Prigerson Et Al 2021 History and Status of Prolonged Grief Disorder As A Psychiatric Diagnosis

Annual Review of Clinical Psychology
History and Status of

Prolonged Grief Disorder as a
Psychiatric Diagnosis
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Annu. Rev. Clin. Psychol. 2021.17:109-126. Downloaded from www.annualreviews.org
Holly G. Prigerson,1,2 Sophia Kakarala,1 James Gang,1

and Paul K. Maciejewski1,3
1
Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York,
NY 10021, USA; email: hgp2001@med.cornell.edu
2
Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
3
Department of Radiology, Weill Cornell Medicine, New York, NY 10065, USA
Annu. Rev. Clin. Psychol. 2021. 17:109–26 Keywords

First published as a Review in Advance on
grief, bereavement, prolonged grief disorder, complicated grief, mental
February 1, 2021
disorders, reward system
The Annual Review of Clinical Psychology is online at
clinpsy.annualreviews.org Abstract
https://doi.org/10.1146/annurev-clinpsy-081219-
Prolonged grief disorder (PGD) is a diagnostic entity now included in the
093600
International Classification of Diseases 11th Revision (ICD-11) and soon to ap-
Copyright © 2021 by Annual Reviews.
pear in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition,
All rights reserved
text revision (DSM-5-TR). A characteristic feature of PGD is distressing,
disabling yearning that persists a year or more after the loss. Other charac-
teristic symptoms include disbelief and lack of acceptance of the loss, emo-
tional detachment from others since the loss, loneliness, identity disturbance,
and sense of meaninglessness. In this review, we detail psychiatric views on
grief and their evolution over the twentieth century. We then discuss the
development of diagnostic formulations for disordered grief, which culmi-
nated in PGD’s status as a mental disorder in the DSM. After summarizing
recent evidence that may suggest that PGD is linked to the neural reward
system, we suggest further areas of research. In particular, we note the need
for studies that extend the evidence base concerning PGD across cultural
and sociodemographic boundaries and that investigate novel treatments.
109
Contents
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
2. THEORIES OF GRIEF AND ASSOCIATED PATHOLOGIES . . . . . . . . . . . . . . . . 111
2.1. Mourning and Melancholia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2.2. Normal and Pathological Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
2.3. Attachment and Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
2.4. Stage Theories of Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
3. PROGRESS TOWARD PROLONGED GRIEF DISORDER AS A
DIAGNOSTIC ENTITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.1. Distinguishing Grief from Bereavement-Related Depression . . . . . . . . . . . . . . . . 116
3.2. Developing Consensus Criteria for Disordered Grief . . . . . . . . . . . . . . . . . . . . . . . . 117

3.3. Testing Consensus Criteria for Disordered Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

4. CURRENT STATUS OF PROLONGED GRIEF DISORDER . . . . . . . . . . . . . . . . . 119
4.1. Diagnostic Criteria for Prolonged Grief Disorder in ICD-11
and DSM-5-TR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
4.2. Diagnostic Classification for Prolonged Grief Disorder: Reward System
Disruption, Stress Response Syndrome, or Depressive Disorder? . . . . . . . . . . . . 121
5. CONCLUSIONS AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
1. INTRODUCTION
Grief is a nearly universal, largely unavoidable, painful part of life that has its origins in the sev-
ering of meaningful relationships. For as long as people have loved and then lost objects of that
love, there has been grief. For as long as there have been mothers and fathers, sisters and brothers,
grandparents, children, lovers and friends, there has been grief. In the vast majority of cases, grief
is most intense immediately after a loss and thereafter subsides over a period of months. However,
a significant minority of bereaved people can become stuck in a state of chronic mourning. For
these individuals, intense grief may persist for years and become dysfunctional and even danger-
ous, putting those afflicted at a significant risk of self-harm. Although most bereaved individuals
adjust to life in the wake of a significant loss, prospects of serious adverse outcomes among those
with problematic adjustments highlight the need for accurate, sensitive detection of mourners in
profound psychic pain.
In this article, we begin by introducing psychiatric theories of grief. We cover psychoanalytic,
attachment, and stage theories of grief and the distinctions that have been made between the nor-
mal and pathological variants of grief. Next, we summarize the data that support the inclusion
of prolonged grief disorder (PGD) as a new diagnostic entity in the International Classification of
Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). We discuss
PGD diagnostic formulations that led to and resulted in the ultimate criteria set that the Amer-
ican Psychiatric Association (APA) Assembly approved for inclusion in Section II of DSM-5 text
revision (DSM-5-TR) as a new mental disorder. We also discuss key aspects of PGD: its etiology,
outcomes, and proven as well as promising (yet to date unproven) novel interventions to reduce
the distress and dysfunction associated with it. We end with some directions for future research.
Our overall aims are to provide historical context concerning the distinction between normal and
pathological grief and the course of grief resolution, to give an update on the status of PGD as a
new mental disorder, and to provide guidance regarding promising topics for future study of and
intervention for PGD.
110 Prigerson et al.

