What is the treatment for prolonged grief disorder?

Treatment of Prolonged Grief Disorder

Complicated grief therapy (CGT) is the first-line treatment for prolonged grief disorder, with exposure therapy being an essential component to achieve optimal symptom reduction.

Understanding Prolonged Grief Disorder

Prolonged grief disorder (PGD) is a recently recognized mental health condition included in both ICD-11 and DSM-5-TR 1, 2. It is characterized by:

• Persistent yearning or preoccupation with the deceased
• Emotional pain, identity disturbances, and loss of meaning
• Functional impairment
• Symptoms persisting beyond 6-12 months after bereavement
• Affects approximately 10% of bereaved individuals 3

Evidence-Based Treatment Approaches

First-Line Treatment: Complicated Grief Therapy (CGT)

CGT is the most evidence-supported treatment for PGD, incorporating cognitive-behavioral techniques with specific grief-focused components 4. The therapy should include:

1. Exposure therapy component - Critical for optimal outcomes

   • Emotional processing of memories related to the death
   • Significantly greater PGD reduction compared to CBT alone (p=.003) 3
   • Lower rates of PGD diagnosis at follow-up (14.8% vs 37.9%, p=.04) 3

2. Core therapeutic themes 4:

   • Understanding and accepting grief
   • Managing painful emotions
   • Planning for a meaningful future
   • Strengthening ongoing relationships
   • Telling the story of the death (exposure)
   • Learning to live with reminders
   • Establishing an enduring connection with memories of the deceased

3. Treatment structure:

   • 20-25 sessions for optimal outcomes 5
   • Can be delivered in both individual and group formats
   • Large effect sizes for grief symptom improvement (Cohen's d=1.32-1.61) 5

Cognitive Behavioral Therapy for PGD (PG-CBT)

Integrative cognitive behavioral therapy specifically adapted for prolonged grief has shown efficacy with 5:

• Large between-group effect sizes (Cohen's d=1.61 for completers)
• Acceptable dropout rates (21%)
• Improvements in comorbid depressive symptoms

Trauma-Focused Approaches

For cases with traumatic bereavement elements:

• Cognitive therapy approaches similar to CT-PTSD may be beneficial 6
• Trauma-focused CBT is recommended for addressing traumatic aspects of grief 7

Assessment and Identification

Clinicians should identify individuals at risk for complicated bereavement or prolonged grief disorder 1:

• Assess for persistent grief symptoms beyond 6-12 months
• Evaluate functional impairment
• Screen for comorbid conditions (depression, PTSD)
• Consider the circumstances of death (traumatic, unexpected)

Special Considerations

Comorbidity Management

PGD often presents with comorbidities that require concurrent treatment 5:

• Depression: Consider SSRIs if significant depressive symptoms are present 7
• PTSD: Address trauma symptoms with trauma-focused approaches
• Substance use: Avoid benzodiazepines; address substance use concurrently 7

Bereavement Support

For family members experiencing normal grief, provide 1:

• Bereavement support through hospice teams or mental health professionals
• Condolence expressions (calls, letters)
• Referrals to community bereavement resources
• Monitoring for progression to prolonged grief disorder

Clinical Pitfalls to Avoid

1. Delaying treatment - Early intervention is crucial to prevent chronicity 7
2. Omitting exposure components - Exposure to memories of the death is essential for optimal outcomes 3
3. Confusing normal grief with PGD - Normal grief doesn't require specialized treatment but should be monitored
4. Overlooking comorbidities - Address concurrent depression, PTSD, and other conditions
5. Using benzodiazepines - These may worsen outcomes and have high abuse potential 7

Treatment Algorithm

1. Assess for PGD (6-12 months post-loss)
2. If PGD confirmed:
   • Initiate CGT with exposure therapy component (20-25 sessions)
   • Address comorbid conditions concurrently
   • Monitor treatment response
3. If partial response:
   • Intensify exposure components
   • Consider adjunctive treatments for comorbidities
4. If minimal response:
   • Reevaluate diagnosis and comorbidities
   • Consider referral to specialized grief treatment center

The evidence strongly supports that including exposure therapy that promotes emotional processing of memories of the death is crucial for achieving optimal reductions in PGD severity 3.