The Paradoxes of Prolonged Grief Disorders

Grieving adequately is painful, but the paradoxical outcome can be more resilience and emotional strength.

I was so pleased to see that the ICD-10 Coordination and Maintenance Committee of the Centers for Disease Control and Prevention (CDC) was meeting next week, and that prolonged grief disorder was one of the agenda items.

It seems paradoxical to me, that with all these losses over the last year, that a new diagnostic category in psychiatry seemed to slip by us without much attention – as if even we in medicine were in some denial and did not want to hear about it – but that fit the time precisely.

In October, the Assembly of the American Psychiatric Association approved the new diagnostic category of Prolonged Grief to be included in the imminent update to DSM 5, DSM 5TR.

Although it has always been hard to draw the line with normal mourning, and hence what should draw the attention of medicine and psychiatry, this does seem to be a distinct problem. It also has some similarity to what has been called persistent complex bereavement disorder.

Brain-wise, prolonged grief shows increased activity in the nucleus accumbens, the region of the brain associated with reward, which doesn’t occur with clinical depression. With the involvement of

the reward system, it has more in common with addiction.

Prolonged grief is characterized by distressing and disabling yearning for the deceased, or what has been lost, accompanied by intense emotional pain for at least six months after the loss, along

with some symptoms such as anger and guilt. It occurs more often when there are many casualties, perhaps occurring in up to a quarter of those close to the deceased. Prolonged grief symptoms are also typically elevated when deaths are unexpected, traditional grief rituals are absent, and live physical social support is lacking. Sounds like it should occur a lot, therefore, with COVID 19, doesn’t it?

With prolonged grief, formal treatment is often needed. What doesn’t seem to help is medication. However, varieties of cognitive behavioral therapy (CBT) do, and they’re starting to be

used online. Support groups for those with similar losses can also help. Though we are focusing on grieving deaths, major losses of other sorts can also lead to prolonged grief. One COVID example is the loss of health in long-term sufferers with chronic symptoms.

For children, another form of CBT called CBT Grief-Help seems to work. Studied using nine sessions, interventions include imagining exposure (that is, telling the story of the loss) and writing, such as a letter to the lost person about what the patient misses most. For children, prolonged grief is especially common after losing a parent.

Grieving adequately is painful, but the paradoxical outcome can be more resilience and emotional strength.

Without prevention or treatment, prolonged grief can last indefinitely and lead to substance abuse, suicidality, sleep problems, and impaired immune functioning.

Our increased understanding of prolonged grief may also lead to some preventive techniques, too. If symptoms escalate after unexpected deaths, unavailable traditional rituals, and absent

live social support, then pay attention to those situations, and try alternatives to tradition. Let’s look for more societal opportunities to do so. Just think what we could do just by having all those

waiting to get the vaccine fill out the simple Bereavement Challenges Scale, which can help identify specific thoughts and behaviors that pose a risk for prolonged grief.

Feedback on the score could then be provided, and help suggested. If only.