Hello all you wonderful therapists out there and welcome back to our Licensure Exams podcast . I'm Dr Linton Hutchinson , coming to you from warm and cozy Florida , and I'm with my co-host , stacey Frost , who is currently braving the frosty 20 degree weather in Michigan .
Has the chills seeped into your bone , jet , and are you perhaps considering moving back here , stacey ?
Are you kidding me , Linton , and give up my treasured mitten and scarf collection ? Never I'll have . You know that I just invested in a new pair of long johns .
I'll bet you did .
Yes . So this newly official Michigander is impervious to cold . Now I've got my new long johns on under my snowsuit , hand warmers in my mittens and a knitted hat pulled down over my eyebrows . I'm snug as a bug . A little winter weather isn't going to stop me from our mission to equip therapists with the knowledge to pass their licensing exams .
I'll bet you're nice and toasty there , stacey , I am .
Never been toastier .
Oh , that's the spirit . Now that we've got the blood pumping , let's warm up our brains and demystify some disorders . Which one are we covering today , Stacey ?
Well , as you may know , there's a new disorder in the DSM-5TR and it's called prolonged grief disorder .
What you mean . I've got to buy another DSM , but I just finish off paying my student loans and I can't believe that I can't just continue using the DSM-5 I purchased last year Stacey .
Freed not . Freed not .
Well , it was hard enough when I had to go from the DSM-3 to the DSM-4 , and then the DSM-4TR and then to the 5 . And now you're telling me the exam is now based on the DSM-5TR . We've already lost a number of familiar diagnoses along the way , and now this that's right , bucko .
You need to suck it up , spend some moolah and get up to date with the profession there . Buddy , if you miss the exam by one point because you cheated out Linton , you're going to regret it . Just remember , I warned you .
Okay , okay , okay , I get the message . So tell me again what were we covering ?
Looks like someone could also work on their attending skills . Well , today we'll be talking about how you can distinguish between prolonged grief disorder and uncomplicated bereavement or normal grief .
So uncomplicated bereavement , if you haven't heard of this , is located way in the back of the DSM-5TR , hiding under the additional conditions or problems that may be a focus of clinical attention , and the brand new shiny minted prolonged grief disorder is sandwiched between adjustment disorders and other specified trauma and stressor-related disorders .
Got it . Even though grief is a normal reaction to loss , in some cases it becomes really pathological and turns into a mental disorder . The DSM-5-TR distinguishes between grief that follows a normal trajectory of grief versus prolonged grief that is persistent and , most importantly , impedes functioning .
With prolonged grief disorder , the grieving process must be clearly out of proportion or inconsistent with cultural , religious or age-appropriate norms . What are those areas of functioning that you might want to know for the exams , Stacey ?
This is where your memory device comes in handy Linton .
You mean ROSE R-O-S-E , rose , relational Occupational , social and Educational Functioning .
L-M-M-M . That's the one . So ROSE is a great way to remember the different areas of functioning . In order to diagnose any mental disorder , the client has to exhibit impairment in at least one of those areas . So let's start by clarifying the criteria for prolonged grief disorder .
This disorder involves an intense yearning or longing for the deceased and or a preoccupation with the deceased or the circumstances of the death .
R-M-M . But haven't you forgot about durations ? L-m-duration is the most important thing for making that diagnosis or differentiating , wouldn't you say R-M-M ?
I would yep so for prolonged grief disorder . According to the DSM-5TR , if your client is an adult , you can't even consider making this diagnosis until it's been at least 12 months since a death .
L-M-M-M . Ah , okay , r-m-m-m .
And if your client is a child or an adolescent , that timeframe is decreased to six months .
L-M-M-M . Six months . Why is there a difference in the duration R-M-M-M .
So overall , the intent is to diagnose prolonged grief disorder faster in children and adolescents so that treatment can start early to support normal functioning and development . And the shorter timeframe acts as kind of a safety net for youth who are trying to navigate their grief .
Their coping skills are less established , so diagnosing prolonged grief disorder earlier allows for treatment and intervention before lasting effects become solidified .
L-M-M-M . That actually makes sense . So what else is important for making a diagnosis ? R-m-m-m .
Well , there's a cluster of symptoms that must be present for most days , l-m-m-m .
What are those ?
R-M-M-M . Okay , so , since the loss , the client has to be experiencing at least three of these symptoms L-M-M-M , three R-M-M-M . All right , get ready . Yep , I've got a list here . L-m-m-m .
Okay .