2. THEORIES OF GRIEF AND ASSOCIATED PATHOLOGIES
2.1. Mourning and Melancholia
Psychoanalytic theories formulated by Sigmund Freud have shaped current thinking about grief—
in particular, the distinction between normal and pathological grief. In “Mourning and Melancho-
lia,” Freud [1953 (1917), p. 124] wrote that characterization of “the normal emotion of grief, and
its expression in mourning, would throw some light on the nature of melancholia.” Mourning
and melancholia, in Freud’s view, were both responses to “object loss”: Mourning represented a
healthy, adaptive process of detachment, whereas melancholia was a chronic, destructive reaction.
Freud held that the difference between mourning and melancholia lay in the stability of the libido.
In mourning, the libido gradually detached from the mental representation of the love object—
a painful but normal process, known as “grief work,” that eventually allowed for reattachment
to another object (cathexis). Melancholia resulted from a destabilized libido: The libido could
be destabilized by narcissistic identification with the love object, ambivalent fixation (a love–hate
relationship), or rejection. In other words, the roots of melancholia were theorized to lie in past re-
lationship experiences that generated unresolved conflict between the mourner and the deceased
person. The unstable libido then “introjected” against the ego, causing the deterioration of self-
esteem that Freud claimed distinguished melancholia from mourning.
In further characterizing melancholia, Freud [1953 (1917), p. 125] noted that the mourner felt
a “profoundly painful dejection, abrogation of interest in the outside world, loss of the capacity to
love, inhibition of all activity, and a lowering of the self-regarding feelings to a degree that finds ut-
terance in self-reproaches.” These symptoms that Freud described as melancholia resemble many
of those in the current formulation of PGD criteria to appear in DSM-5-TR (APA 2021) (see
the sidebar titled DSM-5-TR Criteria for Prolonged Grief Disorder). For example, the literature
on PGD reveals nuanced manifestations of the melancholic person’s low self-esteem: a sense of
meaninglessness or purposelessness without the deceased person and a sense of identity distur-
bance (the mourner’s sense of role confusion and feeling that at least a part of his or her self has
died along with the deceased person) are among PGD’s symptom criteria in DSM-5-TR. Freud
believed that the melancholic mourner could be prone to hallucinate about such a reunion and
become psychotic; those with PGD are known to avoid reminders of the reality of the death and
to engage in reveries about reuniting with the deceased, if not actual auditory or visual hallucina-
tions (Prigerson et al. 1995b). Although Freud described emotional pain resulting from unavail-
ability of the love object in both mourning and melancholia, he considered a defining feature of
melancholia to be ambivalence resulting from a conflict between a decathexis—the withdrawal of
libidinal interest, a disinvestment of emotional energy—and a libidinal drive to remain connected
to and invested in the love object. This conflict could manifest itself as the painful yearning for the
deceased (the defining symptom characteristic of PGD) and the seemingly countervailing PGD
symptoms of emotional detachment, identity confusion, and avoidance of reminders of the death.
Furthermore, the Freudian notion of cathexis is consistent with the primacy of strong emotional
dependency on, though not ambivalence toward (van Doorn et al. 1998), the deceased as a cardinal
risk factor for PGD onset ( Johnson et al. 2007).
With respect to associated features and outcomes of melancholia, Freud [1953 (1917), p. 128]
described “sleeplessness and refusal of nourishment. . .by an overthrow of. . .that instinct which
constrains every living thing to cling to life.” These observations accord with data from the
Family Health Project and the Yale Bereavement Study demonstrating that sleep disturbances
and appetite disturbances are significantly associated with meeting diagnostic criteria for PGD
(Prigerson et al. 1997, 2009). Freud also identified suicide risk among those with melancholia,
which he explained by theorizing that a mourner’s narcissistic attachment to the deceased could
www.annualreviews.org • History and Status of Prolonged Grief Disorder 111

DSM-5-TR CRITERIA FOR PROLONGED GRIEF DISORDER
A. The death, at least 12 months ago, of a person who was close to the bereaved (for children and adolescents,
at least 6 months ago).
B. Since the death, the development of a persistent grief response characterized by one or both of the fol-
lowing symptoms, which have been present most days to a clinically significant degree. In addition, the
symptom(s) have occurred nearly every day for at least the last month:
1. intense yearning/longing for the deceased person
2. preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoc-
cupation may focus on the circumstances of the death)
C. Since the death, at least 3 of the following symptoms have been present most days to a clinically significant
degree. In addition, the symptoms have occurred nearly every day for at least the last month:
1. Identity disruption (e.g., feeling as though part of oneself has died) since the death
2. Marked sense of disbelief about the death
3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by
efforts to avoid reminders)
4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging
with friends, pursuing interests, or planning for the future)
6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death
7. Feeling that life is meaningless as a result of the death
8. Intense loneliness as a result of the death
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning.
E. The duration and severity of the bereavement reaction clearly exceeds expected social, cultural or religious
norms for the individual’s culture and context.
F. The symptoms are not better explained by major depressive disorder, posttraumatic stress disorder, or an-
other mental disorder, or attributable to the physiological effects of a substance (e.g., medication, alcohol)
or another medical condition.
Copyright 2020 American Psychiatric Association, all rights reserved. Reprinted with permission.
transform into intense self-hatred and a self-destructive impulse. It has been shown repeatedly
that mourners who meet criteria for PGD are at an increased risk for suicide (e.g., Latham &
Prigerson 2004, Maciejewski et al. 2016).
Later work distinguished PGD from major depressive disorder (MDD; i.e., Freud’s melancho-
lia), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) secondary to
bereavement (e.g., Boelen & Prigerson 2007; Boelen & van den Bout 2005, 2007; Boelen et al.
2003, 2007; Maciejewski et al. 2016; Prigerson et al. 1995a, 1997, 1999a, 2009) and showed that
in terms of relationship style, emotional dependency on the deceased person is a more common
and relevant risk than ambivalence (e.g., Johnson et al. 2007, van Doorn et al. 1998). Neverthe-
less, Freud’s articulation of the broad distinctions between normal and pathological grief laid the
groundwork for later diagnostic formulations. His analysis also established relinquishment of the
attachment to the deceased person (in Freudian terms, decathecting from the love object) and
receptivity to new attachments (cathexis to another) as goals of grief therapy.

Where treatment was concerned, Freud considered mourning (i.e., grief ) a necessary process
that should not be the focus of medical intervention. He believed that grief resolves naturally over
time and viewed any interference with it as “inadvisable if not even harmful” [Freud 1953 (1917),
p. 125]. By contrast, he considered melancholia a pathological condition that posed a risk for
suicide and warranted medical attention. This fundamental distinction—whereby mourning (i.e.,
grief ) is the normal response to bereavement, and melancholia (i.e., depression) is the pathological
response—pervades psychiatric thinking to this day. As we describe in more detail below (e.g., in
Section 3.1), while several elements of PGD resemble melancholia/depression (e.g., loneliness,
loss of meaning or purpose without the deceased person), PGD diverges from depression in several
important respects, not the least of which is a lack of response to antidepressant medications; it
also diverges with respect to its core symptoms (e.g., yearning, emotional detachment, avoidance
of reminders of the reality of the death). Nevertheless, a case can be made that the intellectual
roots of the disorder that became PGD grew from the seeds planted by Freud in “Mourning and
Melancholia.”
2.2. Normal and Pathological Grief

