Prolonged grief disorder in section II of DSM-5: a commentary (2023)

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Prolonged grief disorder in section II of DSM-5: a commentary (1)

European Journal of Psychotraumatology

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Dear Editor,

The American Psychiatric Association (APA) has proposed to change the position of disturbed grief in DSM-5, replacing criteria for Persistent Complex Bereavement Disorder (PCBD), currently in Section III (American Psychiatric Association, 2013), for criteria for Prolonged Grief Disorder, to be moved into Section II (APA, 2020). This novel DSM diagnosis shares its name with grieving disorders put forth by Prigerson et al. (2009), by Maercker et al. (2013), and included in ICD-11 (World Health Organization, 2018). However, the criteria do not overlap completely. DSM-5 PGD is present when, after the death of someone close at least 12months earlier (Criterion A), a person experiences intense yearning or preoccupation (Criterion B), plus at least 3 of 8 symptoms of identity disruption, disbelief, avoidance, emotional pain, difficulties moving on, numbness, a sense that life is meaningless, and loneliness (Criterion C) for at least one month, that cause distress or disability (Criterion D), exceed cultural and contextual norms (Criterion E), and are not better explained by another mental disorder (Criterion F). DSM-5 PGD represents the sixth candidate criteria-set for disordered grief, next to PCBD, three prior proposals for PGD, and Shear et al.’s (2011) criteria for Complicated Grief (CG) (Boelen & Lenferink, 2020).

In our view, it is a welcome step if criteria for DSM-5 PGD are added to Section II, as disordered grief would then be recognized as a formal DSM diagnosis. It would be a logical consequence of research demonstrating that different combinations of putative PGD symptoms1 meet the definition of a mental disorder (e.g., Stein et al., 2010). The symptoms form a recognizable set of symptoms that can be reliably identified (Lichtenthal et al., 2018). Factor, latent class, latent trajectory, and network analyses have shown that these symptoms are distinct from symptoms of depression, posttraumatic stress, and generalized anxiety (e.g., Djelantik, Robinaugh, Kleber, Smid, & Boelen, 2020; Lenferink, Nickerson, de Keijser, Smid, & Boelen, 2020) and incrementally predict distress and disability beyond these neighbouring syndromes (Prigerson et al., 2009). Studies have shown that trajectories of resilience and recovery are much more prevalent than trajectories of chronic PGD symptomatology (Nielsen, Carlsen, Neergaard, Bidstrup, & Guldin, 2019), indicating that PGD is not ‘an expectable response to a common stressor’ (cf. Stein et al., 2010, p. 1762). Moreover, there is evidence that PGD symptoms have distinct neurobiological correlates (Bryant, Andrew, & Korgaonkar, in press). The clinical utility of PGD symptoms is supported by evidence that these symptoms are more successfully treated using grief-specific rather than other (e.g., depression-focused) interventions (e.g., Shear et al., 2014).

In clinical care we, and many clinicians with us, commonly see that deaths of loved ones precipitate persistent pain that exacerbates rather than abates as time goes by, that, in patients confronted with traumatic losses (e.g., to homicide, traffic accidents), separation distress (yearning/longing or preoccupation) overshadows traumatic distress (including intrusive symptoms and alterations in arousal and reactivity), and that bereaved patients report difficulties engaging in usual activities that resemble symptoms seen in depression but might better be conceptualized as inhibition of the exploratory system driven by separation distress.

So, we welcome the inclusion of PGD in DSM-5’s Section II. We do so as researchers, considering that this will stimulate research on the prevalence and maintaining mechanisms of, and preventive and curative care for disturbed grief. This is crucial because this research is still limited, compared with research on other common mental health disorders, and insufficiently generalizable, due to the many different ways disordered grief has been defined. And we welcome this inclusion in Section II as clinicians, considering that an established DSM-5 disorder fosters the identification of, communication about, and the provision and reimbursement of targeted care for the significant minority of bereaved people in need of help following loss. We recognize that establishing PGD as a DSM diagnosis also comes with inevitable drawbacks resulting from misconceptions about mental illness, such as stigmatization of people diagnosed with PGD (e.g., Eisma, 2018), but we believe that these disadvantages are outweighed by the advantages of this development.

