Question 1

Is bereavement in the context of suicide a risk factor for PGD?

Holly Prigerson · Accepted Answer

Yes it is. And it is also a risk for suicidal thoughts and behaviors among bereaved individuals, regardless of PGD, though PGD is the mental disorder among the bereaved which we have found to present the highest risk for suicidal thoughts and behaviors.

Question 2

Has anyone looked at the unique factors involved in treating PGD in the context of early pregnancy loss and stillbirth and infant death?

Holly Prigerson · Accepted Answer

Yes, a very long time ago I reviewed an article that found that the age of the mother and number of other children she had were significant risk factors for PGD in the context of early pregnancy loss. It would appear the loss might be a function of loss of the possibility of being a mother that is critical to PGD in this context.

Question 3

Is pharmacotherapy indicated for PGD and is it often used in conjunction psychotherapy?

Holly Prigerson · Accepted Answer

There has been very little research on pharmacotherapy for PGD.  The initial studies found tricyclic antidepressants and IPT were not effective for symptoms of grief as they were for those of depression.  A few open trials of SSRIs have yielded modest results.  We are now developing experimental trials of naltrexone, based on a review of the literature implicating reward system dysfunction in PGD, but expect there will be pushback to this suggestion.

Question 4

Does attachment style play a role in prolonged grief disorder?

Holly Prigerson · Accepted Answer

Yes, you may be familiar with Bowlby's "personalities pronte to pathological mourning"?.  We have studied this and a few "insecure attachment styles" (e.g., compulsively self-reliant, excessively dependent, compulsive caregiving) were associated with elevated PGD symptomatology compared to secure attachment styles among the bereaved individuals studied.

Question 5

As a clinician, what things do I need to be aware of when treating clients who have lost a loved one to crime, violence and/or terrorism?

Holly Prigerson · Accepted Answer

We have compared types of loss and those from violent crimes result in more anger (rage) and questioning of why. There may be elements of PTSD, with fear, helplessness and horror complicating the bereavement adjustment. In this case, it is not simple an attachment disturbance, but a traumatic stress response replete with feelings of the injustice of what happened, intrusive thoughts, a sense of helplessness and foreshortened future.

Question 6

What gender differences have been found in PGD?

Holly Prigerson · Accepted Answer

There have not been significant gender differences associated with PGD. Some studies show men are more at risk, some show women are more at risk, most show no significant association with PGD risk by gender.  The exception is mothers who have lost a child who appear more devastated on average than fathers, but even in this circumstances there are many exceptions to this exception.

Question 7

Can you diagnose PGD in the context of loss to chronic pain?

Holly Prigerson · Accepted Answer

I'm not sure I understand the question. Are you asking if pain could trigger PGD?  I have been asked this multiple times, which suggests to me that there might be something too it -- so the loss is of normal function -- and the survivor grieves the loss of normalcy.  Having no evidence to confirm this relationship, however, I'd rather not speculate.

Question 8

What do you think about the concept of resilient grieving?

Holly Prigerson · Accepted Answer

I'm unfamiliar with the term but if this suggests that grieving is necessary to a healthy, adaptive adjustment to loss, then that is sounding like the Freudian notion of grief work (i.e., that a person needs to express or work on grief to adjust).  If by this non-expression of grief there is a conclusion that this represents resilience, then I think that there are many instances in which either the person was not that attached to the deceased so there is not much grieving experienced and that is not resilience, per se, or that there is a delayed grief reaction which is also not necessarily resilience (e.g., in combat this can happen when someone is overwhelmed by loss and grief and cannot process what has happened). I would need to know more about the what is meant by resilient grieving to be able to answer this satistfactorily.

Question 9

Does the diagnosis for PGD allow for grief in the context of loss of function, loss of identity and dreams, loss of autonomy etc?

Holly Prigerson · Accepted Answer

Yes. Grief is essentially wanting something very much (e.g., something that is self-defining, a source of comfort and security and place in this world) that you cannot have.  If the "thing" lost is one's freedom, autonomy, livelihood, marriage, and you yearn intensely to have it back and do not know what to do without it and how you will get on, then that thing could trigger PGD.

Question 10

I have concerns about labelling grief as a disorder. Aren't we at risk of pathologising everything?

Holly Prigerson · Accepted Answer

When decades of research demonstrate that a significant minority of bereaved people meet the proposed criteria, that those that do are at significantly increased risk of making a suicide attempt, hospitalization, physical and mental disorders, then it is no different than accurately and reliably diagnosing any other disorder, be it diabetes or cancer.

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