Prolonged grief disorder

Prolonged grief disorder (PGD) is new in DSM-5-TR, and case questions test whether you can tell normal grief, PGD, and major depression apart while honoring the client's bond with the person who died.

Criteria at exam depth. A person close to the client died at least 12 months ago (at least 6 months ago for children and adolescents). Since the death, the client has had a persistent grief response with intense yearning or longing for the deceased and/or preoccupation with thoughts or memories of the deceased (in youth, often about the circumstances of the death), present most days at a clinically significant level, nearly every day for at least the last month. The client also has at least 3 of 8 associated symptoms in that month: identity disruption (as if part of oneself died), marked disbelief about the death, avoidance of reminders that the person is dead, intense emotional pain (anger, bitterness, sorrow), difficulty reintegrating into relationships and activities, emotional numbness, feeling that life is meaningless, and intense loneliness. The response causes distress or impairment, clearly exceeds the client's cultural and religious norms for grief, and is not better explained by major depression, PTSD, or another disorder or by a substance or medical condition.

Hinge differentials.

• Normal bereavement: painful but gradually integrated, within expected cultural norms and timeframes; grief alone is not a disorder.
• Major depressive disorder: pervasive low mood, hopelessness, worthlessness, and anhedonia across life; in PGD the distress centers on yearning for and preoccupation with the deceased. Both can co-occur.
• PTSD: intrusions and avoidance center on the traumatic event and its threat; PGD centers on longing for the person. A violent death can produce both.
• Adjustment disorder: expected grief is excluded, and PGD takes precedence when its criteria are met.
• Separation anxiety disorder: fear of separation from living attachment figures, not yearning for someone who died.

On the NCMHCE. Screen suicide risk; wishes to join the deceased require direct, careful assessment. Check substance use, sleep, and health. Measures such as the Inventory of Complicated Grief support assessment and tracking. Introduce the diagnosis in a way that validates the bond while naming where grief is stuck, so it does not feel like being told to "move on." Grief-specific therapy, such as complicated (prolonged) grief treatment, combines loss-oriented work (revisiting the death, imaginal conversations) with restoration-oriented work (personal goals, reconnecting with others). Treatment goals target adaptation to the loss rather than mood alone. Respect cultural and religious mourning practices and continuing-bond rituals.

Clinical Pearl: At least 12 months after the death (6 for youth) + daily yearning or preoccupation + at least 3 associated symptoms beyond cultural norms = PGD. Yearning for the person points to PGD; global hopelessness and worthlessness point to MDD.