Prolonged Grief Disorder in the DSM 5 TR | Symptoms and Diagnosis

Welcome back, everybody, to this series on DSM 5 TR revisions. Today we're going to be discussing prolonged grief disorder. I'm your host, Dr. Donnelly Snipes. In this presentation, you're going to learn the criteria for what is now a new diagnostic label that is in the DSM 5TR called prolonged grief disorder. So let's start out with what are these criteria? What is it? Well, the first criteria is that there must have been the death of a close person that occurred at least a year ago for adults or six months ago for children. Now, that is the criteria. My questions about the criteria, things that, you know, I ponder when I read that was know historically, I have been taught when doing grief work that for uncomplicated grieving, it takes at least a year of going through all of the anniversaries, all of the holidays and those sorts of things to really move forward. So we have to really consider for prolonged grief disorder the intensity of the impairment that the person is experiencing. You know, after my parents died, the first two months was a whole lot harder than the ensuing eight months. Now, the ensuing eight months weren't easy. There were periods of grief bursts and days that I was more melancholy than others and I was still a little more exhausted. But. But I was able to largely get back to moderate functioning. I was reduced in some of my activities just because I didn't have the energy. But I was largely able to start reintegrating into life after the death of either one of my parents. So what we're talking about here with prolonged grief disorder is somebody who is still exhibiting symptoms that are of the intensity that you would see in that acute phase, and they can't seem to adjust as well. Now, my other question for this criteria is what about other types of losses? They're very specific. It has to be the loss or the death, not no other kind of losses, the death of a person that is close to you. So what about other types of losses? Like after divorce, Some people have a prolonged grieving period if they feel intensely abandoned, especially if that triggers prior or historical abandonment issues. Some people may get very stuck in this prolonged grief miscarriage. Now, whether you call that a close person or not, I tend to call it a close person, but not everybody would. So would this apply to a miscarriage? Would it apply to a first trimester miscarriage? What about a second or a third trimester miscarriage? You know, those are questions we're going to have to answer and clarify. And then we've had a lot more recently, I think, or maybe I'M just more aware of it recently. A lot more immigration and I know there's a lot of unrest in other areas of the world and I'm trying to keep this as general as possible because this is going to be a longer tale video. It's not just for this month, but people who are being forced out of their homeland. Not everybody is leaving by choice. Not everybody is an immigrant by choice. So what about the people who don't want to leave? The children who are being brought along by their parents and they're kind of kicking and screaming and fussing the whole way. They may grieve the loss of their friends and their homeland, even if nobody dies in the process. There is a significant grieving process for some people. So I think it's important to consider, consider and recognize that grief is not always about death. However, for the DSM5TR, this criteria only applies to the death of a close person. The symptoms must be present for at least the last month, most days, to a significant degree. So we're talking about a grieving process that's gone on for a year. But then they say it has to be present for at least the last month. So that was a little bit confusing to me. Obviously, if they have been in this prolonged grief process and it's been going on for at least a year for adults, then of course it is going to have been present for at least the last month, most days, to a significant degree. But what are we looking for specifically? Intense longing for the person. Now think about the longing that occurs after a death. And it's not just after people in my family have passed. I've experienced episodes of intense longing for the person even more months or a year or more after their death. But those are very short lived. They're episodic. They're not present for most days to a significant degree. So that's again really what we're talking about is a continuum. The grief process is a normal process that people need to experience and we don't want to pathologize that. I fear that by calling this a disorder, that's exactly what we're doing. Some people, depending on the circumstances, may experience prolonged grief and they may benefit from counseling and therapy to help them work through that prolonged grief because the circumstances or whatever complicate it so greatly that it can be helpful to have somebody to help them work through it. What I see is adding this to the DSM has enabled clinicians to more effectively bill for it. And that's what I try to communicate to people. The Fact that we use the term disorder is unfortunate, but we need to have a code to give insurance companies in order to bill. So anyway, back to the criteria. Death of a close person at least a year ago for adults, six months ago for children, and then present for at least the last month, most days to a significant degree. Intense longing for the person, preoccupation with thoughts or memories. And