The German psychiatrist Erich Lindemann did not formally propose diagnostic criteria for patho-
logical grief, but he did make important contributions to defining the symptoms, phases, and man-
agement of grief on the basis of his clinical experience as a psychiatrist at Massachusetts General
Hospital (MGH) in Boston. Lindemann drew his conclusions about normal and pathological grief
reactions from his observations of the mentally ill patients he treated who became bereaved, rel-
atives of those who died at MGH, relatives of soldiers who died in war, and bereaved survivors of
individuals who died in the Cocoanut Grove fire in Boston (Lindemann 1944).
Regarding the symptoms of normal grief, Lindemann (1944, p. 141) wrote: “The picture shown
by persons in acute grief is remarkably uniform. Common to all is the following syndrome: sen-
sations of somatic distress occurring in waves lasting from twenty minutes to an hour at a time,
a feeling of tightness in the throat, choking with shortness of breath, need for sighing, an empty
feeling in the abdomen, lack of muscular power, and an intense subjective distress described as
tension or mental pain.” As discussed in the next section of this article, Lindemann’s waves of
discomfort resemble what Parkes (1998) referred to as the “pangs of grief”: transient, intense
feelings of pining for the lost person accompanied by intense anxiety, which Parkes claimed were
most common in the second phase of grief after the initial shock and disbelief had faded for most
mourners. Lindemann (1944, p. 141) noted that these pangs of grief could be precipitated by trig-
gers such as the mere mention of the deceased’s name and that they resulted in “a tendency to
avoid the syndrome at any cost—to refuse visits lest they should precipitate the reaction, and to
keep deliberately from thought all references to the deceased.”
Lindemann (1944, p. 141) described features of a normal grief response as follows: “(1) the
marked tendency to sighing respiration; this respiratory disturbance was most conspicuous when
the patient was made to discuss his grief. (2) The complaint about lack of strength and exhaus-
tion is universal and is described as follows: ‘It is almost impossible to climb up a stairway.’. . .
(3) Digestive symptoms are described as follows: ‘The food tastes like sand.’ ‘I have no appetite at
all.’” Lindemann (1944, p. 142) went on to describe altered sensations, disorientation, and emo-
tional detachment (e.g., “a slight sense of unreality, a feeling of increased emotional distance from
other people. . .and there is intense preoccupation with the image of the deceased”). He added
that the sense of guilt regarding things the bereaved survivor could have or should have done to
prevent the tragedy, a lack of “warmth in relationship to other people, [and] a tendency to re-
spond with irritability and anger” (Lindemann 1944, p. 142), further characterized normal grief
responses.
Despite categorizing the above symptoms as typical of normal grief, Lindemann (1944, p. 142)
went on to state, “These five points—(1) somatic distress, (2) preoccupation with the image of the
deceased, (3) guilt, (4) hostile reactions, and (5) loss of patterns of conduct—seem to be patho-
gnomonic for grief.” For Lindemann it was the intensity of these grief symptoms, and their lack
of resolution, that distinguished pathological grief from normal grief. Lindemann also pointed
to identificatory behavior (e.g., dressing in the manner of the deceased, experiencing the same
symptoms of the deceased prior to death) as a pathognomonic phenomenon. Lindemann further
noted that pathological grief could appear immediately after the loss but also could be delayed,
and he argued that psychiatric intervention held the potential to transform a pathological grief
reaction into a normal one by promoting grief work. As with Freud, Lindemann’s goal was to
enable the mourner to emotionally detach from the deceased in order to reengage in life and
other relationships after the loss.

2.3. Attachment and Loss

Attachment theory, conceived by the British psychoanalyst John Bowlby, remains one of the most
influential psychological theories of bereavement. Drawing on functionalist explanations of be-
havior advanced by Charles Darwin (1872), Bowlby proposed that attachment to others served
the evolutionary function of advancing survival of the species by ensuring the safety and security
of its infant offspring (Bowlby 1958a,b, 1961b, 1980). He applied this framework to children who
had been abandoned and institutionalized during wartime (Bowlby 1961a,b, 1980). In observing
these children’s reactions to parental separation, he noted the damage to the child’s ego follow-
ing maternal separation. Bowlby described the child’s initial response to the mother’s absence as
separation anxiety, in which the child would engage in angry protest—crying and shouting to ex-
press the emotional pain felt as a means of gaining the mother’s return. Bowlby believed that when
separation distress was met with a warm, empathic response by a maternal figure (even if not the
actual mother), the child’s ego would largely emerge intact. If, however, it was not met with such
a response, then the child’s ego—the child’s sense of safety, security, worth, and control—would
be damaged. He noted that when the baby’s cries of protest did not result in the return of the ma-
ternal figure, the child exhibited increasing despair—whimpering, yearning, pining, and searching
for her. The final, most distressed state he observed was the infant’s ultimate detachment—a denial
of the need for emotional connections to others—and despair. He saw similarities between this
final reaction and that of concentration camp survivors for whom hope had been extinguished.
Like Lindemann, Bowlby considered the inability to arrive at the final stage of normal grief—
that is, the ability to relinquish persistent yearning for the attachment figure, accept the loss, and
become emotionally attached to others—to constitute pathological grieving. More specifically, the
four types of pathological mourning Bowlby proposed in 1963 included (a) a persistent yearning
to recover the lost object, (b) a persistent anger at both others and the self, (c) compulsive caring
for another bereaved person with whom they identified, and (d) denial of the reality of the loss. For
Bowlby, the adult mourner’s unresolved rage and protest over the loss of the love object were the
essence of pathological mourning (Bowlby 1963). Although the emphasis on unresolved feelings
resembles Freud’s, Bowlby differed from Freud in that he did not consider pathological grief to be
a result of unacknowledged hatred of, or ambivalence toward, the lost love object. Instead, Bowlby
viewed pathological grief as rooted entirely in self-hatred. In other words, the abandonment by
the love object was internalized as a rejection of the self (not the other), a degradation of the ego,
and hence diminished self-worth. As in Freud’s theory, low self-esteem, despair, and lack of what
Bowlby termed “reintegration”—the final stage of grief—defined a melancholic, or pathological,
response to loss.