All that notwithstanding, we have some concerns about the DSM-5 PGD proposal, that we hope can be allayed in the process towards the appearance of the revised DSM-5. First, we think that PGD should be placed in the DSM-5 chapter about trauma and stressor-related disorders. The current proposal is for PGD to be included in the chapter on depressive disorders. This is puzzling, since clinicians will naturally be inclined to position bereavement as a stressful event – the possible mental health consequences of which are closer to symptoms seen in other event-related disorders (Dalgleish & Power, 2004) than to (not exclusively event-related) dysregulation of positive and negative affect characterizing depressive disorders. Notably, in DSM-5, PCBD is, in fact, classified as ‘other specified trauma and stressor related disorder’ (and not as ‘other specified depressive disorder’; American Psychiatric Association, 2013) and in ICD-11, PGD is one of the ‘disorders specifically associated with stress’ (World Health Organization, 2018). Furthermore, across recent latent class analyses, PGD symptoms are consistently more likely comorbid with traumatic stress, than with depressive symptoms (e.g., Djelantik et al., 2020).

Second, the 12months timing criterion should, in our view, be reconsidered taking into account evidence that elevated PGD symptoms in the first few months strongly predict persistent disabling grief beyond this period (Boelen & Lenferink, 2019), that people following chronic grief trajectories mostly show signs of elevated grief before the first anniversary of the death (Nielsen et al., 2019), and that elevated PGD symptoms predict later traumatic stress and depression more strongly than vice versa (Lenferink, Nickerson, de Keijser, Smid, & Boelen, 2019; O’Connor, Nickerson, Aderka, & Bryant, 2015), despite the fact that PTSD and depression can be diagnosed earlier after the loss than PGD. Moreover, elevated PGD symptoms beyond 6months reliably identify bereaved individuals at risk of long-term dysfunction (Prigerson et al., 2009) and ICD-11 correspondingly adopted this timing criterion. We think there is sufficient evidence to change the timing criterion for DSM-5 PGD into >6months. We also see clinical arguments to do so: it does not make much sense to give other diagnoses to bereaved patients applying for help for disabling grief in the second half year of bereavement (let alone to withhold care if no other diagnoses apply) knowing that, in most instances, this severe grief does not naturally abate (e.g., Lenferink et al., 2020; Sveen, Bergh Johannesson, Cernvall, & Arnberg, 2018).

Third, the proposed F criterion states that ‘The symptoms are not better explained by another mental disorder.’ This broad description deviates from similar criteria in DSM-5 for PTSD and major depressive disorder, in which alternative explanations for the symptoms are more specifically defined (e.g., for PTSD: ‘The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition’). Our concern is that this broad F criterion will lead to PGD being easily mistaken for some other (as yet better known) disorder and, consequently, remain underdiagnosed and treated with less effective interventions. To avoid this, we propose to specify the F criterion, similar to corresponding criteria for PTSD and major depressive disorder.

Fourth, we see some problems with the formulation of Criterion B. This criterion actually includes two symptoms (‘yearning/longing or preoccupation’), with very different prevalence rates (e.g., 61.7% for ‘yearning/longing’ vs. 25.7% for ‘preoccupation’, in Boelen, Lenferink, Nickerson, & Smid, 2018), indicating that they represent different phenomena rather two expressions of one phenomenon. PGD as per ICD-11 also combines separation distress and preoccupation in one single criterion. PGD as per Prigerson et al. (2009) only includes ‘yearning’. In the PCBD criteria, ‘yearning’ and ‘preoccupation’ are two separate symptoms. Considering that yearning/longing and preoccupation are both valid markers of disordered grief (e.g., Boelen & Hoijtink, 2009) we propose to consider including both symptoms as B1 and B2 criteria, adding a diagnostic rule that at least one of these symptoms must be present.