it doesn't have to be necessarily just thoughts or memories of the death experience. It can be of the good times and the bad times. But you're obsessed or preoccupied thinking about this person and everything you do, you're thinking about this person. For people under the age of 18, it may also include focusing on the death circumstance, vivid flashbacks or intrusive memories about the death experience. And I'm not going to get too graphic about it, but especially in prolonged illnesses, there can be a dramatic change in the way the presentation of the person. But also in sudden deaths, you know, all of a sudden somebody has a heart attack after Christmas dinner, oh my gosh, that is like super traumatic. So it's important to recognize that it is not uncommon for people to have a preoccupation with thoughts or memories about that. Identity disruption. Feeling that part of oneself has died is another characteristic that we're looking for. Disbelief that it happened, avoidance of reminders about that person or about the death experience, intense anger, bitterness or sorrow, difficulty reintegrating, finding a new normal, planning for the future, having motivation to even do anything, or emotional numbness, feeling life is meaningless and or loneliness. So again, I want to think about the criteria. Now. We only have to have three of these in here. So if we're talking about death, you know, death of a child, for example, identity disruption, feeling like part of you has died, you're no longer, you know, so and so's mother, or so and so's caregiver, grandparent, whatever. And that's important to recognize too, that often when there is, for example, the death of a child, we think about the intense grief of the parents or the primary caregivers. We also need to recognize the impact it has on grandparents and aunts and uncles and sort of secondary caregivers as well. But there's an identity disruption or a disbelief that it happened. You know, I'm going to wake up tomorrow morning and this is all going to have been a bad dream. Avoidance of reminders. You know, again, if we're talking about a death, if it was a death that involved illness of some sort, avoiding any reminders of that, but also avoidance of reminders of the person may be present. Some people may be immersing themselves in it, other people may avoid it. They don't want to focus on those things. My mother was an avid bird watcher and when I would see birds driving to the office, it would trigger that memory of her and that bittersweet sorrow that initially was pretty intense. And so it is important to recognize that there are all kinds of reminders. I mean something as benign as a hawk flying over while you're driving to work. So some people may become more reclusive in order to avoid reminders. Feeling like life is meaningless without that person or loneliness. I mean, my stepfather, after my mother passed in the acute phase, definitely went through these things. He had also experienced significant other losses. He had experienced a tragedy in his youth with his first children and they had been killed in a fire. And so there's were still reminders that he intentionally avoided as much as possible for the first probably decade that I knew him. And then as his grandkids got older, he started acquiescing a little bit and not avoiding them so much. But it's important to recognize that I don't think he met the criteria for prolonged grief. But, but grief is a process. You don't just wake up one day and okay, the things that remind me of that person or that incident, not a big deal. You know, it's, there's always going to be a part of your brain that may remember that. So again, we don't want to pathologize something that is a perfectly normal experience, especially after a tragedy or a trauma. But death itself can be a tragedy to a lot of people. But let's apply this really quick to something like divorce, identity disruption. If you have somebody who was a full time homemaker, for example, then and they may not be able to do that anymore, they may not be so and so's spouse anymore and not having that, they may not know, okay, what do I do? I've been so and so spouse. I think of my mother in law and oh my gosh, she is the sweetest woman. Love her to death. She has always been a homemaker and she has always, you know, made sure that everything was squared away there so my father in law would go off and do his job and then come home. That very clear, very traditional gender roles. But if for some reason they got divorced, heaven forbid, you know, I think she would flounder for a while because that she hasn't been outside of that role. That's been a significant portion of who she is. So I can see how with death or even with divorce, that there can be identity disruption, there can be avoidance of reminders of the event of the marriage, intense anger, bitterness, sorrow. Oh yeah, I can see that going on. And I, I know people who even a year after the separation or divorce are still very, very angry about what happened. So that right there is three of the symptoms. The caveat here, as I mentioned in on the last slide, the first criteria for prolonged grief says it only applies to a death of a person, nothing else. But all of the other criteria I can say in clinical practice, I've seen in people who, who have experienced other kinds of losses. And the typical thing at the end of most diagnoses in the dsm, the disturbance must cause clinically significant distress. And so that differentiates it from uncomplicated