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Prolonged Grief Disorder (PGD) refers to a syndrome comprised of a distinct set of grief symptoms that are so prolonged and intense that they exceed the expectably wide range of individual and cultural variability. PGD is relatively rare -- experienced by about 10 percent of bereaved survivors, though rates vary depending on the circumstances. This is grief that does not resolve naturally and persists into the indefinite future as a defining feature that severely adversely affects the life of the survivor. The affected person is incapacitated by grief, so focused on the loss that it is difficult to care about much else. S/he ruminates about the death and longs for a reunion with the departed, feeling unsure of his/her identity and place in the world. His/her life is flat and dull, offering little meaning or purpose, and the future holds no prospect of joy, satisfaction or pleasure. The bereaved person who suffers from PGD feels devalued and in constant turmoil, with an inability to accommodate to (if not a frank protest against) life without the beloved.

PGD is defined by its symptoms, duration and intensity. The symptoms are yearning intensely for the person, identity confusion, difficulty accepting the loss, bitterness, emotional numbness, inability to trust others and feeling stuck in grief. These are present every day, cause significant distress and functional impairment and remain intense, frequent and disabling for six months or more after the death.

Description
Grief is a normal response to bereavement. Researchers have found that 10-12% of people experience a prolonged response to bereavement that impacts functionality and has adverse long-term effects on health.

Prolonged grief is considered when an individual’s ability to function and their level of distress over the loss is extreme and persistent. People with PGD feel "stuck" in their grief, a chronic aching and yearning for a cherished person who is now gone, feel that they are not the same person anymore (e.g., unsure of their identity, loss of a sense of self and self-worth), feel emotionally disconnected from others, and lack the desire to "move on" (and may feel that doing so would be a betrayal of the person who is now gone).

What is the difference between normal grief and "Prolonged Grief Disorder" (PGD)?
Although extremely painful, grief is the normal process of accommodating to a new life without the deceased loved one. Most bereaved survivors manage to get through the worst of their grief and continue to function and find meaning in life. Normal grief differs from PGD in that it is not as intense, persistent, disabling and life-altering and is not experienced as a severe threat to the survivor's identity, sense of self-worth, feeling of security, safety or hopes for future happiness. Although normal grief remains with the bereaved person far into the future, its ability to disrupt the survivor's life dissipates with time.

Diagnostic Criteria
Factor analytic studies have determined that the symptoms of PGD form a unitary construct that is separate from symptoms of bereavement-related depression and anxiety. Extensive research has been conducted to identify and isolate the symptoms that constitute PGD and distinguish it from diagnostic “nearest neighbors” such as Major Depressive Disorder or Posttraumatic Stress Disorder. These analyses integrate clinical insights with rigorous empirical analysis to determine the set of symptoms that best indicate which bereaved survivors will be at risk of long term dysfunction and distress (e.g., suicidality, alcohol abuse, disability days, sleep impairment, quality of life impairment, high blood pressure, hospitalizations for serious medical events such as heart attacks).

The table below illustrates the PGD diagnostic criteria proposed for inclusion in the DSM-V and ICD-11.

Risk Factors
Known risk factors and clinical correlates for PGD include a history of:
 * Childhood separation anxiety
 * Controlling parents
 * Parental abuse or death
 * Close kinship relationship to the deceased (e.g., parents)
 * Insecure attachment styles
 * Marital supportiveness and dependency
 * Lack of preparation for death
 * Death in hospital
 * No shortened REM latency
 * Activation of the nucleus accumbens

These risk factors and clinical correlates have been shown to relate to PGD symptoms and not symptoms of Major Depressive Disorder (MDD), Post-traumatic Stress Disorder (PTSD), and Generalized Anxiety Disorder (GAD).

Health Consequences
PGD symptoms have been associated with:


 * Elevated rates of suicidal ideation and attempts
 * Cancer
 * Immunological dysfunction
 * Hypertension
 * Cardiac events
 * Functional impairment
 * Adverse health behavior
 * Reduced quality of life in adults     and in children.
 * Increased health service use and sick leave

Treatment
The unique course of PGD requires targeted treatment. Randomized control trials (RCT) have proven tricyclic antidepressants alone or together with interpersonal psychotherapy ineffective in reducing PGD symptoms, while psychotherapy designed specifically for PGD has been proven to be advantageous. Preliminary results of called HEAL (Healthy Experiences After Loss), an online, self-management intervention to prevent PGD in recently bereaved persons are very promising and a larger randomized controlled trial is being planned.

Incidence
Out of the people surveyed who have experienced a loss, 10%–20% display a prolonged and severe grief response. Thirty one longitudinal studies on grief and pathalogical forms of grief in progress in the United States, The Netherlands, Germany, Swizerland, and Canada. At least 50 additional cross-sectional studies are being conducted across North and South America, Europe, Asia, Australia and Africa. Efforts are underway to pool and compare and contrast results using these international data.

History and Discussion
The DSM-IV and ICD-10 do not distinguish between normal and prolonged grief. Based on numerous findings of maladaptive effects of prolonged grief, diagnostic criteria for PGD have been submitted for inclusion in the DSM-V and ICD-11.

The proposed diagnostic criteria came out of statistical analysis of a set of criteria agreed upon by a panel of experts. The analysis wielded criteria that were the most relevant markers for dysfunction among bereaved individuals. While previous studies have noted the suffering that is associated with chronic mourning, Prigerson et al. produced the first agreed upon and tested diagnostic algorithm for PGD.

Recognizing prolonged grief as a disorder would allow it to be better understood, detected, studied and treated. Insurance companies would also be more likely reimburse its care. On the other hand, inclusion of PGD in the DSM-V and ICD-11 may be misunderstood as the medicalization of grief, reducing its dignity, turning love into pathology and implying that survivors should quickly forget and "get over" the loss. Bereaved persons may be insulted by having their distress labeled as a mental disorder. While this stigmatization would not be the intent, it might be an unintended consequence. In spite of this concern, studies have show that of nearly all bereaved individuals who met the criteria for PGD were receptive to treatment and their families relieved to know they had a recognizable syndrome.

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