment instruments for prolonged grief disorder, convergence of criteria-sets, closing gaps in validity evidence and developing strategies to mitigate the negative effects of grief diagnoses.

Prolonged Grief Disorder and the DSM: A History

ABSTRACT

In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.

How can we know what we don't know? An exploration of professionals' engagement with complicated grief

OBJECTIVE

Research has shown that complicated grief has the potential to adversely affect bereaved individuals, and in this context, understanding how mental health professionals engage with it in practice is of relevance. Gaining an understanding of professionals' knowledge, attitudes, skills and training in relation to complicated grief could provide insights that will inform their training and professional development. The aim of this study was to consider professionals' engagement with complicated grief, as represented by self-reported knowledge, attitudes, skills and training.

METHODS

The study used a three-phase mixed methods design (systematic review, qualitative interviews, and a quantitative survey) with empirical data being collected from psychologists, psychiatrists and counselor/psychotherapists.

RESULTS

Analysis yielded 15 integrated findings across the three phases, which were grouped into two clusters: the first highlighted tension between professionals' reported confidence and competence and the second explored the parameters and contribution of research and training in this area.

CONCLUSION

Professionals' perception of their competence to work with complicated grief seems overstated and research and professional practice are not aligned.

PRACTICE IMPLICATIONS

These findings are positioned to inform empirically supported training that addresses identified deficits in professionals' knowledge, attitudes and skills. It is important therefore that training is reflective of the needs of different professional groups.

Public Stigma of Prolonged Grief Disorder: An Experimental Replication and Extension

ABSTRACT

Prolonged grief disorder's (PGD's) recent recognition as a psychiatric diagnosis has elicited concerns about stigmatization. Although prior research demonstrated that PGD elicits public stigma, moderators of this effect are unclear, and the effect requires replication in an English-speaking population. Therefore, we investigated the effects of PGD, sex of the bereaved, and death expectedness on public stigma toward bereaved persons. We randomly assigned 195 Australian adults (77% female; mean age, 35.7 years) to read one of eight vignettes describing a bereaved male or female subject, with or without PGD, after an expected or unexpected death. Participants reported their emotional reactions and negative attributions toward, and desired social distance from, the bereaved person. A person with PGD (vs. without) elicited stronger emotional reactions, negative attributions, and desired social distance. No robust moderator effects emerged. Results validate concerns that PGD causes stigma. Stigmatization may be targeted by information campaigns or psychological treatment.

Supporting bereavement and complicated grief in primary care: a realist review

Background

Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients.

Aim

To identify what works, how, and for whom, in the management of complicated grief (CG) in primary care.

Design & setting

A review of evidence on the management of CG and bereavement in UK primary care settings.

Method

A realist approach was taken that aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes.

Results

Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time, and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients’ needs can encourage a proactive response and help identify appropriate support.

Conclusion

Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients.

Time elapsed since loss or grief persistency? Prevalence and predictors of ICD-11 prolonged grief disorder using different applications of the duration criterion

BACKGROUND

Prolonged grief disorder (PGD), included in the ICD-11, encompasses a six-month duration criterion, but whether this covers 'time since loss' or 'grief persistency' is unclear. The study estimated prevalence and predictors of probable ICD-11 PGD using different applications of the duration criterion.

METHODS

A register-sampled cohort of bereaved spouses completed self-report questionnaires at two (T1, N=847), six (T2, N=777), and eleven months (T3, N=753) post-loss. The duration criterion was operationalized as single-point PGD (meeting criteria minimally six months post-loss; T2 or T3) and dual-point PGD (meeting criteria at two assessments separated by months; T1+T2 or T2+T3).

RESULTS

Single-point PGD prevalence rates (~15-20%) were significantly higher than dual-point prevalence rates (~10%). While single assessments of PGD varied between T2 and T3, the dual-point prevalence rates did not significantly differ. Early probable grief caseness emerged as the strongest predictor for later PGD.

LIMITATIONS

Without a structured clinical interview, only probable cases of PGD were identified. Caseness relied on a diagnostic algorithm, created by mapping items from different self-report questionnaires. Time frames between assessments did not cover an entire six-month period.

