Prolonged Grief Disorder, Major Depression, or PTSD: Making the Distinction
I would like you to think about your life up until this moment. Look back and identify all the losses you have experienced. Maybe you lost friends or family to death, or perhaps a marriage, a job, health, sense of physical safety, and intact family? What was your grieving process like? How did you react emotionally, cognitively, psychologically, interpersonally, spiritually, physically, and behaviorally?
We all have losses we must integrate into our life narrative. Loss is a universal human experience. Therefore, we can make the argument that most clients, if not all, who come to therapy have had their own losses with their idiosyncratic circumstances and grief processes. Research shows approximately 10-20% of grievers do not manage the grieving process without significant derailment, referred to as complicated bereavement. In these cases, the grief has become acutely distressing and functionally impairing (Prigerson, Vanderwerker, & Maciejewski, 2008). The reactions to the loss are outside what is considered to be uncomplicated based on societal, cultural, spiritual, religious, and age-based norms. However, instead of complicated grief being identified as its own distinct psychological disorder, it is often confused with other mental health disorders, such as major depressive disorder, adjustment disorder, post-Traumatic Stress Disorder, and anxiety disorders. “It constitutes a persistently elevated set of specific symptoms of grief identified in bereaved individuals with significant difficulties in adjusting to the loss” (Prigerson et al., 2008, p.166).
Reactions, such as intense yearning and pining for the deceased (separation distress), are not captured by a depression (MDD) or post traumatic stress disorder (PTSD) diagnosis, nor are the treatments for those disorders necessarily appropriate for complicated grief, and certainly not for uncomplicated grief (which often is diagnosed as depression or adjustment disorders by mental and physical health practitioners due to lack of education and training). There are specific distinctions that can help the clinician identify the etiology of the presenting problem, and avoid misdiagnosing a complicated grief case that wears the mask of other psychological disorders. It is not that MDD or PTSD cannot be concurrent with complicated grief, but rather that complicated, prolonged grief has a distinct set of coherent criteria (discussed in detail below) different from bereavement-related depressive and anxiety symptoms (Prigerson et. al, 2008).
However, a disorder that specifically relates to complicated grief is not identified in the DSM-IV-TR (2000). Bereavement itself is a v-code, and can only be diagnosed for two months, at which time the exclusion criteria requires you, as the treating clinician, identify a different psychological disorder that “fits” the client’s presenting symptoms. Prigerson et al. (2008) state:
A single paragraph in the DSM-IV is devoted to bereavement. It focuses exclusively on symptoms of depression…subsequent to the loss of a significant other…criteria for diagnosing severe, prolonged, maladaptive grief remains conspicuously absent…its guidelines on bereavement are at odds with substantial evidence that symptoms apart from those of depression…constitute a separate pathological form of bereavement-related psychic distress. (p. 166)
Therefore, a distinction between complicated and uncomplicated grief is not made in our profession’s own diagnostic manual. These disorders are not appropriate if the client can be diagnosed with a disorder that reflects the unique contribution of how the client’s complicated grief is the main presenting problem and require treatment based on death, loss, and grief research, theory, and practice. In 2008, the main researchers (Prigerson, et al., 2008) who have proposed and lobbied for the inclusion of Complicated Grief in the soon to be released updated DSM-V (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition) changed their nomenclature to Prolonged Grief Disorder (PGD).
This article aims to help bring to light how to differentiate between major depressive disorder and post-traumatic stress disorder from prolonged-grief disorder.
Prolonged Grief Disorder (PGD)
Those with PGD maintain chronically high levels of specific symptoms for more than six months after the loss. The person is stuck in a state of chronic bereavement, characterized by consistently protesting against the loss, reluctance to adapt to changes in life, a sense of bitter loss and chronic desire for life to return to the state it was before the loss, feeling empty and hollow, having little hope for the future, ruminating, preoccupation with guilt and sorrow, feeling disconnected from previously close friends and family, having a sense of alienation, recurrent and intrusive thoughts about the absence of the person, feeling lack of meaning and life purpose, having difficulty forming new relationships, and feeling like part of him or herself has died with the death, and having a sense of identity that is confused or lost (Prigerson et. al., 2008). Therefore, one may conceptualize the distinctions of PGD by placing them into two major categories: “(a) symptoms of separation distress (e.g., preoccupation with thoughts of the deceased to the point of functional impairment);, and (b) symptoms of traumatic distress (e.g., feeling disbelief about the death, mistrust, anger, and detachment from others as a result of the death)” (Prigerson & Jacobs, 2001, p. 615).
