ICD-116B42	PROLONGED GRIEF DISORDER Prolonged grief disorder
ICD-10F43.8	Other reactions to severe stress
DSM-5-TRF43.81	Prolonged Grief Disorder

1. Definition and nosology

Prolonged grief disorder (ICD-11: 6B42 Prolonged Grief Disorder; DSM-5-TR: F43.81 — added in 2022) — a disorder of grief and preoccupation lasting longer than cultural and religious expectations following the loss of a close person, causing significant functional impairment.

Difference from normal grief: duration, intensity, and functional burden; clinical diagnosis based on specific duration (ICD-11: ≥ 6 months; DSM-5-TR: ≥ 12 months adult, ≥ 6 months child) and symptom profile.

2. History

• Lindemann E. (1944) — studies on acute grief dynamics.
• Bowlby J. (1980) — attachment and loss.
• Prigerson H.G. et al. (1995–2009) — “Complicated Grief” / “Prolonged Grief” concept; development of diagnostic criteria.
• ICD-11 (2019) — first official category.
• DSM-5-TR (2022) — ‘Prolonged Grief Disorder’ added as an official diagnosis.

3. Epidemiology

• Development after close loss: 7–10% in general population, 49% in case of sudden/violent death (Lundorff M. et al. J Affect Disord 2017 meta-analysis).
• Gender: higher in women.
• Risk factors: early age loss, sudden or violent death, child loss, anxious/ambivalent attachment.
• COVID-19 pandemic — significantly increased the prevalence of prolonged grief (Eisma M.C. et al.).

4. Aetiology and pathogenesis

• Attachment theory — impairment in cognitive processing of separation from a close attachment figure.
• Neurobiological — nostalgia-related activation of the reward circuit in response to the lost attachment (O'Connor M.F. fMRI studies).
• Cognitive — “stuck” thoughts, lack of healthy interpretation.

5. Clinical features

• Persistent, intense ‘nostalgia’ or preoccupation with the lost person.
• Persistent symptoms from the following:
  • Disturbance of the sense of self (“a part of me has died”)
  • Difficulty accepting the loss;
  • Emotional pain related to loss (grief, anger, guilt);
  • Loss of meaning in life;
  • Emotional numbing;
  • Avoidance of social activities;
  • Difficulty maintaining relationships.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Death of a close person (partner, parent, child, sibling, close friend).

B. Persistent and intense nostalgia or preoccupation with the lost person lasting ≥ 6 months (ICD-11) / ≥ 12 months (DSM-5-TR adult, ≥ 6 months child) after loss.

C. ≥ 3 of the following symptoms:

1. Disturbance of sense of self;
2. Difficulty accepting loss;
3. Avoidance of reminder stimuli;
4. Intense emotional pain;
5. Difficulty returning to social or other activities.
6. Emotional numbing;
7. Loss of meaning in life;
8. Feelings of loneliness and isolation.

D. Duration and intensity significantly exceeding cultural, social, or religious norms.

E. Significant functional impairment.

6.2 Source-specific clarifications

• ICD-11 — duration ≥ 6 months.
• DSM-5-TR (2022 update) — in adults ≥ 12 months, in children ≥ 6 months; at least 1 core symptom (intense nostalgia or preoccupation) + ≥ 3 additional symptoms.
• NICE — no separate guideline for prolonged grief; general grief management principles.

6.3 Diagnostic algorithm

1. Clinical interview — loss history, symptom profile, cultural context.
2. Scale - Prolonged Grief Disorder-13 (PG-13, Prigerson H.G.).
3. Comorbidity (MDD, PTSD — differentiation in grief context essential).
4. Suicide risk (high in bereaved patients).

6.4 Differential diagnosis

7. Examination and assessment

• PG-13 (Prolonged Grief Disorder-13, Prigerson H.G.) and PG-13-R update.
• ICG (Inventory of Complicated Grief) — 19 items.
• PHQ-9, C-SSRS comorbidity.

