Prolonged Grief Disorder: Understanding the Latest DSM-5 Updates

Arguably the most popular book in mental health, the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, is the standard guide used by mental health professionals to diagnose and treat mental health conditions. In early March, the DSM-5 was revised to include new conditions, clarifications and updated wording.

While editors describe these changes as vital to clinicians and researchers, some mental health professionals are in disagreement as to whether all the changes were necessary.

Prolonged Grief Disorder

One major point of contention is the addition of prolonged grief disorder, a longer-lasting and more disruptive form of grief that extends beyond a year after a death or loss for adults and six months for children. Clinical psychologist Noël Hunter, PsyD, who specializes in trauma and grief, strongly disagrees with the addition.

"This is yet another disgusting display of overreach, pharmaceutical influence and an inability as a society to tolerate painful emotions," Hunter says. "The updates to the DSM are, sadly, representative of a process that has been troubled from the start."

The "trouble" Hunter is referring to is the financial conflict surrounding the DSM-5 and its task force members. According to reporting from the time of the DSM-5's release in 2012, 69 percent of the DSM-5's task force members reported financial relationships with pharmaceutical companies.

"This history, then, does not leave many of us surprised that over-reach continues to spread so much so that grief has officially become a diagnosable disorder," Hunter says. "It was already a consideration under major depressive disorder; this is just the first time it’s become its own separate category. It is abysmal and reprehensible to attempt to justify pathologizing someone for their process of grief. It is a clear attempt to provide medical justification for prescribing more antidepressants and further numb our society."

Licensed clinical social worker Gayle Weill, LCSW, has mixed feelings on the subject. On the one hand, the diagnosis allows individuals to receive treatment that's covered by their insurance. Without the diagnosis, affected individuals may not have been able to access therapy sessions or clinical treatment.

"On the other hand, everyone reacts to loss differently," Weill says. "I worry with having this new diagnosis that it will be misdiagnosed for someone who is going through a natural process—that of missing a dearly departed loved one."

The New Experience of Grief

The timing of this addition is also important to consider. After two years of an ongoing pandemic, perhaps the most intense and extended period of loss some of us have ever experienced, many people are still in the process of grieving. And Iris Waichler, MSW, LCSW, who specializes in grief and loss, notes that the pandemic took away the opportunity to hold certain rituals and services that typically help us move forward in coping with loss.

"Covid-19 created new emotional hardships for many people who have suffered additional layers to their grief," Waichler says. "They were unable to be with their loved ones and unable to say goodbye to them in person... The fact that none of this was possible directly impacts how their grief was experienced."

Understanding the impact of these constraints will take time. And to now establish a "normal" timeframe to for this process could be dangerous, points out neurosurgeon and nationally recognized grief specialist Joseph Stern, MD.

"Critics fear that it will lead to more false positives and encourage pharmaceutical companies to jump at the opportunity to develop new medications and to convince the public that they need medical treatment to cope with the universal life experience of bereavement or mourning," Stern says. "This can be especially harmful because, when a bereaved person is in a vulnerable state and an expert tells them they are ‘disordered’ or ‘abnormal’, they may begin to mistrust themselves or their emotions."

Other Important Updates

While prolonged grief disorder has garnered the most attention, other important updates were made to the DSM-5, as well. Diagnostic criteria was revised for several conditions, including autism spectrum disorder, substance- or medication-induced mental disorders, post-traumatic stress disorder (PTSD) in children, major depressive disorder, and bipolar disorder, among others.

New symptoms codes were also added that allow mental health professionals to indicate the history or presence of suicidal behavior, non-suicidal self-injury, or dangerous behavior that could lead to injury. These codes don't indicate mental disorders in themselves but help clinicians track and document symptoms and behavior if further attention is required.

Caitlin Weese, LMSW, finds some of the updates refreshing. For example, the entry for gender dysphoria contains new wording that updates "desired gender" to "experienced gender" and "cross-sex medical procedure” to “gender-affirming medical procedure."

"I think these reflect a larger push to see dysphoria through a medical lens versus a mental health condition that needs to be 'treated,'" Weese says.

Overall, the updates to the DSM-5 cover more than 70 disorders. Some of these are praised for affirmation and inclusivity, and others are viewed as unnecessary or even harmful. While its contents may be the subject of debate among clinicians and researchers, the DSM-5 continues to be a useful tool in understanding mental health.