Fifth, we are concerned about the proposed symptoms not all being tapped by the most commonly internationally used and well-validated measures of disturbed grief, including the Inventory of Complicated Grief (ICG, Prigerson et al., 1995), the revised ICG (ICG-R, Prigerson & Jacobs, 2001), and the PG-13 (Prigerson et al., 2009). For instance, ‘identity disruption’ is not captured by the ICG, ‘difficulties moving on’ is not captured by the ICG and ICG-R, and ‘preoccupation’, ‘loneliness’, and ‘disbelief’ are not included in the PG-13. So, with the entrance of PGD in DSM-5’s Section II, a set is proposed that is largely but not completely captured by extant measures; and data on disordered grief gathered to date largely but not completely map onto these criteria. This disturbs the continuity of assessment of PGD in research and practice. It is not easy to dispel these concerns. But – to the extent that such is justified by empirical evidence – some revisions in wording of some of the symptoms may be considered to align the criteria with existing measures

Sixth, further concerns are connected with the proposed diagnostic algorithm. The good thing is that this algorithm, with a cut off of 3/8 symptoms for Criterion C, yields only 219 symptom combinations, which is much less compared to, e.g., PCBD and ICD-11 PGD (37,650 and 3,069 combinations, respectively). Also, preliminary evidence shows that the diagnostic agreement between DSM-5 PGD and other candidate criteria-sets is substantial (Boelen & Lenferink, 2020). However, our worry is related to the fact that the chosen diagnostic algorithm has significant consequences for the prevalence rate, heterogeneity, and diagnostic agreement with other grief disorders. For example, the lenient PGD ICD-11 algorithm has been shown to yield two- to threefold higher prevalence rates compared to PCBD criteria (e.g., Boelen et al., 2018). So, although ‘the data strongly supported a cut-off of 3/8 symptoms for Criterion C’ (APA, 2020), research is needed to substantiate the predictive validity, as well as the sensitivity and specificity, of this 3/8 threshold – considering the impact of this threshold on disorder prevalence. It would be worthwhile to evaluate different symptom thresholds in conjunction with different timing criteria (e.g., PGD with a time criterion of >6months and a 4/8 Criterion C threshold) relative to the currently proposed >12months and 3/8 symptom threshold.

Taken together, we firmly support APA’s proposal to move disordered grief as a formal diagnosis to Section II of the DSM-5. There are some caveats with this move, that we hope can be addressed in fruitful future scientific and clinical exchanges.


1.For reading ease, we use the term ‘PGD symptoms’ to refer to different grief disorders proposed over the years, that have been assessed with different measurements instruments.

Disclosure statement

No potential conflict of interest was reported by the authors.


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What is the DSM-5 criteria for prolonged grief disorder? ›

DSM-5 PGD is present when, after the death of someone close at least 12 months earlier (Criterion A), a person experiences intense yearning or preoccupation (Criterion B), plus at least 3 of 8 symptoms of identity disruption, disbelief, avoidance, emotional pain, difficulties moving on, numbness, a sense that life is ...

What is the DSM-5 ICD 10 code for prolonged grief disorder? ›

ICD-10 code F43. 81 for Prolonged grief disorder is a medical classification as listed by WHO under the range - Mental, Behavioral and Neurodevelopmental disorders .

What is the best description of prolonged grief disorder? ›

The ICD-11 describes prolonged grief disorder as persistent and pervasive longing for, or preoccupation with, the deceased that lasts at least six months after loss.

Is prolonged grief disorder billable? ›

F43. 81 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What type of disorder is prolonged grief disorder? ›

This is known as complicated grief, sometimes called persistent complex bereavement disorder. In complicated grief, painful emotions are so long lasting and severe that you have trouble recovering from the loss and resuming your own life. Different people follow different paths through the grieving experience.

What is the criticism of prolonged grief disorder? ›

Critics say the diagnosis may pathologize normal behaviors like mourning and doesn't provide a solution to the problems that lead to severe grief.