8. Treatment

1. First-line: Complicated Grief Treatment (CGT — Shear M.K.) — 16 sessions; psychoeducation, imaginal and situational exposure, positive memory reconstruction, future orientation. Evidence: Shear M.K. et al. JAMA 2005 RCT — superior to interpersonal therapy.
2. CBT adapted for grief — Boelen P.A. model; cognitive restructuring + exposure.
3. Pharmacotherapy: Evidence base is limited. For comorbid MDD, SSRI. Comparison of CGT + citalopram (Shear et al. JAMA Psychiatry 2016) — CGT alone or combination compared to CGT alone same efficacy; citalopram alone not superior to placebo.
4. Family and group support.
5. Monitor suicide risk.

Source-specific specifications

• Shear M.K. reviews and RCTs — CGT gold standard.
• Wittouck C. et al. Clin Psychol Rev 2011 meta-analysis — grief-specific interventions superior to universal grief support in prolonged grief.

Treatment methods

1. Complicated Grief Treatment (CGT) — Shear (Shear M.K.) — 16-session manualized protocol; “loss-oriented” + “restoration-oriented” work; imaginal and situational exposure, positive memories, future orientation. Evidence: Shear M.K. et al. JAMA 2005, JAMA Psychiatry 2016 RCT.
2. CBT for grief — Bolen (Boelen P.A.) — Cognitive restructuring + exposure.
3. Prolonged Grief Scale (PG-13) — Prigerson (Prigerson H.G.) — 13-item scale; clinical and population screening; PG-13-R update.
4. Inventory of Complicated Grief (ICG) — 19 items.

9. Prognosis

• Significant improvement in most patients with CGT.
• Without treatment, chronicity and development of comorbid MDD/PTSD.

10. Myths and misconceptions

Myth 1: “Grief always goes through ‘5 stages’ — denial, anger, bargaining, depression, acceptance”

Evidence: The Kübler-Ross model is a semi-scholarly concept; lacks systematic evidence base; grief is a nonlinear, individualized process.

Myth 2: “Prolonged grief — pathologized normal sadness, does not require treatment”

Evidence: Clinical diagnosis established based on duration and functional impairment; proven interventions significant benefit.

Myth 3: “Antidepressant is first-line for prolonged grief”

Evidence: Shear JAMA Psychiatry 2016 — CBT first-line; citalopram no better than placebo; SSRIs only in comorbid MDD.

Myth 4: “Time heals all wounds — just wait”

Evidence: Most people gradually adapt, but 7–10% develop prolonged grief; untreated chronicity.

Myth 5: “Talking about grief is harmful to the patient”

Evidence: Evidenced interventions (CGT) work specifically with grief content in structured form; avoidance prolongs and strengthens grief.

Myth 6: “Social rituals (charity, commemoration) are harmful, they don't distract the patient from good memories”

Evidence: Cultural and religious rituals provide support during the grieving process; cultural respect is a crucial component in clinical intervention.

11. Sources

1. WHO. ICD-11. 6B42 Prolonged grief disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. Shear M.K., Frank E., Houck P.R., Reynolds C.F. Treatment of complicated grief: a randomized controlled trial. JAMA 2005;293(21):2601–2608.
4. Shear M.K. et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry 2016;73(7):685–694.
5. Prigerson H.G. et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 2009;6(8):e1000121.
6. Lundorff M. et al. Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. J Affect Disord 2017;212:138–149.
7. Wittouck C. et al. The prevention and treatment of complicated grief: a meta-analysis. Clin Psychol Rev 2011;31(1):69–78.
8. Boelen P.A., van den Hout M.A., van den Bout J. A cognitive-behavioral conceptualization of complicated grief. Clin Psychol Sci Pract 2006;13(2):109–128.
9. O'Connor M.F., Wellisch D.K., Stanton A.L. et al. Craving love? Enduring grief activates brain's reward center. Neuroimage 2008;42(2):969–972.
10. Eisma M.C., Boelen P.A., Lenferink L.I.M. Prolonged grief disorder following the Coronavirus (COVID-19) pandemic. Psychiatry Res 2020;288:113031.