2.4. Stage Theories of Grief
The idea that a natural psychological response to loss involves an orderly progression through
distinct stages of grief was first advanced by Bowlby (1961a,b, 1980) and Parkes (1972; see also
Parkes & Weiss 1983). They proposed four stages: (a) shock–numbness, (b) yearning and searching,
(c) disorganization–despair, and (d) reorganization. In her influential book On Death and Dying,
Elisabeth Kübler-Ross (1969), a Swiss psychiatrist, used this conceptual model to formulate a
five-stage model for the experience of terminally ill patients confronting their impending death.
Kübler-Ross’s five stages were denial–dissociation–isolation, anger, bargaining, depression, and
acceptance (commonly abbreviated as dabda), a paradigm quickly absorbed into the study of the
bereaved as well as the terminally ill.
The idea of distinct stages of grief has become embedded in our collective consciousness. In
a recent article, David B. Feldman (2017), a psychology professor, described challenging his un-
dergraduate students to name the five stages of grief. In this informal test, he found that even
students who had not taken a psychology class could correctly name the five stages of grief in
proper sequence without hesitation. The stages of grief not only have become a well-known
psychological theory but also have been applied to a diverse set of other significant losses that
evoke strong emotional responses, from marital breakups (Gray et al. 1991) to job loss (Galbreath
2018, Jenkins et al. 2014). The stage theory of grief has been taught in medical schools for
decades (Downe-Wamboldt & Tamlyn 1997), has been featured in television shows such as
Grey’s Anatomy, and is referenced on the National Cancer Institute’s website on loss, grief, and
bereavement (https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/
bereavement-hp-pdq). It is hard to dispute that the stages of grief have been embraced by both
medical authorities and the general public.
Nevertheless, the stage theory of grief has had its detractors. Many psychologists (Bonanno &
Boerner 2007, Feldman 2017, Stroebe et al. 2017) and authors (O’Rourke 2010) have criticized
the stage theory, asserting that grief is nonlinear and that mourners may return to earlier states
and experience recurrent themes. Parkes (1998, p. 856) argued that with the passage of time,
the intensity and frequency of the pangs of grief tend to diminish, although they often return with
renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind.
Consequently, the phases of grief should not be regarded as a rigid sequence that is passed through only
once. The bereaved person must pass back and forth between pining and despair many times before
coming to the final phase of reorganisation.
In this way, stages—or what we prefer to call states—of grief should not imply that resolution
precludes reexperiencing each proposed psychological state.
In 2007, we set out to test the stage theory using data from the Yale Bereavement Study
(Maciejewski et al. 2007). Data from this study were less than perfect: Subjects entered at varying
times after their loss and had to be grouped into uniform temporal “bins,” grief-stage indicators
were assessed using single items, and participants were mainly white widowed persons in New
England. Nevertheless, the results revealed that on average, each of the proposed states of grief
peaked (i.e., was maximally expressed) in the exact order that Kübler-Ross had proposed. The
likelihood that this would happen by chance was miniscule (p < .008). These results thus provided
the first empirical support for the notion that grief reactions or states, on average, unfold in ways
consistent with the stage theory as proposed by Kübler-Ross.
Furthermore, our empirical test of the stage theory revealed that the positive grief indicator of
acceptance of the loss increased directly in proportion to the decline in negative grief indicators
(e.g., disbelief, anger, depression). In other words, changes in grief over time from loss mirrored

changes in acceptance of the death over time from loss (Prigerson & Maciejewski 2008). And
despite claims of nonlinearity, it is difficult to dispute that the first response to the death of a sig-
nificant other is shock and disbelief and that resignation and reintegration, if not actual acceptance,
are the eventual result for those who do not experience maladaptive grief reactions.
It is important to note, however, that in the study described above, we intentionally removed
all cases in which the bereaved subject met diagnostic criteria for PGD at 6 months or beyond
postloss. The reason for excluding those who met criteria for PGD was to reveal patterns of nor-
mative grief resolution over time, which necessitated excluding those bereaved subjects for whom
intense, dysfunctional grief remained: those stuck in a state of chronic mourning (i.e., those with
prolonged grief ). We turn next to an examination of those excluded subjects to focus on the de-
velopment and testing of diagnostic criteria for PGD.
3. PROGRESS TOWARD PROLONGED GRIEF DISORDER AS A

DIAGNOSTIC ENTITY
3.1. Distinguishing Grief from Bereavement-Related Depression
In the early 1990s, as a young sociologist, H.G.P. (this article’s first author) pursued postdoc-
toral work at Western Psychiatric Institute and Clinic’s Late-Life Mood Disorders research unit.
Charles (“Chip”) Reynolds, a geriatric psychiatrist and bereavement researcher, was lab director.
Reynolds led weekly research meetings in which bereaved patients’ responses to interpersonal
psychotherapy and the tricyclic antidepressant nortriptyline were reviewed and cases were dis-
cussed. At one of these meetings, H.G.P. noticed that while symptoms of depression appeared
responsive to these antidepressant treatments, symptoms of grief did not. When asked why this
might be the case and whether there should be concern about the persistently high grief scores
among the studied patients, the psychiatrists in the room responded that high levels of grief were
not a concern for psychiatrists as they did not indicate a worrisome bereavement reaction. They
explained that bereavement-related depression, in contradistinction to grief, was an important tar-
get of psychiatric intervention. In fact, the psychiatrists expressed their belief that grief was the
normal, if not healthy, adaptive reaction to loss—a view that was consistent with Freud’s notion
of mourning and part-and-parcel to grief work. When Reynolds was asked what evidence existed
to demonstrate that intense grief was benign (if not adaptive in the sense of a mourner’s need-
ing to work through grief—a sort of no-pain, no-gain ethos—to adjust to the loss), he responded
that he was unaware of any study that addressed this question. He encouraged H.G.P. to explore
how the symptoms of grief might distinguish themselves from symptoms of bereavement-related
depression. We (H.G.P. and P.K.M.—this article’s senior author) set out to do precisely that.
We began by seeking to determine whether, among the bereaved subjects in Reynolds’s studies,
symptoms of grief (e.g., yearning, searching, preoccupation with thoughts of the deceased, crying,
disbelief about the death, feeling stunned by the death, lack of acceptance of the death) loaded
on a coherent grief factor that was distinct from a bereavement-related depression factor (e.g.,
depressed mood, psychomotor retardation, apathy) (Prigerson et al. 1995a). We found that the
symptoms of grief formed a factor that was indeed separate from depression. We thus had an
answer to our first question of whether the symptoms of grief could be distinguished as a separate
psychological entity from the symptoms of depression.
But we still needed to address the “So what?” question. The fact that the symptoms of grief
appeared to be a distinctive psychological response to loss did not mean that they were necessarily
pathological. To address this question, we sought to determine whether grief symptoms predicted
enduring dysfunction over and above symptoms of bereavement-related depression; we found
that they did. The results indicated that the baseline assessment of what we were then calling