grieving. I'm not using the word normal because everybody grieves in a different way individually, culturally. There's just a lot of things that influence the grieving process. And what one person may consider clinically significant distress or not moving on or failing to process the grief, someone else may consider and still an appropriate grieving period. The duration and severity clearly exceed expected social and cultural norms. And this is something that we look at with all diagnoses. Sometimes it's not explicitly stated, but we do want to make sure that we are being culturally sensitive and recognize that based on this person's developmental level and culture and all those other factors, that this is something that is in excess to what would be expected to what is considered typical for that particular person's social group and cultural norms. So think about what is the cultural norm for your culture, for other cultures, for, for grieving, a quote, non traumatic loss of your spouse. And what do I mean by non traumatic? If your spouse dies, it's kind of traumatic. When I say non traumatic, I'm thinking someone who passes away peacefully in their sleep when they are 89 years old or something, something that is not expected but also not unexpected. Traumatic losses would be more like heart attacks, car accidents, murder, suicide. Those sorts of things are under a, what I would put under a traumatic umbrella. But just for the sake of considering what a expected social and cultural norm is, I want you to think of the most benign loss that you can think of and, and for your spouse. And what is the cultural norm for grieving that loss? What is the cultural norm for grieving the loss of a child, whether it is due to sids, whether it's due to pediatric illness, whether it is, whether you're 80 years old and your child is 65 and or okay, a little bit younger than that, that would put you at 15 when you had them. But you get my point, it's still your child. Even if you are older when they pass, it's still your child. So how long is it normal to grieve for that? And culturally normal? What about the death of your parent? And you know, it felt really weird and I'm sharing a lot more about myself in this video than I probably intended to. But when my mother passed on, it felt really weird for a moment because all of a sudden that was my last living family. And you know, I have some like fourth cousins out somewhere that I've never met. But in terms of what I call family, people that I interface with, I've met, that was it. And so when she died it was a bit different or it felt a bit different than when my father passed 20 years ago. They were both still intensely painful, but there were different conditions. So what is the norm for grieving those things? What about caregivers? And I've done a video on caregiver and I'm going to talk a little bit about more care, a little bit more about caregivers in a minute. But someone who has been a, I don't remember the term, but an at home caregiver for a relative, whether it's your spouse, your child, your, your parent for an extended period of time because they had Alzheimer's, dementia, they were frail, they had cancer, whatever the case, if you were a full time or large, large portion of time caregiver for that person when they are no longer with you, that represents a significant change to your day to day activities, to your responsibilities, to your role. You've now lost that role of caregiver in addition to losing the physical being of that person. And prolonged grief disorder cannot be better explained by another mental disorder. So such as major depression or PTSD or attributable to the effects of a substance. Okay, well you can concurrently diagnose major depression and prolonged grief. We're going to talk about that in a minute. And confusingly you can also co diagnose PTSD and prolonged grief disorder. So if it's not better explained by another mental disorder, if it's better explained by ptsd, then how can you concurrently diagnose them? That's a little bit confusing in the diagnostic criteria but I'm glad that they do acknowledge that some deaths are extremely traumatic associated features. So now we're out of the diagnostic box and down into the write up associated features. I anticipatory grief has been found to be a significant predictor of prolonged grief disorder. Now, anticipatory grief was not mentioned in the dsm, but I did some further research and did find several very good studies. Articles on anticipatory grief having guilt about the death. Also potentially an associated feature or a feature that can contribute to the development of prolonged grief disorder. We may see survivor guilt in people who survive a car accident, for example, or maybe just someone who lived a similar lifestyle, but they didn't die, they didn't get cancer and their loved one did. And moral injury is another issue that comes up. And moral injury is when you have to do something that has deleterious consequences and it's against your values, against your judgment, but you had to do it anyway. And some people, especially if whatever you had to do caused the death of another person, there can be moral injury involved. Diminished future life goals. Already talked about that a little bit. But it's important to recognize that people with prolonged grief disorder, their focus may very often be on that person or their focus may have turned to one of helplessness. And what's the point in trying to do anything? Because, you know, life ends and