What is another name for prolonged grief disorder? ›

Complicated grief

What is the ICD-10 code for difficulty coping with grief response? ›

F43. 21 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What is the ICD diagnosis for grief? ›

“So ICD-10 has grief as a Z code, as one of the 'factors influencing health status and contact with health services,' that is, Z63. 4, Bereavement (Uncomplicated),” Dr. Moffic explained.

What is the difference between grief and prolonged grief? ›

Prolonged grief is the most common form of complicated grief in adults (5). It is different from normal grief in that the immediate grief reactions persist over time with more or less undiminished strength, causing a considerable loss of everyday functioning (2).

What causes prolonged grief disorder? ›

Factors that may contribute to prolonged grief reactions are maladaptive thoughts (e.g., blame), avoidance behaviors, inability to manage painful emotions, differences in health and social status, and lack of social support that interferes with adaptation to loss (11–13).

Is prolonged grief disorder the same as complex grief? ›

“Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief”, are one and the same diagnostic entity: an analysis of data from the Yale Bereavement Study.

What is the difference between F43 81 and F43 8? ›

F43. 8, "Other reactions to severe stress," is being subdivided into two new codes — one to capture prolonged grief disorder (F43. 81) and another to capture the rest of what was otherwise reported under F43. 8 (F43.

What medication is used for prolonged grief disorder? ›

Naltrexone has the theoretical potential to be another form of treatment that can improve the mental health, physical health, and well-being of the bereaved with PGD.

What are the physical symptoms of prolonged grief? ›

Extreme Fatigue. Intense exhaustion is a common symptom in early grief, often preventing people from accomplishing even simple tasks. Your body may feel fragile and weak, almost as if you have the flu. Insomnia is also common, but if it becomes a problem, consider consulting a doctor.

What can prolonged grief actually have a negative impact on? ›

If you can't process the permanence of the loss, it is difficult to move forward.” Regardless of who experiences it, prolonged grief comes with increased health risks. In Shear's work, suicidality, heart trouble, cancer, and other physical ailments often accompany the condition's emotional effects.

What is the most common response to unresolved grief? ›

In most cases, people with unresolved grief deny or avoid it. They hold onto their loved one and refuse to accept the loss, hindering the healing process.

What is the controversy with the DSM-5? ›

The DSM-5 promotes the idea that for most psychological disorders, there is a genetic component, yet there is no known gene variant for about 97% of diagnoses. The DSM-5 also perpetuates the chemical imbalance theory, which is the idea that mental disorders are caused by an imbalance of chemicals in the brain.

What is the ICD-10 code for grieving loss of loved one? ›

ICD-10 code Z63. 4 for Disappearance and death of family member is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the ICD-10 code for severe emotional distress? ›

ICD-10 code: R45. 7 State of emotional shock and stress, unspecified.

What is the ICD-11 code for prolonged grief disorder? ›

6B42 Prolonged grief disorder - ICD-11 MMS.

What does F43 23 mean? ›

F43. 23 Adjustment Disorder with Mixed Anxiety & Depressed Mood: A combination of depression and anxiety is predominant.

Is prolonged grief disorder in the DSM-5? ›

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) introduces a new diagnostic entity, prolonged grief disorder (PGD). Prolonged grief disorder was added to Section 2, trauma- and stressor-related disorders chapter.

Is prolonged grief disorder now an officially recognized mental illness? ›

Prolonged grief disorder is now officially recognized as a mental health condition by the American Psychiatric Association (APA). It occurs when someone experiences extensive and intense feelings of grief after experiencing loss.

How long can prolonged grief disorder last? ›

After a loved one dies, painful thoughts and feelings tend to get better within 6 months. But for some people, they linger and become hard to control. PGD is common in those who've lost a child or romantic partner. It's more likely to happen after a violent or abrupt death, such as murder, suicide, or an accident.

