Board Approves New Prolonged Grief Disorder for DSM
Abstract
The next step is a review and vote on the new disorder by the Assembly. Among other issues the Board discussed were structural racism in psychiatry and the development of a model for communities to determine how many inpatient beds they need.
APA Trustees approved the inclusion of prolonged grief disorder in DSM, subject to approval by the Assembly, at its virtual October meeting. The recommendation for the inclusion came from the DSM Steering Committee after a two-year process of review by the committee and relevant APA components and taking into account public comments.
“There is substantial evidence that the proposed category would meet criteria for a mental disorder, have strong evidence of validity, and be capable of being applied reliably,” said Kenneth Kendler, M.D., vice chair of the DSM Steering Committee. “We believe it will have substantial clinical value, identifying a group of patients now not receiving appropriate clinical attention and facilitate the appropriate use of available treatments.”
Items are usually approved by the Assembly before being considered by the Board, but the new diagnosis was brought to the Board to meet the deadline for inclusion in DSM-5-TR, which is reaching the final stages of production. A full list of the criteria for the disorder appears in the box below.
Kendler told the Board that studies dating back several decades suggest that many people experience persistent difficulties associated with bereavement that are substantially prolonged beyond “culturally normed expectations.” Data suggest that symptoms of prolonged bereavement are different from those associated with major depression, he said.
Moreover, specific treatment approaches have been developed and tested for sustained symptoms of bereavement.
DSM-5 included a category of persistent complex bereavement disorder (PCBD) as a “Condition for Further Study” in Section III of the manual. In 2018 a proposal was submitted to include the category in the main text of the manual, which underwent review by the DSM Steering Committee and the Review Committee on Internalizing Disorders. In June 2019 a workshop was held in New York City to develop consensus around appropriate criteria for the diagnosis.
Criteria were finalized later in 2019 and approved by the DSM Steering Committee this past January. They were posted for public comment in the spring and approved by the steering committee in August.
The Board also approved a number of action items brought by the Presidential Task Force on Structural Racism Throughout Psychiatry to increase participation of Black members in APA governance. By approval of the Board, a list of Black APA/APAF Fellows will be reported to the district branches, which will be instructed to reach out to them and encourage their participation and leadership as well as consider them for APA Assembly representative positions.
As recommended by the task force, the Board also directed the Assembly Executive Committee to take the following actions to increase participation of Black members in the Assembly. Among them:
Establish a mentor/sponsor program for Black psychiatrists drawing on senior Assembly leaders as mentors.
Adopt consistent term limits for all Assembly Area representatives and Assembly Area deputy representatives.
Instruct the Assembly Nominating Committee about the importance of nominating a diverse pool of nominees.
Include the minority/underrepresented (M/UR) caucuses and the M/UR Committee of the Assembly in the Assembly nomination process by having them submit nominations directly to the Assembly Nominating Committee.
Identify “Equity Advisors” to advise the Assembly on all aspects related to diversity and equity.
In comments to Psychiatric News after the meeting, task force Chair Cheryl Wills, M.D., said she believes the task force has made promising progress since its inception in June.
“The work groups have been using data including recent membership surveys to inform how they proceed,” she said. “If the data suggest an absence of member diversity in a particular area, such as the APA Assembly, then the relevant work group strives to identify potential reasons for the deficit and suggests actionable items that may remedy the problem. Each work group’s analysis is presented to the task force for further discussion and refinement before the final draft is presented to the Board of Trustees. Work groups are also looking at diversity within the APA governance and the councils and committees.”
New Criteria Identify Prolonged Symptoms Unlike Typical Grief Related to Death of a Loved One
These are the criteria for Prolonged Grief Disorder, approved by the APA Board of Trustees (subject to approval by the Assembly) for inclusion in DSM.
The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago).
Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) have occurred nearly every day for at least the last month:
Intense yearning/longing for the deceased person
Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death)
Since the death, at least 3 of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
Identity disruption (e.g., feeling as though part of oneself has died) since the death
Marked sense of disbelief about the death
Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders)
Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future)
Emotional numbness (absence or marked reduction of emotional experience) as a result of the death
Feeling that life is meaningless as a result of the death
Intense loneliness as a result of the death.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The duration and severity of the bereavement reaction clearly exceeds expected social, cultural or religious norms for the individual’s culture and context.
The symptoms are not better explained by major depressive disorder, posttraumatic stress disorder, or another mental disorder, or attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
She also said the task force wants to examine the Annual Meeting Scientific Program to help ensure a diverse range of speakers and sessions that address cultural psychiatry, diversity, and structural racism.
Wills added that she believes the benefits of the task force recommendations will extend beyond Black psychiatrists to psychiatrists of other M/UR groups.
Trustees also heard a report from past APA President Anita Everett, M.D., who is chair of the APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the United States (see Psychiatric News here and here).
Everett said the task force is on track to produce the first iteration of a model for determining how many psychiatric beds a community needs before or shortly after the new year. In past interviews with Psychiatric News, Everett explained that the model is likely to be rudimentary but can be refined over time to incorporate more variables impacting community need. The kinds of variables that might mitigate the need for inpatient beds include the presence of crisis intervention teams, day treatment programs and Assertive Community Treatment teams.
“Working under a very ambitious timeline, we are hoping to have a model that can inform the nation about a holy grail of public psychiatry,” Everett told the Board. “How much inpatient service does a community need versus outpatient service, and what kind of services mitigate the need for inpatient care?” ■
Information about the Presidential Task Force to Address Structural Racism Throughout Psychiatry is posted here.
APA members interested in learning about the Presidential Task Force on Psychiatric Beds in the United States or contributing their time or expertise to it are urged to contact Laura Thompson in the APA Division of Research at [email protected].