life ends too soon. There can be a lot of negative self talk that undermines any motivation to set future goals, whether it be a month from now or ten years from now. Now it's important to remember that hallucinations about the deceased may occur during typical grief where the grieving person can hear the voice of the deceased, or see a shadow of the deceased, or feel the presence of the deceased. That is not uncommon and that is actually quite common in a lot of people. So it is important to recognize that that can be a part of the typical grieving process. But if those hallucinations become scary or violent or something else, then it may become more problematic. Or if the person starts developing a relationship, so to speak, with the hallucinations, then it can become more problematic. A lot of times there's reduced self care in the, in the acute period of grief. But in prolonged grief, you also may see continued reduced self care. Not going to the doctor, not eating well, not bathing as much as they should. Those sorts of things that you would also probably see in major depressive disorder. Prolonged grief disorder was found to be distinct from PTSD and major depression disorder on an mri. This is really interesting. People with prolonged grief disorder had greater recruitment of the medial orbitofrontal cortex. Now this is where we do self referential processing. So when people were shown sad faces, people with prolonged grief Disorder, but not PTSD or mdd had greater recruitment, greater activation of this self referential processing. It was like, that's me. Yeah, I'm feeling that, that, that I connect with that. They also had greater activation in the left amygdala, which we know the amygdala, we typically just call it our fear processing area, but there's a lot more to it. The left amygdala is specifically involved in harm avoidance as well as rumination via another segment of the brain. So the left amygdala triggers or activates other areas of the, of the brain that are involved in rumination. And one of the criteria or symptoms, if you will, of prolonged grief disorder is rumination or obsessive thoughts. So I thought that was really interesting that on an mri people with PGD do show distinct differences from other disorders. So it does highlight the fact that there are different cognitive processes, you know, the different wirings lighting up as a, as a result of pgd. Now interestingly, also interestingly, I did not find any studies, not to say they haven't been done, but I didn't find them. Comparing the MRIs of somebody with acute grief to someone with prolonged grief, I'd be interested if those same areas of the brain lit up. But the prevalence of prolonged grief disorder in the DSM, it says 7 to 10% of the general population and 18% of youth. Wow, just let that sink in. Almost twice as many youth struggle with prolonged grief disorder, which indicates to me that there is a lot that we could do in terms of prevention and processing processing with youth because it appears they may be having more difficulty or may lack the skills to cope with the traumatic loss. I'm hypothesizing here, but that is a pretty stark difference between the general population and youth in particular. Now a 2021 study found prolonged grief disorder at 13.8% of the general population. Now remember, during the ensuing two years prior to 2021, we were dealing with the pandemic. So I'm wondering if that had an impact because, you know, a lot of people were not able to get quote clos weren't able to be with their loved ones. Toward the end, there were a lot of issues that came up that complicated the process. But suffice it to say, in 2021, when the this study was published, which means the data was probably quit being collected at the end of 2020, the general population number had increased significantly. And my guess is it's still continuing to increase. Hopefully it'll start going down now, but it's certainly something to look at palliative care, and this isn't discussed in the dsm, but I think it's important to recognize the research. For almost 20% of caregivers who have provided palliative care to a loved one, the symptoms of prolonged grief disorder appear to persist at least three years post bereavement or after the death, I guess is what they mean in partners of AIDS victims, especially with those who fear death themselves, whether it's because they they too have the HIV virus or they've seen what it does. But in people that have fear of death and their partners died of AIDS, 35% of those people experienced prolonged grief disorder. Now, you can hypothesize about what some of the confounds might be here because you have to wonder, okay, in those dyads or in those relationships, is the surviving partner the one who gave the HIV virus to the partner that died, or do both of them, you know, does the surviving partner also have hiv? And that's contributing because they're seeing, it's almost like foreshadowing to what they can experience. We don't know for certain. The article was not very explicit on some of those confounds. However, if you're working with somebody whose significant other died of aids, especially if they were a caregiver for that person, note that more than more than one in three will experience prolonged grief disorder, according to studies that are out there right now. In refugees, the prevalence of prolonged grief disorder has also been estimated to be 3, 30% now they say estimated. And what this article pointed out, which is, you know, makes makes