complicated grief scores at 3–6 months postloss were significantly associated with future impair-
ment in global functioning, mood, sleep, and self-esteem at 18 months postloss, controlling for
depressive symptoms at baseline. We had initial evidence that symptoms of complicated grief
might indicate a mental disorder separate from MDD and worthy of clinical attention.
This was encouraging, but it was just the start. There would need to be many more studies,
including much more evidence from other investigators, other countries and cultures, different
kinship relationships to the deceased, and different causes of death, before the notion of a patho-
logical grief syndrome would be taken seriously. Whereas psychiatrists were skeptical first of the
distinction between a pathological grief disorder and MDD, and later between it and PTSD,
the public harbored concerns about medicalizing grief, stigmatizing it, and pathologizing a
normal response to loss (Bambauer & Prigerson 2006, Breen et al. 2015, Johnson et al. 2009). We
would need ample evidence to support our contention that grief symptoms at significantly high
levels, persisting 6 months or more postloss, were distressing, disabling, and meriting of clinical
intervention.
Before studies of this grief-related disorder could be conducted, however, there needed to be
a psychometrically sound measure of what we were then calling complicated grief. To address
this need, H.G.P. and P.K.M. developed and tested the Inventory of Complicated Grief (ICG)
(Prigerson et al. 1995b). In contrast with Faschingbauer and colleagues’ (1977) Texas Revised
Inventory of Grief, which was designed to measure normal grief, the ICG was designed to measure
pathological grief. We started with the items that had emerged as a coherent, distinctive symptom
cluster predictive of enduring dysfunction (i.e., the symptoms identified in Prigerson et al. 1995a).
To these we added other symptoms described in the literature on grief, such as those described
above by Freud, Lindemann, and Bowlby, and symptoms of normal grief described by Zisook et al.
(1982) and Faschingbauer et al. (1977). The additional symptoms included avoidance of reminders
of the deceased, pain in the same part of the body as that of the person who died, loneliness, anger
over the loss, envy of others who have not lost someone close, a feeling that life is meaningless,
an inability to care about others or feelings of distance from significant others, survivor guilt, and
auditory and visual hallucinations of the deceased.
In addition to traditional psychometric tests of reliability and validity, we used the TETRAD
II analytical software (P. Spirtes, R. Scheines, C. Meek & C. Glymour, unpublished software) to
filter out depressive symptoms and yield a pure measure of complicated grief symptomatology.
Nineteen ICG items produced a highly internally consistent scale (Cronbach’s α = 0.94) that was
stable across a 2-week test–rest period (r = 0.80). Respondents with ICG scores greater than 25
were found to be significantly more impaired in general, social, mental, and physical functioning
and to have more bodily pain than those with scores below that threshold (Prigerson et al. 1995b).
Equipped with a psychometrically sound measure of complicated grief distinct from both nor-
mal grief and bereavement-related depression, the field could then advance because it had sur-
mounted the apples-and-oranges problems in grief measurement that had undermined the in-
terpretability and comparison of prior results. Thus, the ICG was novel because it had isolated
symptoms of pathological grief from those of normal grief and bereavement-related depression,
and, furthermore, results of studies that used it to assess complicated grief could be accumulated
and compiled to build an evidence base regarding whether this set of symptoms captured a distinct
mental disorder worthy of clinical diagnosis and treatment.
3.2. Developing Consensus Criteria for Disordered Grief

By 1997, we (H.G.P. and P.K.M.) began receiving encouragement from psychiatrists and the Na-
tional Institutes of Health Center for Scientific Review study section reviewers to move beyond

the ICG and develop diagnostic criteria for pathological grief. The ICG was performing well in
other studies and was in demand among both researchers and clinicians, but it did not provide
what clinicians needed to formulate a treatment plan or to bill for the delivery of psychiatric ser-
vices. To respond to this need, we organized a consensus conference to review available evidence
regarding the distinctiveness of complicated grief as a mental disorder. Experts in depression and
PTSD, nosology, and bereavement were invited to a 2-day workshop. Workshop participants in-
cluded psychiatrists (Mardi Horowitz, M. Katherine Shear, Colin Murray Parkes, Sidney Zisook,
Selby Jacobs, Beverley Raphael, and Michael First), a social worker ( Janet Williams), psychologists
(Camille Wortman, Ellen Frank, and Thomas Widiger), a sociologist and psychiatric epidemiol-
ogist (H.G.P.), and an engineer and statistician (P.K.M.). The invited expert evaluators concluded
that the preliminary data supported moving forward with the formulation of diagnostic criteria
for complicated grief. Workshop participants then drafted a provisional criteria set.
The first preliminary test of these consensus criteria used the best available data at that time:
Zisook and colleagues’ San Diego Widowhood Project data (Prigerson et al. 1999b). Receiver
operator characteristic analyses tested the performance of the proposed criteria on 306 widowed
respondents at 7 months postloss. Results indicated that three of four separation distress symp-
toms (yearning, intrusive thoughts about the deceased, searching, loneliness) had to be endorsed
as at least sometimes true and that four of the final eight symptoms of what we then referred as
traumatic distress (purposelessness or feelings of futility about the future; emotional numbness;
disbelief; feeling that life is empty or meaningless without the deceased; feeling that a part of one-
self had died; a shattered worldview—lost sense of security, trust, or control; assuming symptoms
or harmful behaviors of the deceased person; excessive irritability, bitterness, or anger related to
the death) had to be endorsed at least as mostly true. This algorithm produced criteria with a
sensitivity of 0.93 and a specificity of 0.93 for a diagnosis of what we were calling at the time trau-
matic grief. These results, which suggested that the consensus criteria had satisfactory operating
characteristics, pointed the way toward further refinement of the criteria set.
Notably, one of the experts who had participated in the consensus criteria workshop, Mardi
Horowitz, had also formulated criteria for complicated grief disorder. Horowitz, a leading author-
ity in stress response syndromes, had played an important role in the DSM’s inclusion of PTSD.
He and his colleagues published a report in 1997 in which they developed and tested an algo-
rithm for diagnosing complicated grief disorder (Horowitz et al. 1997). The symptoms included
the following, assessed 1 year postloss: “intensive intrusive thoughts, pangs of severe emotion,
distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent
of the deceased, unusual sleep disturbances, and maladaptive levels of loss of interest in personal
activities” (Horowitz et al. 1997, p. 904). Importantly, Horowitz et al. found that subjects who met
criteria according to this algorithm did not overlap significantly with those bereaved subjects who
had met criteria for MDD.
For us (H.G.P. and P.K.M.), the next step would be to conduct a field trial of the provisional
consensus criteria for disordered grief, extended to include Horowitz’s symptoms to ensure that
we would not miss potentially informative items.
3.3. Testing Consensus Criteria for Disordered Grief

In 2009, we published results of the Yale Bereavement Study, a National Institute of Men-
tal Health–sponsored R01 investigation designed to test the consensus criteria for disordered
grief, and presented a comprehensive, evidence-based proposal for a new diagnostic entity, PGD
(Prigerson et al. 2009). This study (N = 291; predominantly white widowed persons residing in
Connecticut) systematically evaluated measurement characteristics of individual consensus and

