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Prolonged grief disorder

Article in The Lancet Psychiatry · September 2022

DOI: 10.1016/S2215-0366(22)00263-2

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Holly G Prigerson
Harvard University
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S2215-0366(22)00263-2
Linked to 22tlp0596 and 22tlp0624 [Authors’ reply]
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Prolonged grief disorder
In The Lancet Psychiatry, Cacciatore
and Frances1 make inaccurate and
misleading assertions about prolonged
grief disorder, while ignoring evidence
supporting its inclusion in the
DSM-5-TR. They write, “Pathologising
grief is an insult to the dignity of
loving relationships—it proclaims
grievers as mentally ill and will too
often result in the careless prescription
of antidepressants or other drugs to
treat enduring symptoms, without
consideration of the context.” Not
only do we question why a prolonged
grief diagnosis would insult the dignity
of a relationship (would a person who
meets the criteria for major depressive
disorder a year after the death, or
who dies by suicide or of a so-called
broken heart, insult the dignity of a
loving relationship?), we also wonder
what evidence they have that those
loving relationships would be insulted.
The authors imply that a diagnosis of
prolonged grief disorder dishonours
the decedent and stigmatises the
survivor. However, in a study of
bereaved individuals in the USA who
were asked about their attitudes
and feelings about a diagnosis of
a grief disorder, 130 (96%) of 135
said that they would be “relieved to
know [they] were not going crazy”
and “relieved to know [they] had a
recognizable problem”, 135 (100%)
reported that they would be interested
in receiving treatment for their severe
grief symptoms, and only three (2%)
thought that their family would be
less understanding of what they were
going through if they received such a
diagnosis.2
Cacciatore and Frances assert
that prolonged grief disorder “has a
remarkably easy symptom threshold
to meet”. 1 However, data from a
previous study found that only 30
(1%) of a representative sample of the
general German population (N=2498)
and only 38 (4%) of the bereaved
subgroup (N=914) met the criteria for
prolonged grief disorder.3 Because a
diagnosis of prolonged grief disorder
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Correspondence
requires grief-related distress and
functional impairments, and because
it is significantly associated with
concurrent and future depression and
suicidality, and also a risk for other
adverse health outcomes (eg, bodily
pain, worse general health, vitality,
and social and role functioning),4
this diagnosis has, by definition
and by data, proven indicative of a
pathological response to bereavement.
Cacciatore and Frances state that,
in their opinion, “the evidence for
prolonged grief disorder is surprisingly
thin”. 1 Although we cannot here
present all the evidence of the
reliability and validity of a prolonged
grief disorder diagnosis, our analysis of
data from the USA, the Netherlands,
and the UK4 and exemplary evidence
from one of ten systematic reviews in
the past 5 years5 show the scientific
support for the inclusion of prolonged
grief disorder in the DSM-5-TR to be
remarkably strong.
We declare no competing interests.
*Holly G Prigerson, Paul K Maciejewski
hgp2001@med.cornell.edu
Department of Medicine (HGP) and Department of
Radiology (PKM), Weill Cornell Medicine, New York,
NY 10021, USA
1 Cacciatore J, Frances A. DSM-5-TR turns
normal grief into a mental disorder.
Lancet Psychiatry 2022; 9: e32.
2 Johnson JG, First MB, Block S, et al.
Stigmatization and receptivity to mental
health services among recently bereaved
adults. Death Stud 2009; 33: 691–711.
3 Rosner R, Comtesse H, Vogel A, Doering BK.
Prevalence of prolonged grief disorder. J Affect
Disord 2021; 287: 301–07.
4 Prigerson HG, Boelen PA, Xu J, Smith KV,
Maciejewski PK. Validation of the new
DSM-5-TR criteria for prolonged grief disorder
and the PG-13-Revised (PG-13-R) scale.
World Psychiatry 2021; 20: 96–106.
5 Heeke C, Kampisiou C, Niemeyer H,
Knaevelsrud C. A systematic review and meta-
analysis of correlates of prolonged grief
disorder in adults exposed to violent loss.
Eur J Psychotraumatol 2019; 10: 1583524.
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