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Section 24
Diagnostic Criteria for Traumatic Grief

Question 24 | Test | Table of Contents

Diagnostic Criteria for Traumatic Grief
A panel of experts in the areas of bereavement, trauma, and psychiatric nosology convened in January, 1999, to discuss the need for diagnostic criteria for complicated grief, or what we now prefer to call Traumatic Grief (Prigerson et al., 1999). The workshop reviewed a series of studies based on samples of bereaved people drawn from both the community and the clinic. These studies demonstrated that symptoms of separation distress (e.g., yearning, searching for the deceased, excessive loneliness resulting from the loss) form a unidimensional cluster with symptoms of traumatic distress (e.g., intrusive thoughts about the deceased, feelings of numbness, disbelief about the loss, being stunned or dazed, a fragmented sense of security and trust). This unidimensional cluster of symptoms is distinct from depressive and anxiety symptom clusters (Prigerson, Frank, et al., 1995; Prigerson, Maciejewski, et al., 1995; Prigerson, Shear, et al., 1996; Prigerson, Bierhals, et al., 1996; Chen et al., 1999). Additional analyses provide evidence that this cluster of symptoms is associated with disability such as impaired role performance, functional impairment, subjective sleep disturbance, and low self-esteem (Prigerson, Frank, et al., 1995). Also, these symptoms predict substantial morbidity. The morbidity includes a high risk of cancer, cardiac disorders, increased alcohol and tobacco consumption, and suicidal ideation, over and above depressive symptoms (Prigerson, Frank, et al., 1995; Prigerson, Maciejewski, et al., 1995; Chen et al., 1999; Prigerson, Shear, et al., 1996; Prigerson, Bierhals, Kasl, et al., 1997; Prigerson, Bierhals, et al., 1996; Prigerson, Bridge, et al., (in press). Moreover, these symptoms last several years among a significant minority of bereaved subjects (Prigerson, Bierhals, Kasl, et al., 1997; Prigerson, Shear, et al., 1997; Prigerson, Bierhals, Wolfson, et al., 1997). Finally, these symptoms, unlike depressive symptoms, do not respond to interpersonal psychotherapy and/or a tricyclic antidepressant such as nortriptyline (Pasternak et al., 1991; Reynolds, et al., 1999).

The panel concluded that the evidence justified the development of diagnostic criteria. Participants then discussed the symptoms that should be included in a diagnosis and, ultimately, proposed a consensus set of criteria for Traumatic Grief (see Table 1). The criteria set includes four main criteria patterned on the format used in the DSM (American Psychiatric Association, 1994). Criterion A specifies that the symptoms of the disorder occur after the death of a significant other and include intrusive, distressing separation distress (e.g., yearning, longing, or searching). Criterion B includes eleven marked and persistent symptoms that reflect the bereaved person's feelings of devastation as a result of the death (see Table 1 for a list). Criterion C specifies that the duration of symptoms must be at least two months. Criterion D requires that the symptomatic disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. We provide a detailed discussion of these criteria elsewhere (Prigerson et al., 1999; Jacobs, 1999).

The term Traumatic Grief was chosen as it (a) describes more precisely the disorder encompassed by the consensus criteria, (b) is less vague than other terms such as complicated grief or unresolved grief, and (c) is less negative than terms such as morbid or pathologic grief. In our usage, "traumatic" does not refer to etiology of the disorder or aspects of the death but rather to the phenomenology of the disorder. Indeed, bereaved persons who develop Traumatic Grief might do so via two pathways. Via one pathway, a bereaved person might experience a loss from a sudden, violent, horrific death, as in the case of natural disasters, accidents, and criminal violence. This exposure might cause an attachment disturbance as the result of a pervasive change in the bereaved person's assumptive world, even in bereaved persons without preexisting vulnerability. In addition to Traumatic Grief, a posttraumatic stress syndrome as well as other psychiatric disorders might emerge as coexisting morbidity in these circumstances. A second, equally important pathway stems from a death of a significant other for bereaved persons with vulnerability in their attachment styles. The vulnerability might be the result of inherited characteristics, early nurturing experiences, or combinations of the two that shape the person's attachment style and might be captured in DSM Axis II diagnoses. Comorbidity might occur as a result of this pathway too. As this discussion of terminology illustrates, a death need not be objectively violent to cause Traumatic Grief. Therefore, we emphasize the idea that "traumatic" in our usage is basically descriptive of the disorder and does connote the etiology except in the first scenario above.

Several authors have described variations in the symptoms of pathologic grief depending on their severity, chronicity, and temporal course (Middleton, Raphael, Martinek, & Misso, 1993) Middleton, Burnett, Raphael, & Martinek, 1996; Parkes, 1970, 1972; Parkes & Weiss 1983; Wortman & Silver, 1989; Zisook & Lyons, 1989). The consensus criteria for Traumatic Grief are designed to diagnose these variations. Delayed grief is one variation in pathologic grief described in the literature (Parkes, 1970, 1972; Parkes & Weiss, 1983), which suggests there may be a pattern of Traumatic Grief with delayed onset that might be particularly difficult to diagnose. We believe that the consensus criteria would identify delayed cases of Traumatic Grief if bereaved persons who are suspected to be at high risk were monitored over the first six months of bereavement. All these assumptions require systematic testing.

