Prioritizing Practical Care When Treating Prologued Grief Disorder

Over 2 years after the onset of the COVID-19 pandemic in the United States, few lives remain untouched by the public health crisis that disrupted everyday life in countless ways, including established cultural rituals for final farewells to the dearly departed.

On Saturday, September 17th, at the 35th annual Psych Congress in New Orleans, Alana Iglewicz, MD, clinical professor of psychiatry, University of California, San Diego, presented her session entitled, “Good Grief!: Prolonged Grief Disorder in the Context of COVID and Beyond” before an audience of mental healthcare professionals, including doctors, nurse practitioners, care advocates, and non-profit representatives.

Ahead of her presentation, Dr Iglewicz spoke with Psych Congress Network about how the pandemic affected diagnoses of PGD, key symptoms clinicians should keep an eye out for, common misconceptions about the disorder, and where providers can find more resources for clinical practice.

Psych Congress Network (PCN): How have the effects of the COVID-19 pandemic impacted the way in which clinicians diagnose and treat Prolonged Grief Disorder (PGD), which is now formally recognized in the DSM-5-TR?

Alana Iglewicz, MD: To say that the COVID-19 pandemic has been a time of loss is a gross understatement.

Since the start of the pandemic, over 1 million Americans and more than 6.5 million people globally have died of COVID. At this point in the pandemic, nearly everyone knows someone who has died of COVID. Millions of people are more intimately grieving the death of a loved one to COVID-19. In essence, the world is collectively grieving. The pandemic has necessitated profound disruptions in death, dying, and mourning. With disruptions in families’ abilities to say their final goodbyes, attend in-person funerals, and follow mourning rituals, many more people are at risk for developing and suffering from Prolonged Grief Disorder (PGD).

The COVID-19 pandemic has taught clinicians about the importance of incorporating themes of grief into our assessments, formulations, and support of patients. Our patients, our colleagues from other specialties, and the public are looking towards mental health professionals for our expertise on grief. My hope is that the pandemic has inspired mental health professionals to gain clinical sophistication with grief more broadly, and PGD, its assessment and treatment, more specifically.

PCN: What are the key symptoms of PGD that clinicians should look out for in their patients?

Dr Iglewicz: PGD is a form of complicated and prolonged grief that is associated with considerable functional impairment, morbidity, and mortality. It occurs when people’s normal, adaptive grief experiences essentially get derailed. Key symptoms include pronounced yearning and longing, preoccupation with thoughts and/or memories of the deceased loved one, disruption in identity, a marked sense of disbelief, considerable struggles integrating back into life after the death, feeling life is now meaningless because of the death, and avoidance of reminders of the death—all of which last 12 months or longer according to the DSM-5-TR, but notably 6 months or longer per the ICD-11. For most people who have PGD, the symptoms last endlessly without treatment. Many suffer for years to decades.

From a clinical perspective, it is helpful to pay attention to the qualitative feel of the grief. People who have PGD are not just “stuck” in their grief, they are frozen in the acute stages of grief. In PGD, grief can be all-consuming. Individuals suffering from PGD often feel as though grief is all they have left and that to stop grieving so intensely would be a betrayal to their deceased loved one. Subsequently, there is not breathing room left for life to enter back in. When evaluating a patient who experienced the death of a loved one, their pain feels so raw, so near to the surface that you naturally assume their loved one must have died in the past two months; then, you learn that the death occurred years ago, possibly decades ago, that disconnect is key and should be salient. It strongly hints that you should further evaluate for PGD and refer for life-affirming and, at times, life-saving treatment if PGD is present.

PCN: In your session, you mention there was controversy over PGD being included in the DSM-5-TR. Are there any misconceptions on this topic that you would like to clear up?

Dr Iglewicz: One of the most heavily debated changes to the DSM-5—and now the DSM-5-TR—centers around grief. With the DSM-5, the debate was more specifically related to the removal of the bereavement exclusion. With the DSM-5-TR, the debate relates to the addition of Prolonged Grief Disorder as a formal diagnosis. Those opposed to these changes fear the medicalizing and pathologizing of a natural human process: grief. Proponents of these changes fear the lack of recognition of, and thus, lack of treatment for a condition that leads to profound suffering and that has a robust evidence base for efficacious treatment.

In many senses, those in opposition to and those in favor of the changes to the DSM-5 and DSM-5-TR are having different debates. Those opposed to the changes are having a philosophical debate, proponents of these changes are having a practical debate. From a philosophical standpoint, concerns about medicalizing and pathologizing the human condition apply to the near entirety of psychiatric diagnoses. Nearly every human has experienced anxiety. At some point, we draw a line and past that threshold we call it an anxiety disorder. All humans experience sadness. At some point, we draw a line and past that threshold, we call it a depressive disorder. Grief is an easy target for such a debate. In my experience, those who are most opposed to the addition of PGD in the DSM-5-TR are not trained in its most evidence-based treatment, Prolonged Grief Disorder Therapy, and have not had the privilege of helping to utterly transform people’s lives with this powerful mode of treatment.

The debate around PGD is an important debate, and is also one that should not be singularly applied to grief. Continued dialogue and critical thought is needed. At the same time, the more of us who are trained in the evaluation and treatment of PGD, the more we can alleviate pronounced suffering. In light of the myriad losses associated with the COVID-19 pandemic, this is more important now than ever in our lifetimes.

PCN: Where can clinicians go to get resources and further education on the disorder and its treatments?

Dr Iglewicz: Key articles delineating how to best conceptualize, evaluate, and treat PGD exist in the medical literature. Notably, PGD was formerly called Complicated Grief (CG), and Prolonged Grief Disorder Therapy (PGDT) was recently and formerly called Complicated Grief Therapy (CGT) in the literature. Although some nuance exists between the different terminology, other terms used interchangeably with PGD include “Traumatic Grief” and “Pathological Grief.”

One of the best resources for learning more about PGD and its treatment is the Center for Prolonged Grief, formerly called The Center for Complicated Grief. The Center’s website (https://prolonged grief.columbia.edu) hosts a wealth of information about PGD and PGDT, both for the public and for professionals.

PCN: Are there any other takeaways you would like to discuss?

Dr Iglewicz: Recognizing and treating people who suffer from PGD can be one of the most meaningful parts of your career. Doing so affords you the privilege of helping people re-engage in life with a renewed sense of meaning, purpose, and connection—not just with the living, but also with loved ones who are no longer alive. 

Alana Iglewicz, MD, is a Clinical Professor of Psychiatry at the University of California, San Diego, as well as the Associate Residency Training Director for the Department of Psychiatry and the Director of Wellness Initiatives at the UCSD School of Medicine. Dr. Iglewicz earned her B.A. in Psychology at the New College of Florida and her M.D. at the University of Pittsburgh School of Medicine. She then completed her residency training in General Adult Psychiatry and subspecialty clinical and research fellowship training in Geriatric Psychiatry at UCSD. Her clinical work is focused at the La Jolla VA, where she works with trainees in the Psychiatric Emergency Clinic and is the Psychiatry Medical Director of the Mental Health Primary Care Clinic. She is passionate about healthcare professional wellness and is the faculty chair for both the UCSD Psychiatry Residency Wellness Committee as well as the S.A.V.E. Committee, which is dedicated to providing support to psychiatry residents after the occurrence of adverse events, such as patient suicide and patient violence toward trainees. Her research focuses on physician wellness, psychiatric education, late and end-of-life depression, and bereavement. Throughout her career, Dr. Iglewicz has received numerous teaching and clinical awards.