Demystifying Disorders: Prolonged Grief Disorder

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Unlock the complexities of Prolonged Grief Disorder (PGD) and discover how it challenges the natural grieving process as defined in the DSM-5-TR. Explore how PGD differs from typical grief, with symptoms that persist beyond usual timelines. We'll guide you through the dual process model of grief and attachment theory, shedding light on why some individuals struggle to adapt naturally to loss. Our discussion also covers key assessment tools like the Prolonged Grief Disorder-13 (PG-13) and Brief Grief Questionnaire (BGQ), which are essential for evaluating the severity and impact of grief. Along the way, we introduce vital grief-related terms such as anticipatory grief, complicated grief, and disenfranchised grief, providing a thorough groundwork in understanding PGD.

Step into the therapeutic world with the poignant case of Sarah, who navigates the turbulent waters of PGD after losing her teenage son. We emphasize the importance of building a robust therapeutic alliance, and share strategies that help integrate loss into life's narrative without diminishing the memory of a loved one. Discover how cognitive restructuring, narrative reconstruction, and exposure-based techniques, including the impactful empty chair method, offer pathways to healing. This episode also underscores the delicate balance between validating profound grief and promoting healthy adaptation, while highlighting the increased suicide risk associated with PGD. Finally, we remind therapists to be mindful of their own grief journeys and potential countertransference, ensuring they remain effective in supporting clients on their path to recovery.

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Episode Transcript

Speaker 1 (00:00):
Let's discuss prolonged grief disorder, pgd,
and what you need to know foryour licensure exam.
Pgd represents a significantadvancement in the understanding
of pathological grief responses.
This condition in the DSM-5-TRdescribes a persistent and
pervasive grief response thatextends beyond expected social,
cultural or religious norms.

(00:20):
According to the DSM-5-TR, thediagnostic criteria for PGD
include experiencing the deathof someone close to the person,
followed by a persistent griefresponse characterized by
intense yearning and longing forthe deceased person or
preoccupation with thoughts ormemories of them.
These symptoms must persist forat least 12 months in adults

(00:43):
and six months in children.
Your client must experience atleast three of the following
symptoms nearly every dayIdentity disruption.
Marked sense of disbelief aboutthe death, avoidance of
reminders of the loss, intenseemotional pain, difficulty
moving on, emotional numbness,feeling that life is meaningless
and intense loneliness.

(01:04):
These symptoms must causeclinically significant distress
or impairment in functioning andexceed cultural, religious or
age-appropriate norms.
The basic assumptionsunderlying PGD center on the
understanding that grief itselfis a natural, adaptive response
to loss, but becomes problematicwhen it persists beyond
expected timeframes andsignificantly impairs daily

(01:26):
functioning.
The grief response in itselfserves an important
psychological and socialfunction in processing loss and
maintaining connections withdeceased loved ones.
However, when grief becomesprolonged and intense, it can
interfere with the naturaladaptation process and lead to
significant psychologicaldistress and functional

(01:47):
impairment.
Key concepts in understandingPGD include the dual process
model of grief, which suggeststhat healthy grief involves
oscillation betweenloss-oriented and
restoration-oriented coping.
Pgd often involves becomingstuck in loss-oriented coping,
preventing the natural movementbetween the two processes of

(02:07):
loss-oriented andrestoration-oriented.
Another crucial concept is therole of attachment theory in
grief responses, where theseverity of PGD symptoms often
correlates with the client'sattachment style and the nature
of their relationship with thedeceased and the nature of their
relationship with the deceased.
Continuing bonds, whichrepresent the ongoing internal
relationship with the deceased,are also fundamental to

(02:30):
understanding PGD.
The progression of PGDtypically follows several stages
, though these are not strictlylinear.
Initially, clients experienceacute grief characterized by
intense emotional pain andpreoccupation with the loss.
In typical grief, thisnaturally transitions to
integrated grief, where the lossbecomes part of one's life

(02:51):
narrative.
In PGD, clients become stuck inacute grief, unable to progress
to integration.
This can lead to a tertiarystage where maladaptive coping
mechanisms and complicatedemotions become entrenched
further, impeding the naturalgrief process.
Assessment instruments used intreating PGD include for

(03:11):
assessing prolonged griefdisorder, pgd use the following
assessment tools that evaluatedifferent aspects of grief
severity and impact.
Prolonged grief disorder 13,pg-13.
This is considered the goldstandard for PGD assessment.
It evaluates the core symptomsdefined in the diagnostic
criteria, including yearning,emotional pain and functional

(03:32):
impairment.
Brief Grief Questionnaire BGQ Aquick five-item screening tool
that can help identifyindividuals who may need more
comprehensive assessment.
Inventory of Complicated GriefICG provides a detailed
assessment of grief symptoms andtheir intensity, particularly
useful for tracking changes overtime.