Horowitz candidate symptoms, using item response theory to eliminate uninformative and biased
symptoms from further consideration; the diagnostic efficiency (as well as sensitivity and speci-
ficity) of alternative DSM-style symptom-diagnostic algorithms, composed of informative and
unbiased symptoms and generated using combinatoric methods; and criterion-related validity of
proposed diagnostic criteria, including an optimal (most efficient) symptom-diagnostic algorithm.
In the item analysis, the symptoms of loneliness and believing the future held no meaning
were removed from further consideration because they were found to be biased with respect to
the respondent’s relationship to the deceased. Envy of others who had not lost someone close
and feeling drawn to places and things associated with the deceased (so-called searching behavior)
were removed because they were found to be relatively uninformative.
In the combinatorics-based analysis of alternative DSM-style symptom-diagnostic algorithms
for PGD, each candidate algorithm was specified in terms of one common, mandatory symptom
(yearning); a specific set of n other, nonmandatory symptoms; and some minimum number of
nonmandatory symptoms within this set, k, required to satisfy the symptom criterion for PGD.
Each candidate algorithm was then evaluated with respect to a criterion gold standard diagnosis—
having a grief intensity score above a specified cutoff score, where the cutoff point was chosen
to provide maximum agreement between gold standard diagnoses and those made on the ba-
sis of clinical judgment. Based on the Yale Bereavement Study data, the optimal, most efficient
symptom-diagnostic algorithm (i.e., symptom criterion) required yearning and at least five of the
following nine symptoms: avoidance of reminders of the deceased; trouble accepting the death;
a perception that life is empty or meaningless without the deceased; bitterness or anger related
to the loss; emotional numbness; feeling stunned, dazed, or shocked; feeling that part of one-
self died along with the deceased; difficulty in trusting others; and difficulty moving on with life.
After analyzing the results for the temporal subtypes of PGD, we proposed that bereaved indi-
viduals who after 6 months postloss met this symptom criterion in association with functional
impairment met full criteria for a diagnosis of PGD. We then found that PGD, as proposed, was
distinct from other mental disorders (i.e., MDD, PTSD, and GAD) and predictive of future psychi-
atric diagnoses (MDD, PTSD, or GAD), suicidal ideation, functional disability, and low quality of
life.
Thus, we had produced a criteria set for PGD that could accurately and reliably identify be-
reaved subjects at heightened risk of enduring distress and dysfunction. The results supported the
psychometric validity of the criteria for PGD that we proposed for inclusion in the DSM and that
appear in ICD-11.
4. CURRENT STATUS OF PROLONGED GRIEF DISORDER

4.1. Diagnostic Criteria for Prolonged Grief Disorder in ICD-11
and DSM-5-TR
The strength of the evidence in support of PGD from the Yale Bereavement Study (Prigerson
et al. 2009), supplemented by confirmatory findings from numerous international studies (e.g.,
Boelen & Prigerson 2007; Boelen & van den Bout 2005, 2007; Boelen et al. 2003, 2007, 2010;
Chiambretto et al. 2008; Morina et al. 2010), compelled both the DSM and ICD editors, chairs,
and workgroups to take proposals for the inclusion of a new disorder of pathological grief seriously.
In March 2010, the DSM-5 Workgroup on Trauma/Stress-Related and Dissociative Disorders,
led by Matthew Friedman, scheduled a conference to discuss the possible inclusion of diagnostic
criteria for a grief disorder in DSM-5. In addition to us (H.G.P. and P.K.M.), Mardi Horowitz,
Paul Boelen, and M. Katherine Shear were invited to participate in the conference, and we each
made our case for inclusion to workgroup members.

We made our case with data not only from our group but from a wide variety of researchers
around the world (e.g., Paul Boelen, Paola Chiambretto, Nexhmedin Morina) in support of the
validity and reliability of the PGD criteria we were advancing. Others recommended criteria based
on their clinical experience. The workgroup ultimately decided that there was a lack of consensus
and thus proposed that persistent complex bereavement disorder (PCBD), which included our
criteria for PGD and a few items nominated by the Shear group, be put in Section III (the Ap-
pendix) of DSM-5 as an emerging diagnosis. Items incorporated from the Shear group included
complicating thoughts; excessive avoidance of thoughts, activities, or situations that arouse grief-
related emotions; and ineffective emotion regulation. As Friedman (2016, p. 864) wrote in the
American Journal of Psychiatry, “Although the DSM-5 subworkgroup was very favorably disposed
toward adding a new diagnosis addressing abnormal bereavement-related emotions and behavior,
. . .it seemed apparent that more research was needed before data supporting specific diagnostic
criteria for a bereavement-related disorder could satisfy DSM-5’s rigorous standards for inclusion
of a new diagnosis.”
By contrast, the ICD-11 Workgroup on Stress-Associated Disorders, chaired by Andreas Maer-
cker, a psychiatrist with expertise in traumatic stress, found the available evidence for PGD suffi-
ciently compelling to recommend its inclusion as a new mental disorder. As Maercker et al. (2013,
p. 202) wrote:
Prolonged grief disorder is a new diagnosis being proposed for ICD-11, which describes abnormally
persistent and disabling responses to bereavement. It is defined as a severe and enduring symptom
pattern of yearning or longing for the deceased or a persistent preoccupation with the deceased. This
reaction may be associated with difficulties accepting the death, feelings of loss of a part of oneself,
anger about the loss, guilt, or difficulty in engaging with social or other activities.
Maercker et al. went on to note that studies from Western and Eastern cultures had supported the
validity of these criteria and asserted that it was time to recognize PGD as a mental disorder in its
own right. Thus, the ICD-11 workgroup chose to move forward with the same name (prolonged
grief disorder) and largely the same criteria set validated in Prigerson and colleagues’ (2009) PLOS
Medicine report.
The DSM, in the position of catching up to the ICD, then sought to harmonize with the PGD
criteria included in ICD-11. In June 2019, the DSM-5-TR Workgroup led by Paul Appelbaum
held a meeting in New York City that invited relevant thought leaders in psychiatric diagnosis
(Philip Wang, David Brent, Kenneth Kendler, Thomas Widiger, Ellen Leibenluft, Katharine
Phillips, Roberto Lewis-Fernández, Kimberly Yonkers, Michael First, and Saul Levin) to discuss
the evidence in support of a bereavement-related disorder from the two leading adult research
groups (M. Katherine Shear and Chip Reynolds; Holly Prigerson and Paul Maciejewski) and
experts in child bereavement (Robert Pynoos and Christopher Layne). We (H.G.P. and P.K.M.)
made our case (our presentation can be found at https://endoflife.weill.cornell.edu/advanced-
directives/dsm-5-tr-consensus-criteria-prolonged-grief-disorder), Chip Reynolds pre-
sented case histories of bereaved adults whom his team had diagnosed with PGD, and Christopher
Layne presented his data on child responses to bereavement.
At the end of the meeting, committee members drafted provisional criteria based on these pre-
sentations; the research groups were then tasked with evaluating these provisional criteria using
extant data. Specifically, we were asked to determine the number of the eight items needed to
meet the diagnostic threshold for Criterion C of the diagnostic formulation (i.e., identity disrup-
tion, disbelief about the death, avoidance of reminders that the person is dead, intense emotional
pain related to the death, difficulty with reintegration into life after the death, emotional numb-
ness as a result of the death, feeling that life is meaningless as a result of the death, and intense