What two factors increase the risk of experiencing prolonged grief disorder? ›

Risk factors include a history of mood or anxiety disorders, alcohol or drug abuse, and multiple losses. Depression in persons who have been caregivers during a loved one's terminal illness and those who had depression early in bereavement are more likely to develop complicated grief later in bereavement.

What is the prevalence of prolonged grief disorder? ›

Background Prolonged grief disorder (PGD) is a recently recognised mental health disorder with an estimated prevalence of 10% in the bereaved adult population.

Which grief is considered the most distressing and long lasting for adults? ›

Grief: Loss of Children and Parents. Loss of a Child: According to Parkes and Prigerson, the loss of a child at any age is considered “the most distressing and long-lasting of all griefs” (p.

What can I use instead of F43 8? ›

Which codes can I use instead of F43. 8? You can use F43. 81 or F43.

What is F43 12 diagnosis DSM 5? ›

Code F43. 12 is the diagnosis code used for Post-Traumatic Stress Disorder, Chronic (PTSD). It is is a mental illness that can develop after a person is exposed to one or more traumatic events, such as sexual assault, warfare, traffic collisions, terrorism or other threats on a person's life.

What is F43 8 to F43 89? ›

8, "Other reactions to severe stress," is being subdivided into two new codes — one to capture prolonged grief disorder (F43. 81) and another to capture the rest of what was otherwise reported under F43. 8 (F43. 89, “Other reactions to severe stress”).

How long does grief last DSM-5? ›

Definition of Uncomplicated Bereavement DSM-5

If someone's disabling grief persists for longer than 6 months to a year, as it does in about 10% of cases, it might instead be considered an adjustment disorder or prolonged grief disorder (PGD), also known as complicated grief.

What does the DSM-5 say about bereavement? ›

Most people grieving the death of a loved one do not develop a major depressive episode. Nevertheless, DSM-5 makes it clear that grief and major depression may exist “side by side.” Indeed, the death of a loved one is a common “trigger” for a major depressive episode — even as the bereaved person continues to grieve.

How many months are required to pass before prolonged grief disorder can be diagnosed in the DSM-5 TR? ›

In order to be sensitive to the concern expressed in the public commentary about pathologizing normal grieving and diagnosing a grief‐related disorder “too soon” after the death, the DSM‐5‐TR PGD criteria specify that 12 months must elapse since the death.

Why was bereavement removed from the DSM-5? ›

The bereavement exclusion was eliminated from the DSM-5 for two main reasons: 1) there have never been any adequately controlled, clinical studies showing that major depressive syndromes following bereavement differ in nature, course, or outcome from depression of equal severity in any other context—or from MDD ...

Is prolonged grief disorder the same as complicated grief? ›

Prolonged grief is the most common form of complicated grief in adults (5). It is different from normal grief in that the immediate grief reactions persist over time with more or less undiminished strength, causing a considerable loss of everyday functioning (2).

How do you treat prolonged grief disorder? ›

Psychotherapy. Complicated grief is often treated with a type of psychotherapy called complicated grief therapy. It's similar to psychotherapy techniques used for depression and PTSD, but it's specifically for complicated grief. This treatment can be effective when done individually or in a group format.

What does unresolved grief look like? ›

With prolonged grief, you may have an intense feeling of longing for a person who has died. You may have trouble thinking about anything other than the person who died. These feelings may interfere with your ability to take care of your daily responsibilities.

Is grief considered a disability? ›

However, for those with Prolonged Grief Disorder those feelings are not eased with time. For some, Prolonged Grief Disorder will be disabling and can make them eligible for Social Security Disability.

What is the psychological response to bereavement? ›

Grief reactions lead to complex somatic and psychological symptoms. Feelings: The person who experiences a loss may have a range of feelings, including shock, numbness, sadness, denial, anger, guilt, helplessness, depression, and yearning. A person may cry for no reason.

What are the stages of grief disability? ›

According to, there are seven stages of grief for chronic disease: denial, pleading, bargaining and desperation, anger, anxiety and depression, loss of self and confusion, and acceptance. Clients can go from one stage to another until finally reaching acceptance.

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