(03:53):
Grief Cognition's QuestionnaireGCQ.
This questionnaire helpsidentify maladaptive thoughts
and beliefs related to the lossthat may be maintaining grief
symptoms.
The Work and Social AdjustmentScale WSS evaluates functional
impairment across different lifedomains, which is crucial for
understanding the impact of PGD.
Phq-9 helps distinguish betweennormal grief reactions and

(04:17):
clinical depression by measuringspecific depressive symptoms
like changes in sleep, appetiteand mood.
Mood GAD-7 identifies anxietysymptoms that may complicate the
grief response, as heightenedanxiety is common after a
significant loss and may requirespecific interventions.
Columbia Suicide SeverityRating Scale systematically

(04:37):
assesses suicide risk, which iscrucial since bereaved
individuals have a highersuicide risk, particularly in
cases where the loss was due tosuicide.
Patient Health Questionnaire 9,phq-9, for diagnosing comorbid
depression and also tracktreatment progress by measuring
symptom severity changes overtime.
Generalized Anxiety Disorder 7,gad-7, for evaluating anxiety

(05:02):
symptoms.
Columbia Suicide SeverityRating Scale for Suicide Risk
Assessment as grief can increasesuicide risk.
Techniques to Use in TreatingPGD.
Cognitive RestructuringTechnique this approach involves
identifying and modifyingmaladaptive thoughts and beliefs
about loss, death and theimplications for the future.

(05:22):
You guide clients in examiningthoughts such as I should have
done more or I'll never be happyagain, helping them develop
more balanced and realisticperspectives while validating
their emotional experience.
Exposure-based techniques thismethod involves gradually
confronting avoided situations,memories or reminders of the

(05:42):
loss.
You carefully guide clientsthrough systematic exposure to
these triggers, while providingsupport and teaching coping
skills.
This might include visitingmeaningful places, looking at
photographs or discussingmemories of the deceased.
Narrative reconstruction thistechnique involves helping
clients construct a coherentnarrative of their loss

(06:04):
experience and integrate it intotheir broader life story.
You help your clients telltheir stories, process difficult
moments and find meaning intheir experiences, while
maintaining a healthy,continuing bond with the
deceased.
Empty chair technique Apowerful intervention where
clients engage in dialogue withthe deceased, expressing

(06:26):
unresolved feelings and thoughts.
Your role is to facilitate thisprocess, helping clients
process emotions and work towardthe resolution of unfinished
business Terms associated withprolonged grief you should know
for your licensing exam.
Anticipatory grief the griefexperience that occurs before an
actual loss, common in cases ofterminal illness.

(06:47):
Complicated grief an older termfor prolonged grief disorder,
referring to grief that becomesstuck and impairs functioning.
Continuing bonds the ongoinginternal relationship maintained
with the deceased, which can beeither adaptive or maladaptive.
Disenfranchised grief griefthat is not socially
acknowledged or validated, suchas the loss of an ex-spouse or a

(07:10):
miscarriage.
Grief oscillation the naturalmovement between loss-focused
and restoration-focused copingin healthy grief.
Processing Loss-oriented theaspects of grief that focus
directly on processing the deathand the relationship with the
deceased.
Restoration-oriented theaspects of grief that involve

(07:30):
adjusting to life changes andmoving forward after a loss.
Dual process model of grief theconcept that healthy grieving
involves oscillating betweenloss-oriented and
restoration-oriented activitiesrather than focusing exclusively
on either one.
Acute grief is the initialintense period of grief
immediately following a loss,characterized by strong emotions

(07:53):
, physical symptoms anddisruption to daily functioning.
Typical grief follows agenerally expected pattern where
the intensity of grief symptomsgradually decreases over time
as the person adapts to the loss, though there may be periodic
increases in grief intensityduring significant dates or
reminders.
Integrated grief is when theloss becomes a part of the

(08:15):
person's life narrative, wherethey can think about their loved
one with less emotional pain,while engaging in meaningful
activities and relationships,though the loss remains a part
of their identity.
Here's what you might see witha client experiencing prolonged
grief disorder.
Sarah, a 45-year-old woman,sought therapy two years after

(08:37):
losing her teenage son in a caraccident Notice the time frame
here.
She presented with classic PGDsymptoms, including intense
preoccupation with her son'sdeath, avoidance of places they
frequented together and apersistent sense of disbelief
about the loss.
Initially, you should focus onbuilding a strong therapeutic
alliance and normalizing Sarah'sgrief experience Using

(09:01):
cognitive restructuring.
Address Sarah's belief thatmoving forward meant forgetting
her son.
Through narrativereconstruction, sarah may begin
to integrate the loss into herlife story.
Finding ways to honor her son'smemory while engaging in
present-focused living Exposurework would assist her in
gradually returning to placesshe had avoided, while the empty

(09:23):
chair technique can allow herto express unresolved feelings
to her son.
In summary, understanding andtreating PGD requires a delicate
balance between validating theprofound nature of loss while
facilitating healthy adaptation.
You should remember that griefis highly clientized and
influenced by cultural,religious and personal factors.

(09:45):
The goal of treatment is not toeliminate grief or memories of
the deceased, but to helpclients integrate the loss into
their life narrative whilerestoring functional capacity.
Regular assessment of suiciderisk is essential, as PGD can
significantly increase risk.
You should also maintainawareness of your own grief
experiences andcountertransference issues when

(10:08):
working with PGD clients.
The therapeutic relationshipprovides a crucial foundation
for all interventions, andprogress should be measured not
just by symptom reduction, butby the client's ability to
engage in meaningful lifeactivities while maintaining
healthy, continuing bonds withthe deceased.