loneliness as a result of the death). We were then asked to evaluate the psychometric properties
of the algorithm that incorporated the C criteria that we had determined to be optimal. Priger-
son and Maciejewski, Shear and Reynolds, and Pynoos and Layne submitted their analyses to the
committee in September 2019.
In our submission to the committee, we (H.G.P. and P.K.M.) compiled a report that analyzed
data from Taiwan, the Netherlands, Turkey, and the United Kingdom to add to our US data from
the Yale Bereavement Study. The analyses first determined the number of Criterion C items
that should be required for a diagnosis and then examined the performance of this provisional
criteria set. Our report and accompanying executive summary of these results can be found at the
Cornell Center for Research on End-of-Life Care website (see https://endoflife.weill.cornell.
edu/advanced-directives/testing-dsm-5-tr-criteria-pgd, https://endoflife.weill.cornell.edu/
advanced-directives/evaluation-performance-prolonged-grief-disorder-diagnostic-criter
ia-dsm-5-tr, and https://endoflife.weill.cornell.edu/advanced-directives/presentation-
how-dsm-can-improve-upon-icd-defining-pgd). The Steering Committee reviewed the data

received and approved inclusion of a provisional PGD criteria set in Section II of DSM-5-TR.
During a public commentary period (April 6, 2020–May 20, 2020), the APA website invited
reactions to the proposed PGD criteria set. Over 53 pages of public comments were submitted
to the APA online portal. One of the main concerns expressed in the public comments related to
pathologizing normal grief reactions. Several commentators expressed appreciation for delaying
the diagnosis of PGD until at least 12 months had elapsed since the death; this was a change
from PCBD’s requirement that only 6 months elapse since the death for a diagnosis. This 6-
month deferment appeared to reduce concerns about prematurely pathologizing grief. The DSM
criteria set for PGD also differed from PCBD in that it acknowledged the possibility of delayed
onset of symptoms, required that three of eight C criteria be met for a diagnosis, and focused
more on yearning for the deceased and less on preoccupation with the circumstances of the death
among adults (the latter of which could be captured by a PTSD diagnosis). The prevalence rates
at approximately 1 year postloss using the DSM-proposed PGD criteria were 5–15% in analyses
of data from the Yale Bereavement Study as well as from Oxford University (PI: K.V. Smith)
and Utrecht University (PI: P.A. Boelen)—rates low enough to limit concerns that the DSM-
proposed criteria would misdiagnose normal grief as pathological. In the sidebar titled DSM-5-
TR Criteria for Prolonged Grief Disorder, we provide the PGD diagnostic algorithm that was
officially approved by the APA Assembly for inclusion in DSM-5-TR on November 7, 2020.
4.2. Diagnostic Classification for Prolonged Grief Disorder: Reward System

Disruption, Stress Response Syndrome, or Depressive Disorder?
Although PGD was considered by Matthew Friedman’s DSM-5 Workgroup on Trauma/Stress-
Related and Dissociative Disorders, the DSM-5-TR Workgroup initially proposed the addition
of PGD for inclusion in the DSM chapter on depressive disorders. Subsequently, PGD criteria
proposed for inclusion in the DSM were considered by the Internalizing Disorders Workgroup.
Internalizing disorders have been described as disorders of mood and anxiety (Andrews 2018), so
this classification appeared appropriate in that it could be construed as straddling depressive and
stress response mental disorders. Yet, ultimately, the APA Assembly chose to include PGD in the
DSM-5-TR chapter on trauma and stressor-related disorders.
In contrast to the ICD-11 and DSM-5-TR classifications of PGD among stress response syn-
dromes, we consider PGD neither a depressive/mood disorder nor a stress/anxiety disorder. In a
recently published systematic review (Kakarala et al. 2020), we found a small but growing body

of neurobiological research that supports conceptualizing PGD as a distinct condition involv-
ing dysregulated reward signaling. The link to reward system disruption was first suggested in
a functional magnetic resonance imaging study (O’Connor et al. 2008), which found that com-
pared with mourners without PGD, mourners with PGD had greater activation in the nucleus
accumbens (NAc)—a critical basal ganglia node that integrates the activities of dopamine, oxy-
tocin, and the endogenous opioids—when shown a picture of their deceased loved one. Although
the methods of this study may be outdated and its results have not been replicated, more recent
neuroimaging studies have associated PGD with differential activity in the basal ganglia writ large
(Schneck et al. 2017, 2018), the orbitofrontal cortex and amygdala (Bryant et al. 2020), and certain
areas of the cingulate cortex (Arizmendi et al. 2016). These regions are also known to be active
in substance addiction (Suckling & Nestor 2017), which arises from dysregulation of the neural
reward system. A further study suggested that oxytocin signaling is altered in PGD (Arizmendi
2018). Animal studies have shown that oxytocin signaling in the NAc is vulnerable to the effects
of separation from a partner (Bosch et al. 2016). Taken together with anecdotal support for the
efficacy of naltrexone, an opioid antagonist typically used to treat addiction, in alleviating symp-
toms of PGD reported for three refractory mourners (personal communication of a psychiatrist
to H.G.P.), the literature suggests a potentially distinctive reward-related etiology. We speculate,
therefore, that PGD may be best classified as a disorder of attachment precipitated by a disruption
of the reward system.
5. CONCLUSIONS AND FUTURE DIRECTIONS