A recent study provides preliminary empirical support for most of the proposed symptoms (Prigerson et al., 1999). In addition, Prigerson and colleagues are currently collecting data from a representative sample of bereaved persons to determine the optimal number and mix of symptoms, their severity, and the duration of symptoms that provides the most accurate diagnosis for TG.

A Case Study of Traumatic Grief
This description of a case seen by one of us illustrates the diagnostic criteria for Traumatic Grief and puts them in a clinical context.

Mrs. A presented for evaluation after the sudden, unexpected death of her 24-year-old son from an acute brain disease, 10 months earlier, and then the death of her mother from cancer 7 months before the clinic visit. She was in a state of disbelief and seemed overwhelmed by the double losses. She had "not grieved" after the death of her son because she concentrated her efforts on caring for her terminally ill mother. When her mother died, her grief "hit" her and she could "not stop crying." Her chief complaint was: "I can't believe it; it is such a shock." She was obsessed with the details of her son's death. She yearned intensely to have him back, and she yearned similarly for her mother. She could think of little else except her losses and was annoyed by distractions from these preoccupations. These feelings were accompanied by crying, and they occurred episodically throughout the day. Often, they were precipitated by empty situations or unexpected reminders, and were time-limited for 20-30 minutes. Her performance at work and her relationships with her surviving children and second husband suffered. The impairment in her functioning provided the main impetus for her seeking help. She came for evaluation under pressure from her family and avoided treatment tasks that focused on the losses for the first 3 meetings. She was compulsively drawn to visit the cemetery where her son was buried, and was fighting this impulse as she felt it was irrational. She also sought solace in a public park that she had frequented with her adult children on holidays, as if she might be reunited with him there. She said she felt as if "part of me was gone." She felt useless to herself and others, especially her surviving children, and felt guilty because she felt she had failed the son who died. She had no interest in or hopes for a meaningful future. She feared the sorrow over her losses was so intense, it would drive her "crazy." She was concerned about a change in her personality, reflecting vague cognitive difficulties she was experiencing. After repeated, careful mental status exams, the cognitive symptoms were seen as identification symptoms related to personality changes in her son during this final weeks of life, before his death from an acute brain disease. She had lost a sense of security, no longer trusted a capricious world, as she viewed it, and felt she had lost control over her life. Much of her life had been devoted to being an efficacious mother, a role that was determined in part as a legacy of her own mother's experiences and recapitulated by herself in raising a young family in poverty after the children's father deserted them. Her anger and irritability, which was somewhat associated with protest over her fate and dissatisfaction with the doctors who were late in diagnosing her son, interfered with her relationships with her surviving children and her second husband. These symptoms and problems had persisted for 7 months without significant improvement and the anniversary of her son's death loomed as a nemesis for her.

This bereaved mother illustrates separation anxiety of severe intensity reflected in a fear that she would be driven crazy. The separation anxiety is characterized by intense yearning, preoccupations, and the impulse to search for her son at the cemetery and in other places. She meets criteria for the diagnosis of Traumatic Grief by reporting both of the symptoms under Criterion A, 8 of the 11 criteria under Criterion B, and meeting both Criterion C and Criterion D. While the deaths were sudden and unexpected in one instance and more-or-less horrible in both instances, neither the death of her son nor the death of her mother resulted from a natural disaster, accident, or suicide. This suggested that the pathway to the development of Traumatic Grief involved at least some degree of preexisting vulnerability.
- Jacobs, Selby, Mazure, Carolyn & Holly Prigerson, Diagnostic Criteria for Traumatic Grief, Death Studies, Apr/May 2000, Vol. 24, Issue 3.

Personal Reflection Exercise #10
The preceding section contained information about diagnostic criteria for traumatic grief.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Katz, A. C., Norr, A. M., Buck, B., Fantelli, E., Edwards-Stewart, A., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K., Rothbaum, B. O., Difede, J., Rizzo, A., Skopp, N., Mishkind, M., Gahm, G., Reger, G. M., & Andrasik, F. (2020). Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Presseau, C., Contractor, A. A., Reddy, M. K., & Shea, M. T. (2018). Childhood maltreatment and post-deployment psychological distress: The indirect role of emotional numbing. Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 411–418.

Smith, K. V., & Ehlers, A. (2020). Cognitive predictors of grief trajectories in the first months of loss: A latent growth mixture model. Journal of Consulting and Clinical Psychology, 88(2), 93–105.

What are the four DSM criteria of traumatic grief? To select and enter your answer go to Test.

Section 25
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