CONCLUSIONS

Momentarily assessed, six-month PGD symptomatology may represent a fluctuating, but remitting grief process for some individuals. Further research could test whether multiple diagnostic indicators during the first year of bereavement improve the identification of genuinely prolonged grief reactions.

Public stigma towards prolonged grief disorder: Does diagnostic labeling matter?

The recent introduction of prolonged grief disorder (PGD) as a diagnostic category may cause negative social reactions (i.e. public stigma). Vignette experiments demonstrate that persons with both PGD symptoms and a PGD diagnosis elicit more public stigma than persons who experience integrated grief. However, the strength of the influence of the diagnosis itself remains unclear: We aimed to clarify if the diagnostic label PGD produces additional public stigma beyond PGD symptoms. We further compared whether public stigma varies between the label PGD and the label major depressive episode (MDE) (when PGD symptoms are present) and if gender of the bereaved person influences public stigma or moderates the aforementioned effects. Eight-hundred fifty-two participants (77% female; M_age = 32.6 years, SD = 13.3) were randomly assigned to read online one of eight vignettes describing either a bereaved male or female, with PGD symptoms and PGD diagnosis; PGD symptoms and MDE diagnosis; PGD symptoms and no diagnosis, or no PGD symptoms and no diagnosis (i.e., integrated grief). Following the vignettes, participants indicated which negative characteristics they ascribed to the person, their emotional reactions, and preferred social distance from the person. People with PGD symptoms and PGD (or MDE) diagnosis were attributed more negative characteristics, and elicited more negative emotions and a stronger desire for social distance than people with integrated grief. However, public stigma did not differ for people with both PGD symptoms and diagnosis compared to people only experiencing PGD symptoms. Gender of the bereaved only had an influence on desired social distance, which was larger towards men. Helping severely distressed bereaved people (regardless of diagnostic status) cope with negative social reactions may help them adapt to bereavement. Results demonstrate that the experience of severe grief reactions, yet not a diagnostic label per se, causes public stigma.

Perceptions of ideal grief and continuing bonds: Undergraduate student survey on persistent complex bereavement disorder

Responding to DSM's call for research on Persistent Complex Bereavement Disorder (PCBD), this study examined to what extent people perceive the criteria as pathological. In total, 385 undergraduate students answered the Continuing Bonds Scale and Persistent Complex Bereavement Inventory as they believe an ideally healthy person of their demographic would respond 12 months post loss. People identifying as women, religious, without past bereavement, and who endorsed continuing bonds as normal tended to perceive PCBD criteria as more normative. Results shed light on whose norms may be reflected in criteria and highlight the importance of assessing client's norms when diagnosing.

Complicated grief knowledge, attitudes, skills, and training among mental health professionals: A qualitative exploration

The knowledge, attitudes, skills, and training of professionals regarding complicated grief influence their practice. We conducted 30 semi-structured interviews with psychiatrists, psychologists, and counselor/psychotherapists; the preliminary findings were contextualized via interviews with three experts in complicated grief research/practice. Findings suggest that professionals did not substantially rely on research evidence, favoring instead personal and professional knowledge. They expressed concern regarding the possible pathologization of normal grief that might arise from having a diagnosis of complicated grief. Deficits in professional training were evident. A need for an improved culture of collaboration between researchers and practitioners was identified.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Clinical Utility and Global Applicability of Prolonged Grief Disorder in the ICD-11 from the Perspective of Chinese and German-Speaking Health Care Professionals

BACKGROUND

Prolonged grief disorder (PGD) is included in the ICD-11 (11th edition of the International Classification of Diseases). The new PGD criteria reflect the requirements and recommendations of the World Health Organization for improved clinical utility and international applicability. Even though the ICD classification system is globally used, no research has investigated how healthcare professionals (HP) in non-Western countries may adopt this change for their own practice.

OBJECTIVE

The present study explored the extent to which the new PGD criteria were accepted and perceived to meet the standards for clinical utility and international applicability among Chinese and German-speaking HP.