It has been a long, somewhat circuitous path leading to the entry of PGD into diagnostic manuals
such as the ICD and the DSM. In this article, we have presented early psychoanalytic distinctions
made between normal and pathological bereavement reactions, described how diagnostic criteria
for PGD were developed and tested, and then concluded with a discussion of the criteria for
PGD approved by the APA Assembly for inclusion in DSM-5-TR. On the basis of our review
of neurobiological correlates of PGD, we believe that there is support for our view of PGD as
a disorder of attachment in which the neurobiological reward system is implicated. Prior studies
have suggested a link between attachment styles and PGD (Captari et al. 2021, van Doorn et al.
1998, Yu et al. 2016) and specifically have suggested emotional dependence on the deceased as a
leading risk factor for PGD ( Johnson et al. 2007, Mitchell et al. 2004, van Doorn et al. 1998).
As noted above, research on pathological grief was prompted by studies that revealed a lack of
response of grief to interpersonal psychotherapy and to the tricyclic antidepressant nortriptyline—
a finding subsequently confirmed in a randomized controlled trial by Reynolds et al. (1999). In
fact, Reynolds et al. (1999, p. 207) explained that nortriptyline and interpersonal psychotherapy,
while effective for reducing the severity of symptoms of bereavement-related depression, could be
failing to have an effect on grief resolution because “persistence of grief is not necessarily abnormal
or pathological” and “preoccupation with the memory of the lost spouse might be the normal or
necessary sequela of genuine attachment and part of a necessary sustenance of life.” As we have
shown in this article, persistent intense grief symptoms may, indeed, be pathological; moreover,
their resolution appears to require interventions that target symptoms of prolonged grief rather
than symptoms of depression.
Some interventions targeting symptoms of PGD have proven effective. For example, Shear
et al. (2016) found that targeted psychotherapy for PGD was associated with a significant reduc-
tion in symptoms of PGD; the antidepressant selective serotonin reuptake inhibitor citalopram,
however, was not. Litz et al. (2014) also found that an online indicated preventive intervention re-
duced the severity of PGD symptoms. Boelen et al. (2007) and Bryant et al. (2014) demonstrated

that cognitive behavioral therapy and exposure therapy were helpful for reducing symptoms of
PGD. Given the lack of support for pharmacotherapy for PGD to date, there appears to be a need
for medication that might help those for whom psychotherapy might not be effective and/or that
might enhance psychotherapy treatment response. We believe that the neurobiological evidence
supports trialing naltrexone for reduction of PGD, given that it targets reward pathways. It may
prove effective for reducing symptoms of PGD when antidepressant treatments have not.
Future research is also needed to confirm that DSM diagnostic criteria for PGD perform well
cross-culturally and among mourners of a wide variety of racial, ethnic, and gender categories. Fur-
ther, studies should examine how PGD criteria perform over time from loss, by various modes of
death, by relationship to the deceased, and by the ages of the deceased and the bereaved survivor.
Although the evidence base has grown exponentially in recent decades, facilitated by standard-
ized (i.e., uniform and agreed-upon) and validated measures to assess pathological grief, there is
a pressing need to put these results into their appropriate cultural and historical context. For ex-
ample, woefully little attention has been paid to cultural variation in the expression of grief or the
role of faith communities and religious beliefs in its resolution. The unprecedented number of
casualties of the global coronavirus pandemic, and its impact on the way people die and grieve in
the current era, is likely to have a profound impact on the risks and outcomes of PGD for years to
come. Research is needed to determine how grief, and bereavement adjustment more generally, is
affected by the infection control measures surrounding the illness and death of a loved one. The
role of telemedicine in health care delivery, both with respect to end-of-life care discussions be-
tween health care providers, patients, and family members and also with respect to psychotherapy
in the provision of bereavement care, seems a topic worthy of future study. And lastly, research is
needed to investigate the potential harms and benefits of the use of social media and online inter-
ventions as a means of combating social isolation in general and of reducing symptoms of PGD in
particular. Studies should address the role of technology in promoting as well as preventing and
resolving symptoms of enduring and disabling grief.
Although we have come a long way toward advancing understanding of the parameters that
define pathological responses to the death of a significant other, there is a long way to go to
improve the precision and generalizability of this diagnosis and the efficacy of treatments for it.
We believe the field is on the right track and are confident that, guided by informative, relevant,
and useful theories of grief resolution and evidence to light the way, the future for those affected
by PGD is bright.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review. The views expressed are those of the
authors and not necessarily those of the supporting institutions.
ACKNOWLEDGMENTS
This work was supported by grants from the US National Cancer Institute (CA197730 and
CA218313), the US National Institute on Minority Health and Health Disparities (MD007652),
the US National Institute of Nursing Research (NR018693), the US National Institute on Aging
(AG049666), and the US National Institute of Mental Health (MH121886).
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Annual Review of Clinical Psychology

History and Status of

Holly G. Prigerson,1,2 Sophia Kakarala,1 James Gang,1

Annu. Rev. Clin. Psychol. 2021. 17:109–26 Keywords

3.2. Developing Consensus Criteria for Disordered Grief . . . . . . . . . . . . . . . . . . . . . . . . 117

3.3. Testing Consensus Criteria for Disordered Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

110 Prigerson et al.

www.annualreviews.org • History and Status of Prolonged Grief Disorder 111

112 Prigerson et al.

2.2. Normal and Pathological Grief

other relationships after the loss.

2.3. Attachment and Loss

114 Prigerson et al.

www.annualreviews.org • History and Status of Prolonged Grief Disorder 115

3. PROGRESS TOWARD PROLONGED GRIEF DISORDER AS A

116 Prigerson et al.

3.2. Developing Consensus Criteria for Disordered Grief

www.annualreviews.org • History and Status of Prolonged Grief Disorder 117

3.3. Testing Consensus Criteria for Disordered Grief

118 Prigerson et al.

4. CURRENT STATUS OF PROLONGED GRIEF DISORDER

www.annualreviews.org • History and Status of Prolonged Grief Disorder 119

120 Prigerson et al.

how-dsm-can-improve-upon-icd-defining-pgd). The Steering Committee reviewed the data

4.2. Diagnostic Classification for Prolonged Grief Disorder: Reward System

www.annualreviews.org • History and Status of Prolonged Grief Disorder 121

5. CONCLUSIONS AND FUTURE DIRECTIONS

122 Prigerson et al.

www.annualreviews.org • History and Status of Prolonged Grief Disorder 123

124 Prigerson et al.

of prior failure experience. J. Bus. Ventur. 29(1):17–33

www.annualreviews.org • History and Status of Prolonged Grief Disorder 125

126 Prigerson et al.

Volume 17, 2021

Smoking Treatment: A Report Card on Progress and Challenges

Network Analysis of Psychopathology: Controversies and Challenges

Intimate Relationships and Depression: Searching for Causation

Disorder on What It Means to Be Human

Developmental Perspectives on the Study of Persons

An online log of corrections to Annual Review of Clinical Psychology articles may be

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