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

Abstract

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.

Psychometric evaluation of the Swedish Traumatic Grief Inventory Self‐Report Plus (TGI‐SR+) in bereaved parents

“…This aligns with concerns voiced by researchers that differences in symptom count and content between past and current criteria sets, and the lack of correspondence between past questionnaires and current criteria sets, threaten the generalizability of past findings on pathological grief to the newest versions of PGD (e.g. Eisma, 2023;Eisma et al, 2022;Lenferink et al, 2019).…”

On the Classification and Reporting of Prolonged Grief: Assessment and Research Guidelines

“…The measurement techniques thus often fall short of the mandatory procedure for establishing a PGD diagnosis in this respect as well. Since current PGD criteria differ from past proposed criteria sets in symptom content, count, and diagnostic algorithms, 4,10 it cannot be assumed that their phenomenological characteristics are the same (see, e.g., American Psychiatric Association [2022] 6 and Eisma et al [2020] 12 ). This could form an important source of bias in estimates of prevalence.…”

“…While not the primary focus of our review, one additional problem concerns the use of the term prolonged grief disorder for prolonged grief disorder symptoms assessed with outdated scales (e.g., versions of the ICG). These outdated scales either do not actually assess the most recent criteria sets or only approximate them (for discussions of diverse assessments of PGD symptoms across instruments/diagnostic categorizations, see Treml et al [2020], 3 Eisma [2023], 4 and Haneveld et al [2022] 10 ). To elaborate: very few of the scales included in the selected studies comprehensively assessed all specified symptoms of PGD per ICD-11 and DSM-5-TR.…”

“…3 Prolonged grief has been shown to be related to, but distinguishable from, symptoms of neighboring disorders of depression and posttraumatic stress disorder, to predict lower quality of life and suicidal tendencies, and to be treated most effectively with grief-specific interventions. 4 Accordingly, a disorder characterized by such grief reactions was added to the 11th revision of the International Classification of Diseases (ICD-11) as prolonged grief disorder (PGD). 5 In 2022, a related but distinct disorder with the same name was included in the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).…”

“…Prolonged grief has been described as grief reactions that become abnormally persistent and cause significant impairment in daily functioning 3 . Prolonged grief has been shown to be related to, but distinguishable from, symptoms of neighboring disorders of depression and posttraumatic stress disorder, to predict lower quality of life and suicidal tendencies, and to be treated most effectively with grief-specific interventions 4 . Accordingly, a disorder characterized by such grief reactions was added to the 11th revision of the International Classification of Diseases (ICD-11) as prolonged grief disorder (PGD) 5 .…”