The ICD-11 diagnosis ‘Prolonged Grief Disorder’ – Problems and opportunities

Urs Münch, a psychologist and psychotherapist from Berlin, Germany, and currently a vice-president of the German Association for Palliative Medicine, continues the discussion on the recent proposal of the World Health Organization (WHO) to add the diagnosis of ‘prolonged grief disorder’ to a new version of the International Classification of Diseases (ICD-11).

Urs Münch.

I read with interest Dr Karl Onnasch’s recent post, The healing power of grief, concerning the WHO recent proposal for a new diagnosis called ‘prolonged grief disorder’. The criteria suggested by WHO led to an intensive controversy especially about the time criterion of six months minimum following the loss. In this post, I would like to offer a rather different viewpoint. In my opinion, an ICD-11 diagnosis could help to support interdisciplinary scientific research, especially in Germany, and therefore improve treatment for those who do not experience their bereavement as normal or as a healing power.

As a young psychotherapist, immediately after my exams I started to work on a psychiatric day ward in a German hospital. Soon a new patient came in, a 58-year-old woman. She was well known on the ward and I was told “she is difficult” and “she has no motivation to improve and to get well”. Her diagnosis: severe recurrent depressive disorder, treated with strong antidepressants. Getting to know her better, I understood she had suffered the loss of her beloved husband. But all treatment was solely targeted on depression. A couple of weeks later she was discharged from hospital with only slight improvements.

During my three years at this hospital she was my patient three times. I learned that her husband loved the countryside, so they had moved out of town and built a house in a small village. She personally preferred to live in the city but went along with her husband’s wishes. After his death she felt lonely but stayed in the village where she did not have much support from other people. When she was admitted to our hospital for the third time she and I had already established a trustful relationship that allowed her to tell me her big secret: the ashes of her husband were buried next to the house in the garden. She feared that if she broke her promise and moved back to the city it would be disloyal to her husband. Whether this woman suffered a prolonged grief disorder is open to debate. But the fact is that she got a false diagnosis and therefore wrong treatment – something that is still happening today.

In Germany, many bereaved people with complications in their grieving process end up in psychotherapy or psychiatric treatment but do not get treated adequately there. For example, there is no evidence that antidepressants or tranquillisersare of any help to people suffering from complications in their grief process.They may even be harmful to the bereaved.

International bereavement research points out that there are still a lot of open questions when it comes to grief, complicated grief and the forthcoming ICD-11 diagnosis of a prolonged grief disorder.Nonetheless, it is about to be included, so who are we helping by condemning it? 3

Germany severely lacks systematic and enduring bereavement research. An ICD-11 diagnosis could help to support interdisciplinary scientific research, especially in Germany. It could help to support knowledge transfer so that psychiatrists, psychotherapists and general practitioners are better informed about bereavement and its treatment possibilities. Additionally, psychiatrists or psychotherapists will not have to use a wrong label when treating the bereaved.

However, there is still a great need for more current knowledge, more professionalism in training of practitioners and reliable diagnostic tools to meet misdiagnoses. Grief as a topic deserves the undivided attention of all professionals working with the bereaved.

References

1. Bui E, Nadal-Vicens M, Simon NM (2019). Pharmacological approaches to the treatment of complicated grief: rationale and a brief review of the literature. Dialogues Clin Neurosci. 14 (2), 149-157; and The Lancet(2012). Living with grief. The Lancet, 379, 589.

2. Stanton Chapple H et al (2017) The body of knowledge in thanatology: An outline. Death Studies, 41:2, 118-125.

3. Dietl L, Wagner B, Fydrich T (2018). User acceptability of the diagnosis of prolonged grief disorder: How do professionals think about inclusion in ICD-11? Journal of Affective Disorders 229 (2018) 306–313; and https://www.dhpv.de/tl_files/public/Aktuelles/Stellungnahme/DHPV_StellungnahmeTrauerICD-11_2018.pdf or https://www.dhpv.de/tl_files/public/Aktuelles/Stellungnahme/Stellungnahme_TrauerICD_EF_27062016.pdf

More about the author…
Urs Münch is a hospital-based psycho-oncologist and has worked with a palliative care team in Berlin since 2010. He is currently a vice-president of the German Association for Palliative Medicine (DGP), and active in DGP’s ‘AG Psychosocial and Spiritual Care’ and ‘AG Bildung’. Contact Urs Münch by email.

Links
Read more posts on bereavement on the EAPC blog, including the one from Dr Karl Onnasch referred to above.

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