METHODS

Individual semistructured interviews were conducted in person, by phone, or online (e.g., via Skype), with 24 Chinese (n = 10) and German-speaking (n = 14) HP working with bereaved populations in China and Switzerland, and analyzed using a qualitative framework analysis. Questions included "what items are currently missing from the PGD criteria?".

RESULTS

Across all HP, the majority supported the inclusion of PGD and were generally aligned with the current criteria. HP found that the criteria distinguished between normal and abnormal grief and considered the criteria easy to use if their modifications were considered. Merits included, among others, improved clinical decision making, research promotion, and social acknowledgment. Main concerns included misdiagnosis, pathologization, and a lack of specificity of criteria. The importance of international applicability was emphasized across Chinese and German-speaking HP. Different grief-specific symptoms were identified by German-speaking and Chinese HP.

CONCLUSIONS

These findings provide evidence for the clinical utility and international applicability of ICD-11 PGD criteria among German-speaking and Chinese HP, as well as cultural similarities and differences in the barriers to implementation of these criteria.

Psychiatrists', psychologists' and counselors' attitudes regarding complicated grief

BACKGROUND

Complicated grief encompasses various presentations where aspects of grief do not become integrated into the bereaved person's life. Professionals' attitudes to complicated grief may impact how they engage with bereaved patients/clients. The aim of this study was to empirically examine the attitudes of mental health professionals, specifically psychologists, psychiatrists and counselor/psychotherapists, regarding complicated grief and to investigate any between profession-differences.

METHOD

Psychiatrists, counselor/psychotherapists and psychologists were recruited using publicly available databases managed by professional bodies. A total of 185 professionals (71.8% female), returned a questionnaire containing usable data (23.8% response rate).

RESULTS

Over two-thirds of the professionals (68.5%) supported the inclusion of complicated grief in diagnostic manuals while only a quarter (25.1%) thought that recognition of complicated grief might lead to the pathologization of 'normal' grief. The majority of respondents (83.0%) thought that diagnosing complicated grief would increase the likelihood of clients accessing support and there was no significant difference between the groups.

LIMITATIONS

Although the response rate compares favorably with other studies it is nonetheless somewhat lower than optimum, and it is possible that those who responded were more interested in bereavement and consequently, that the attitudes held by participants are different from those who did not participate.

CONCLUSION

The attitude to a diagnosis of complicated grief was more positive than the specialist literature suggests, with the benefits of having a diagnosis of complicated grief outweighing the risks of pathologization.

Does prolonged grief or suicide bereavement cause public stigma? A vignette-based experiment

Prolonged grief disorder (PGD), characterized by severe, persistent and disabling grief, is newly included in the International Classification of Diseases 11 (ICD-11). Receiving a PGD diagnosis could lead to stigmatizing public reactions (i.e. public stigma), yet research on this topic is limited. Additionally, while there is evidence that experiencing suicide bereavement causes public stigma, no studies to date have investigated the interaction between PGD and cause of death on public stigma. To fill these knowledge gaps, this experimental study tested if a PGD diagnosis (vs. no diagnosis) and experiencing suicide bereavement (vs. homicide and natural loss) cause public stigma. Three hundred and seventeen adults from the general population were randomly assigned to read one of 6 different vignettes of a person with and without PGD who had lost a spouse through a suicide, homicide or a stroke. After reading a vignette, negative attributions, emotional reactions, and desire for social distance were assessed. Notably, only persons with PGD were attributed relatively more negative characteristics, and elicited more anger, anxiety and pro-social emotions, and a larger preferred social distance in participants. This study supports the claim that PGD causes public stigma, but nuances claims that suicide bereavement induces public stigma.

[Prolonged grief disorder]

Grief is a natural response to the loss of a loved one and its intensity usually lessens over time. Approximately 10% of bereaved persons, however, experience persistent symptoms resulting in the development of a prolonged grief disorder (PGD). A PGD shows a distinct symptom cluster and is considered for inclusion as a diagnosis in the upcoming revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). It is distinct from other mental disorders but symptoms overlap, especially with major depression and posttraumatic stress disorder. In addition to diagnostic criteria and differential diagnosis, the following article also describes prevalence rates, comorbidities, risk factors as well as treatment options for PGD.