sense. There's a lot of people who are refugees who don't have insurance, who aren't going to be seeking out mental health resources. So it's the numbers we have versus the, the actual numbers are probably somewhat divergent. There's probably a lot more cases of prolonged grief disorder in refugees, especially if someone in the group died during the immigration process, that contributes to prolonged grief disorder. But even in people who didn't experience a death as a result of the immigration, being completely separated from their culture, being completely separated from the people that they knew and the people that they loved, can produce a lot of grief feelings. So this study, obviously we're talking about refugees here and which may not involve necessarily a death. So the criteria were being applied kind of loosely. But it is important to recognize that a lot of refugees do experience a lot of stuff in their immigration process, and we need to consider all of the things that may complicate their Grief Process Development and Course of Prolonged Grief Disorder the course of prolonged grief disorder may be complicated by comorbid ptsd, which is more common following the violent death of a loved one, like a murder or a suicide, which, as I mentioned earlier, kind of conflicts with the symptoms are not better explained by ptsd, which would imply you choose one or the other in the development and course they're indicating that they can be comorbid. Older age may be associated with a higher risk and an elevated risk for progressive cognitive decline. This is something that we've known about for a while, but it's, you know, associated with prolonged grief that older people, the stress of the grief process can contribute to progressive cognitive decline and speeding up that cognitive decline if they stay stuck in an extreme grief state. Culture related was pretty minimal in terms of their explanations. I was really hoping for a lot more information about, okay, if you're looking at somebody from XYZ culture, what does their culture prescribe for? What is the cultural expectation for grieving a particular type of loss? And I didn't find that. I did not find research on that in PubMed at all. So there's still a lot of work to be done here to find out, you know, what's expected. There are some religions, some cultures where the grieving process or the surviving person may be expected to grieve and stay in mourning for a prescribed period of time. Functional Consequences of Prolonged Grief Disorder There are often marked increases in the risks for stress related medical conditions, including cardiovascular disease, cancer and autoimmune issues. I was really impressed, I guess is the word I'll use. I don't want to say happy because that sounds awful. I was very impressed that this was put in there because it highlights the mind body interaction. It highlights the impact that extreme ongoing stress has on the body and the fact that stress does significantly, cognitive, emotional stress does significantly increase the risk for a variety of physiological health issues. There was also evidence of people with prolonged grief disorder who had diminished educational or occupational functioning or attainment. With people who were younger, they may decide not to go to college or not to pursue higher education, or they may change their plans completely. And for people who had already gotten past that point, the desire for promotions or further advancement in their career may also diminish. Some people quit their jobs altogether and impaired cognitive functioning again in middle aged and older adults. We know that cognition starts to decline even in middle age, even though we don't want to admit it. But we can see a speeding up of that process for people who are experiencing prolonged Intense emotional or cognitive stress, including but not limited to prolonged grief disorder. Differential diagnosis. This is what you've been waiting for, I'm sure. Depressive disorder. Now I said technically. Depressive disorder may also be able to be comorbid with or diagnosed at the same time as bereavement. Depressive disorder is different from prolonged grief because in grief, the thoughts and the emotional aspect is focused on the loss and yearning. In depression, the main descriptor is sadness and lack of ability to feel pleasure or anhedonia. So if the main mood component is about the person, the loss and the yearning, then that's going to be prolonged grief disorder. If it is sadness and anhedonia, that would be major depression. Now some people, grief can trigger a major depressive episode as well. So we need to understand a little bit what we're dealing with in ptsd. How do you differentiate ptsd? The intrusive memories focus on the death. In prolonged grief disorder, the intrusions are more general about the deceased. Memories of things that they did together? Yes. Memories of the death or the illness. Memories of things that they said. It's just general. You're thinking scrapbook type memories versus intrusive, violent, horrific, traumatic memories. Now you can have both. And it's important to consider, since they said that PTSD can be comorbid. Separation anxiety is different than prolonged grief disorder because separation anxiety involves separation from a living person. In pgd, the person has to be dead. In separation anxiety, the person is, is alive, maybe separated from. Psychotic disorder requires more symptoms than just hallucinations about the deceased. So the person is not