Prolonged Grief Disorder, as previously mentioned, is not part of the DSM-IV-TR, but researchers and practitioners have made a strong case for its inclusion of the DSM-V due out some time in 2012-2013. The research on the development of this proposed diagnostic category, the clinical measures, studies, and development and use of test inventories is beyond the scope of this article (the reader may find this type of additional information by authors such as Prigerson, Jacobs, Maciejewski, and Horowitz to name a few), but the proposed criteria is listed here in what will be familiar to the reader as the DSM-IV-TR style (Prigerson, et al., 2008).
•Yearning, pining, longing for the deceased
•Yearning must be experienced at least daily over the past month or to a distressing or disruptive degree
•In the past months, the person must experience four of the following eight symptoms as marked, overwhelming, or extreme.
•1. Trouble accepting the death
•2. Inability trusting others since the death
•3. Excessive bitterness or anger about the death
•4. Feeling uneasy about moving on with one’s life (e.g., difficulty forming new relationships)
•5. Feeling emotionally numb or detached from others since the death
•6. Feeling life is empty or meaningless without the deceased
•7. Feeling the future holds no meaning or prospect for fulfillment without the deceased
•8. Feeling agitated, jumpy or on edge since the death
•The above symptom disturbance causes marked dysfunction in social, occupational, or other important domains.
•The above symptom disturbance must last at least 6 months
So, you are now familiar with the description and criteria of PGD. But how to differentiate between PGD and other psychiatric disorders is essential to application of it to your work with your clients. MDD and PTSD are two psychiatric disorders often confused with PGD. However, it is important to note that anxiety disorders are often diagnosed as well. However, in the interest of length, I will focus on MDD and PTSD.
Uncomplicated Bereavement vs. PGD
What are the essential differences between uncomplicated bereavement and PGD? In uncomplicated bereavement, separation anxiety is present, but does not remain at markedly high level and does not remain intrusive. Feelings of purposelessness of futility diminish over time, and the bereaved may take on characteristics of loved one (e.g., being more kind because it is a characteristic that the bereaved admired in the decreased) (Prigerson & Jacobs, 2001).
In PGD, separation anxiety does not diminish over time, is markedly high, and prolongedly interferes with functioning. Feelings of futility do not diminish over time. The bereaved can over identity with deceased by engaging in unhealthy behaviors of deceased (e.g., deceased died from an overdose, so the bereaved begins to use the same substance) or may adopt symptoms of terminal illness of deceased (Prigerson & Jacobs, 2001).
PTSD vs. PGD
There are also significant psychological, behavioral, and physiological differences between PTSD and PGD. Individuals with PTSD attempt to avoid threatening stimuli, have a phobic avoidance of reminders of traumatic event, fear violent physical harm to self or others, are hyperaroused and/or hypervigilant for impending attack, and experience no separation distress. Research also shows that on a physiological level, those with PTSD experience an increased heart rate while discussing the traumatic experience (Buckley & Kaloupek, 2001).
In PGD, the avoidance of threatening stimuli is not present, but there is avoidance of reminders of loss being real. He or she has difficulty accepting loss, avoids moving on with life, and has significant separation distress. When discussing the loss, those with PGD actually experience a decrease in their heart rate when they discuss the experience of the loss (Bonanno, Keltner, Holen, & Horowitz, 1995; Lepore, Ragan, & Jones, 2000). Rather than avoidance, the more salient behavior is one of searching for reminders of the deceased (Prigerson & Jacobs, 2001). Furthermore, in EEG sleep studies, those with PGD do not have hyperaroused sleep that is present in PTSD (McDermott, Prigerson, & Reynolds, 1997).
MDD vs. PGD
MDD is often one of the “default” diagnoses for complicated bereavement. However, in MDD, yearning, disbelief, separation distress, meaninglessness, not moving on, bitterness, and feeling emotionally numb are not part of MDD diagnosis. The depressed mood, psychomotor retardation, and poor self-esteem are specific to this disorder and are not present in PGD. Depression is treatable with psychotropic medications and have a distinct neuroendrocine response (Jacobs, 1987).
In contrast, PGD includes feelings of intense yearning and pining for the deceased, disbelief of loss, feeling life is empty and meaningless without the deceased, difficulty moving on, and feeling bitter or emotionally numb, all of which are specific to this disorder. Based on the diagnosing criteria, depressed mood, psychomotor retardation, and poor self-esteem not included because they do not distinguish it from other mental disorders. PGD also does not respond to psychotropic medications and has a distinct EEG profile compared to that of MDD (McDermott, Prigerson, & Reynolds, 1997).
Although many of us never had a required course in bereavement studies, practitioners are all confronted with clients who have experienced loss. These clients may present with symptoms of other psychiatric disorders when in fact they are actually experiencing complicated bereavement. However, due to our lack of exposure to bereavement theory and research, we are not equipped with the tools necessary to make the distinction. It is hoped that with this article, you have become more aware of these distinctions.
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