Advantages and disadvantages
There is little doubt that the proposal to introduce a separate grief diagnosis has been met with considerable scepticism. The strongest argument against its introduction is the fear of «medicalising» normal grief (17). The American sociologist Jerome Wakefield claims that the symptoms of prolonged grief disorder are not distinctively different from normal grief reactions, and that there has been a failure to distinguish the condition sufficiently from intense normal grief, where the healing process is gradual and prolonged (18). Wakefield claims that the research on prolonged grief disorder is at odds with recent knowledge on how long a normal grief process may require, and that this will result in numerous false-positives.
It is obviously important to recognise that a person may be stricken by intense and persistent grief, but that this cannot necessarily be characterised as abnormal or as a type of grief that cannot be accelerated or «healed» by treatment. There is also a risk of stigmatisation and of being branded as ill when going through profound grief. Others fear that their social network may withdraw when greater emphasis is placed on treatment of grief, but there is little research evidence for this assertion (13).
Adherents claim that the introduction of a grief diagnosis will make it easier to identify those who endure problems because of their grief, thus enabling them to receive help and support that are better adapted to their needs (13). In this respect, the introduction of a grief diagnosis may have a clinical value. With current practices, those who are stuck in their grief may be given various diagnoses that are not necessarily adequate for their problems. A recent Danish study showed that providing information on prolonged grief disorder to general practitioners may make them recognise the condition more easily, and thus have a positive effect on the subsequent clinical pathway (19). Moreover, the introduction of a grief diagnosis may prompt allocation of funds for research in key areas such as risk factors, prevention and treatment. Diagnoses also imply certain entitlements as regards access to treatment, sick leave and social compensation.
Last, but not least, it is claimed that a grief diagnosis will not only provide better knowledge for those who should help grieving people, it can also be of help to those who are stricken. The well-known psychiatrist and grief researcher Colin M. Parkes claims that those who struggle with grief may be met with greater recognition of their problems, an increased understanding of the nature of prolonged grief disorder and a confirmation that help is available (20). A study from the USA supports this assertion (21). Otherwise, however, there is a paucity of research in this area.
Some questions still remain with regard to the introduction of a grief diagnosis, such as how it should relate to other sub-groups of pathological grief (22). As yet, the main emphasis has been placed on prolonged grief with intense separation distress, while other variants such as traumatic grief, where intrusive memories/thoughts of a dramatic death block the release of normal grief, and delayed or inhibited grief are not recognised in the same manner. These sub-types are clinically interesting and may give rise to other therapeutic challenges than prolonged grief disorder. Nor would the proposal for a separate grief diagnosis have an effect on current practices, for example with regard to granting sick leave to mourners before six months have passed since a bereavement, even for those who experience intense grief reactions and considerable functional impairment.
In addition, it is necessary to review critically whether the criteria are appropriate for describing grief in children and adolescents. Even though prolonged grief disorder has been described also in these age groups (23), it remains a fact that many children have greater problems in regulating emotions than adults, which may lead to more avoidance of thoughts and feelings (24). A development perspective is thus key to understanding how children cope with loss and grief, and some adaptations have been suggested in DSM-5 (25).
The strong sense of loss that may characterise the grief felt after the loss of a loved one may be just as prevalent after other types of loss, and it remains unclear why grieving after a death should be so fundamentally different from the experience of loss of a job, function or health, or a spouse lost through divorce etc. A study undertaken after hurricane «Katrina» showed that not only loss of loved ones, but also other types of loss (including job and financial position) were related to prolonged grief disorder (26).
The introduction of a grief diagnosis may entail certain practical implications. In practice, many of those who struggle with their grief will most likely be in contact with the health services already. Some studies also show that many of those who suffer from prolonged grief disorder do not seek any help (27). In other words, the introduction of a grief diagnosis may result in increased attention to the need for and entitlement to therapy, which may represent a challenge to the hard-pressed health services.