necessarily having a psychotic episode. And we need to make sure that we normalize hallucinations in the grieving process, such as the ones I discussed earlier. Those are typical in many people's grieving process. Comorbidity. Over 50% of bereaved caregivers, people who were caregivers to someone with a long term illness. Over 50% of bereaved caregivers had clinically significant depressive symptoms one year after the death of their relative. So we need to look at the bereaved caregivers and identify, okay, what portion of these symptoms are prolonged grief disorder and what portion of these symptoms would be major depressive disorder. As I mentioned and the DSM mentioned, PTSD can be also diagnosed comorbidly or at the same time as prolonged grief disorder. Addiction is something else that we see occurring comorbidly. And this is another one of those things that's really not a surprise. Some people, in order to quiet those Ruminations, in order to numb some of the pain during the acute grieving process, may turn to addictive substances. Unfortunately, addiction generally, because of its ability, if you will, to help the person numb, escape, avoid, prevents them from experiencing and integrating what has happened. So addiction may contribute to the development of prolonged grief disorder. My uncle, his wife, my aunt passed away from cystic fibrosis. Now this was, you know, way back in the late 1970s, and I don't know what the treatment for cystic fibrosis is now, but back then he was a full time caregiver for her. There were therapy exercises that they had to do multiple times a day to help keep her lungs clear and other things like that. And after she passed, he very quickly descended into alcohol addiction and really didn't, in my estimation, fully process that loss. Interacting with him over the next 30 years, there always seemed to be a sense of depression, a sense of loss, definitely ongoing substance misuse. And as highlighted by what we just talked about, he did end up also developing cancer and succumbing to that. So there is a lot of comorbidity. Separation anxiety with the living may also co occur with prolonged grief disorder for the dead. Totally makes sense, especially for younger people and children. But even for older people, if you lose someone that's close to you, you may fear being away from the other people that you love, because, oh my gosh, I can't imagine going through this pain again, especially right now. So you can see how separation anxiety can develop comorbidly with prolonged grief disorder. It's also important to recognize that there is a whole host of stress related physical illnesses that may also develop. There may be changes in thyroid functioning. We see changes in thyroid functioning, especially in people with PTSD or cptsd because ongoing activation of the HPA axis actually also causes dysregulation of the HPT or hypothalamic pituitary thyroid access and the hpg, hypothalamic pituitary gonadal axis. We may see alterations in gonadal or sex hormones as well. We may see the development in, in people who are biologically female of polycystic ovarian disease or syndrome. So there are a lot of other things that can happen that would influence the person's presentation. Hypothyroid, low testosterone, low estrogen, pcos. All of those are associated with depression, like symptoms. And it's important to recognize that, especially if there is a mental health issue that is prolonged, which generally they are, by the time they come to counseling, a thorough physiological workup physical is really, really helpful to identify any other changes, physiological changes that may be occurring, that may be contributing to the presenting symptoms for some people, because mental illness and being diagnosed with a disorder is still seen as not okay, still seen by the culture as something shameful. Helping them understand that there may be some physical underpinnings to what they're feeling, what they're experiencing may give them something to hold on to that can help them work through that process and feel less pathologized. Understanding that, oh, my thyroid's gone wonky now, that's not going to solve the grieving process, but that can help them understand some of their somatic symptoms. Obviously, if the person is presenting more with somatic symptoms then talking about their cognitive symptoms, then we do want to evaluate those and make sure they understand that we recognize that it is a biopsychosocial event. It's not quote all in their head. It does affect their physiology. And even when it's not prolonged grief during the grieving process, hormones change, the body changes in, in reaction to stress, oxytocin levels change, even other perspectives. The intensity and duration of grief is highly variable, not only in the same individual over time. So the way somebody reacted when they were 20 may be different than the way somebody reacts to a similar loss when they're 50. And like I mentioned, when my father died, I was 28. And yes, it was devastating. My reaction when my mother died and I was 48 was different because they died of the same disorder, they died under the same sort of circumstances and hospice care, blah, blah, blah. But she was my last remaining family member, and so that complicated the picture a little bit. So the intensity and duration of the grief was a little bit different. It can also be different if you've got similar situations, but you're closer to one parent than the other, closer to one person than the other. That may impact