Mourning Sickness: Prolonged Grief Disorder (PGD)

By Dr. Anna Darbonne*, PsyD

Grief is the worst kind of suffering. It’s not just missing a loved one, it is intense psychological anguish, deep yearning, social upheaval, and existential crises all at once. The excruciating nature of grief usually lasts for just the first of three very normal grief phases (acute, early, and integrated). But for some mourners, the unbearable intensity of acute grief remains locked in for years. The hopeful news: with time and support, healing and relief will come.

The natural grief process leads roughly 90% of individuals through insufferable sorrow (acute grief) to a place where emotions feel slightly more manageable. The second phase (early grief) remains painful, but includes oscillations of “normal life.” It involves feeling the pain of grief, adjusting to life without the loved one, allowing joy, and feeling connection with self and others. With this emotional work and lapse of time, grief can become integrated. In the third and often longest phase, the individual lives a meaningful life that includes ongoing (albeit revised) relationships with their loved one and their grief.

For the remaining 10% of the bereaved, however, the chasm between grief and fully living feels not only uncrossable but undesirable. The thought of a future without their beloved is unfathomable. Their grief is both debilitating and halting. Their experience of grief prevents the normative mourning process and resuming life functions – they feel “stuck” and can’t “move on.”

These grievers’ chronically heightened state of mourning frequently includes: single-minded focus on the death and their loved one, inability to accept the loss, guilt, self-blame, bitterness, purposelessness, the perception that life without their loved one is meaningless, withdrawal from social interactions, and an inability to enjoy life. Those with PGD often berate themselves for their perceived part in the loss and punish themselves by withholding the option of healing.

To categorize and support those whose grief appears maladaptive, the latest diagnostic manuals now feature Prolonged Grief Disorder (PGD)1,2. Whether grief should be diagnosed and pathologized has long been debated among experts3. Some consider that labeling grief as an illness also pathologizes love, a normative and healthy process4. Yet substantial research documents that some grief presentations are distinct from standard bereavement5 and require targeted intervention6.

What may “cause” the development of PGD is unknown. Susceptibility for complicated grief responses is linked to the combination of the relationship with the deceased and the cause of death in conjunction with one’s attachment style, personality, previous loss and life experiences, and culture. For example, the death of a child or someone who the griever was dependent on are incredibly destabilizing losses. Deaths that were unexpected, violent, or from disaster can also be particularly world shattering7. Furthermore, socially stigmatized losses (like death by suicide or addiction) and disenfranchised losses (like prenatal or military related deaths) add pains of social judgment and ambivalence. For example, research shows that families mourning a loved one’s death by suicide receive less support (e.g., less visits, casseroles, condolences) than those grieving deaths for other reasons8. As such, lack of a support system and social isolation are additional risk factors. Finally, a personal history of traumatic experiences, major life stressors, and mood or other mental health disorders can also factor into whether PGD develops.

If you identify with any of these descriptions or recognize someone who does, please know that there is hope. Grief does not automatically necessitate professional assistance or attendance in grief groups, but PGD does. Working with a mental health provider who has specialized training in bereavement can help by creating intentional time to mourn, allowing a space to emote without fear of judgment or being a burden, learning coping skills for distress tolerance and emotional regulation (i.e., responding to emotions in a kind, supportive way), challenging beliefs about the loss and grief process, and identifying what would provide meaning to life.

Grief is an adaptive process – it shows us who we love and what we value, motivates us to connect with community, and helps us feel emotions that add vibrancy to life. For the majority of those in mourning, adaptation to the loss occurs and grief becomes integrated into their everyday lives. Grief, by nature, is prolonged. We will grieve our loved ones all our lives. But with time, and, importantly, with clinical assistance for those with PGD, we will be able to remember them with more love than pain. We can even cultivate the type of wonderful life that we had hoped our loved ones would live, which can be an incredibly meaningful way to honor them each day.

*Dr. Darbonne is a licensed clinical psychologist at her private practice, Bamboo Center for Grief, Growth, and Well-being. She is a certified Grief Educator and Compassionate Bereavement Care provider who gently and humorously companions adult clients as they navigate life and loss transitions.

REFERENCES:

1. World Health Organization. International statistical classification of diseases and related health problems (10th ed., Clinical Modification). 2019. From https://icd.who.int

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed., text rev.). 2022. From https://doi.org/10.1176/appi.books.97808904255966

3. Breen LJ, Penman EL, Prigerson HG, Hewitt LY. “Can Grief be a Mental Disorder? An Exploration of Public Opinion.” J Nerv Ment Dis. 2015. Aug; 203(8):569-73. DOI: 10.1097/NMD.0000000000000331.

4. Thieleman K, Cacciatore J. “When a Child Dies: A Critical Analysis of Grief-Related Controversies in DSM-5.” Research on Social Work Practice. 2014; 24(1):114-122. DOI:10.1177/1049731512474695

5. Maciejewski PK, Maercker A, Boelen PA et al. “’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.” World Psychiatry 2016; 15:266‐75.

6. Shear K, Frank E, Houck PR, et al. “Treatment of complicated grief: a randomized controlled trial.” JAMA. 2005; 293:2601‐8.

7. Clare Killikelly & Andreas Maercker. “Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability.” European Journal of Psychotraumatology, 8:sup6. 2017. DOI: 10.1080/20008198.2018.1476441

8. Feigelman, W., Gorman, B. S., and Jordan, J. R. “Stigmatization and suicide bereavement.” Death Stud. 2009. 33, 591–608. DOI: 10.1080/07481180902979973

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