Complicated Grief Can Be Complicated

While there has been over a century-old history of attempting to delineate and classify complicated forms of grief within thanatology (the scientific study of death) little of this was reflected in earlier versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In fact, it was only in 1980 that the DSM-III included post-traumatic stress disorder as a form of anxiety disorder—an addition now readily accepted but, at the time, considered controversial.

Afterward, it was only in the DSM-5 (and subsequently the DSM-5-TR) that a variety of forms of complicated grief were acknowledged. In addition to PTSD related to a traumatic death, complicated forms of grief were noted in a number of other ways in the DSM-5 (American Psychiatric Association, 2013).

For example, separation anxiety disorder now can be diagnosed in adults. The DSM-5 makes the distinction that while grief involves yearning for the deceased, fear of separation from or loss of other attachment figures is the central factor in separation anxiety disorder.

Adjustment disorders are problematic responses to general life stressors that limit the individual’s ability to function in key roles. The DSM-5 allows such a diagnosis as a response to a significant loss—noting that if it extends over time, it may meet the criteria for prolonged grief disorder―a condition to be discussed later in this article. Normal bereavement retains a Z-code indicating “other conditions that might be a focus of clinical attention.”

The Demise of the Bereavement Exclusion [1]

One of the more controversial decisions in DSM-5 was the removal of what was called “the bereavement exclusion.” Ironically, this decision harks back to Freud’s (1917) initial piece that sought to differentiate grief from depression.

In the DSM III, the bereavement exclusion was added. This specified that a person who experienced the death of a significant other should not be diagnosed with a depressive disorder within two months of the death. The bereavement exclusion, continued with minor modifications in DSM III-R (1987) and DSM IV (1994), still allowed a diagnosis of depression if there was suicidal ideation, preoccupation with feelings of unworthiness, psychosis, or psychomotor retardation even within that period.

As work began on the DSM-5, the question was raised about consistency. It seemed inconsistent that the loss of a child could not trigger depression but the loss of a job or a marriage could. Ultimately the decision was made to remove the exclusion.

This decision triggered controversy. Some argued that since depressive episodes were not uncommon in grief, it would lead to the pathologizing of normal grief reactions and provide a market for pharmaceutical companies to advertise medications to grieving persons―a prediction that remains, at least in the present, unfulfilled (Zachar, First, & Kendler, 2017).

Prolonged Grief Disorder [2]

The inclusion of prolonged grief disorder in the DSM-5-TR (2022) followed a long and circuitous route. It began with preliminary work on complicated variants of grief by two teams led by Katherine Shear and Holly Prigerson. The Shear group initially sought recognition for a disorder called complicated grief, while Prigerson sought validation of prolonged grief disorder.

While both teams had substantial data underlying the development of these proposals and the differences were not that substantial, a consensus could not be reached. Instead, a candidate disorder was proposed—that is, a diagnostic entity that with subsequent research might be included in a subsequent version of the DSM. This disorder, called persistent complex bereavement disorder, attempted to combine elements of both groups.

However, the workgroup involved in the ICD (International Classification of Diseases) (WHO, 2019) decided that the evidence for the inclusion of prolonged grief disorder (PGD) was sufficient and the syndrome was included in ICD-11 (WHO, 2019). Since there is a mutual desire for consistency between the ICD and the DSM, the American Psychiatric Association (APA) reconsidered the evidence and suggested the inclusion of PGD in the newest edition of the DSM.

It did make one change—based on public comments to the APA online portal—that PGD could not be diagnosed for 12 months after a death (compared to 6 months in the ICD-11). With these changes, PGD was accepted for inclusion in November 2020 (Prigerson, Kakarala, Gang, & Maciejewski, (2021).

Conclusion

Despite concerns and controversies, the DSM-5-TR (2022) has made considerable progress in acknowledging varied forms of complicated grief. In doing so, it can play a significant role in aligning clinical and theoretical understandings—rooting them in diagnostic categories that both enhance understanding and treatment of complicated grief.

Grief Essential Reads

A Code of Honor for the Dying and Their Family

Conversations With Patients Who Have Died

Yet, as Rando and a group of international colleagues (2012) noted over a decade ago in "A Call to the Field," there are many forms of complicated grief that need to be researched, delineated, and, at some point, acknowledged in the DSM. The DSM-5-TR cannot be the end of that process—only the end of the beginning.