the intensity and duration of your grief. So just because it was difficult to do this one time, don't expect it's going to be the same the second. Likewise, something that was difficult the first time, you know, it may have been, oh my gosh, you know, I can't imagine going through that again. You also have to look bigger and consider that grief and death and loss do not occur in a bubble, in a vacuum. What else was going on? You know, were you also dealing with excessive stress and financial stress and relationship stress, and you hated your job and all this other stuff, but now there's a similar loss, but you don't have all those other Stressors also draining you and pulling your mood down. So don't ex. You can't necessarily expect this situation to be the same as any past situation. In cbt, we talk about context a lot. It's important to recognize not only what's going on, but what's going on in this context at this time. How is it similar and different to what was going on in that context at that time? The American Academy of. Oh, I'm sorry, I jumped ahead of myself. So the intensity and duration of grief is highly variable, not only in the same individual over time or after different losses, but also in different people dealing with ostensibly similar losses. Two people who both are impacted by a tornado and lose somebody to death, we'll even just stick with the true criteria for prolonged grief disorder. They both lose a family member to death as a result of a tornado that happened two weeks ago or a year ago. Even though they were neighbors, even though they went through the same loss due to the same issue, they may deal with it very, very differently. And that really makes a lot of sense, too. The American Academy of Family Physicians states, quote, in response to grief and prolonged grief, quote, you may start to feel better in six to eight weeks, but the whole process can last anywhere from six months to four years. Now, I thought that was interesting. They also do note that people in a typical grief resolution process see gradual improvements over time. So four years after the loss, the intensity, duration, frequency of the symptoms is a lot less than it was four days after the loss. But people may still continue to experience symptomatic episodes for quite a while. And as I mentioned earlier, when we grieve the loss of somebody, even 10, 15, 20 years later, it doesn't mean we've forgotten them. It means we've integrated the experience, however devastating, into our. Into our story. And when those memories are triggered, it doesn't mean that we are going to not have those memories or not be touched by them, but the intensity of the reaction is often different. Now, I can think about those last days of my mother's life, and yeah, they're distressful, but they don't devastate me to the same intensity. Now, they're sorrowful memories, but I also don't get stuck in them anymore. And it's important to start looking for things like that, but helping people recognize, and that's my ultimate point, that even if you're thinking about that person occasionally, four, five, ten years later, they were an important part of your life. And you wouldn't want to. Most people wouldn't want to not think about them. So having memories and even having memories that occasionally make you sad isn't necessarily indicative of anything pathological. What we're talking about here is something that is extremely intense, that causes clinically significant distress and impairment and functioning a year or more after the death for adults or six months for children. Prolonged grief disorder is a diagnosis that is distinct from PTSD and Major Depressive Disorder and is characterized by significant ongoing impairment in functioning or one year for adults, six months for children. That diverges significantly from what is expected culturally and clinically. Critics argue that it pathologizes grieving and therefore may inhibit people from experiencing their loss fully or seeking treatment for grief. Just putting that out there, that's what there's been a lot of debate. Clinicians can work to destigmatize, in my opinion, the diagnosis by explaining that the addition of prolonged grief Disorder to the DSM 5TR provides an avenue for us to make treatment available. Because now that we have a diagnosis, we can bill for it. And if we can bill for it, then, you know, you can get affordable treatment for it, theoretically. So we can help people really start understanding a little bit more about how we use the DSM and hopefully move away from the focus on the fact that it has the word disorder in the title, like major depressive disorder or prolonged grief disorder. When I'm talking with people about stuff, I talk about major depression, I talk about prolonged grief, and I don't see the need to throw disorder on there, personally, when I am having discussions with patients or even in the community. When we're talking about things that clinicians can help with or things that cognitive behavioral therapy or EMDR might be helpful with. I don't necessarily tack on the word disorder, because I do. I feel that that can be overly pathologizing and prohibit people from other cultures, especially from trying to access services. But that's my little soapbox on it anyhow. Prolonged grief disorder, whether you like it, you hate it, or somewhere in between, it's there, and it seems like it's there to stay. I hope they clarify some things in the next iteration of the dsm, but now you got something to work with.