R-M-M-M . Okay so disrupted sense of identity following the death , such as feeling that a part of oneself died along with the deceased . A persistent disbelief or inability to accept the reality of the loss . Avoidance of people , places , objects or other reminders of the deceased . Overwhelming feelings of sorrow , anger or bitterness related to the death .
Difficulty re-engaging in social , occupational or other activities after the death . Emotional numbness or detachment following the death . Loss of a sense of purpose or meaning in life since the death . And I got one more here a profound sense of loneliness or isolation due to the absence of a deceased . So , Linton , that's a whole long list of symptoms there .
Do you have a memory device ? Well , a matter of fact , I have a sentence that sort of encapsulates that . Here it is . After my initial disbelief regarding my partner's death , there was a period of avoidance and profound sorrow and anger before I chose to re-engage with others , to move past my numbness , renew my sense of purpose and ease my loneliness .
Wow , it almost sounds poetic . Want to say that again , Linton .
Oh , okay . After my initial disbelief regarding my partner's death , there was a period of avoidance and prolonged sorrow and anger before I chose to re-engage with others , to move past my numbness , renew my sense of purpose and ease my loneliness .
All right , I see what you've done here . We'll have to practice this a little bit more , but I think it's going to work for me .
Okay , thanks , thacey . Oh yeah , these symptoms typically appear within the first few months following a death . The duration of prolonged grief disorder symptoms may be particularly long-lasting for parents that unfortunately are grieving the death of a child .
And what about children who experience a loss ? Maybe they lost a parent or a sibling ? How would their presentation maybe look different than it would if you're treating an adult client ?
Their distress may manifest through play , behavioral changes , developmental setbacks and separation .
Anxiety Lie Well , young kids may become angry or they'll melt down when their daily routines are performed differently than how the deceased did them , such as what you do , your morning rituals , new foods that are given to eat , discipline or going to bed , any kind of transitional periods . If those are altered , then you may see them go ahead and melt out .
They may express intense anxiety about their future , safety and health and repeatedly ask questions about death due to not grasping its permanence , and they'll continually ask where's mommy , where's daddy , where's my brother , where's my sister ? When are they going to come home ?
And they may engage in searching behaviors in hopes of literally reuniting with the dead , so they may look around the house trying to find where that person is . Common somatic symptoms include sleep , appetite , digestive and energy disturbances .
The loss can also make kids feel different from their peers , especially during events such as Mother's Day , father's Day , or when they see a friend playing with their sibling .
Gotcha Well . Thanks , Linton , that's really helpful . Let's walk through a few case studies to make this information a little bit more concrete . What do you say ?
Okay , so how about Joanna ?
You read my mind All right . Joanna is a 32 year old woman , and her husband and their infant died in a car accident about 18 months ago . Since their deaths , joanna has been unable to return to her work as a teacher . She's withdrawn socially , unable to face friends and family without breaking down . She feels utterly alone and like no one understands her grief .
Joanna spends most of her time at home crying and looking through old photos of her husband and infant . She continually goes into her daughter's room , thinking she will somehow be there . Then she flips and feels angry that her husband left her and guilty about his and their daughter's death because she didn't stop him from driving that day .
Then she thinks it's all her fault . Then the next second she feels like they could both walk through the door .
Wow , it sounds like Joanna is really having a difficult time . From what you described , she's likely suffering from prolonged grief disorder based on the duration , it's been more than 12 months since her husband and infant died and functional impairment . She can't go back to work Now . Let's contrast this with uncomplicated bereavement .
Well , with uncomplicated bereavement or normal grief , the intense sadness and longing tend to gradually subside after the loss . So the grieving person slowly starts to adjust to life without the deceased , returns to their usual activities and establishes a new identity .
Okay , Well , let's take the example of uncomplicated bereave with Samuel , whose wife died of cancer six months ago . The first few months were extremely difficult for Samuel but with the support of friends and family , he has started to go out again . He's picked up some new hobbies and recently returned to work part-time .
He still misses his wife terribly , but is learning to adapt to this new reality .
So the critical difference is that Samuel's grief symptoms are steadily improving over time rather than persisting at a severe level . His functioning is largely intact , unlike Joanna , who remains completely debilitated .
That's an excellent point , Stacey . The duration and intensity of symptoms release the critical distinguishing factor . Prolonged grief will require clinical intervention .
Absolutely Left untreated prolonged grief disorders associated with adverse health outcomes , like depression , substance abuse and even suicidal ideation . That's why it's really , really important for therapists to recognize the signs and provide appropriate support .
Okay , let me ask you a question . When my grandfather , who was a minister , died , my father told us that my grandfather would be coming back anytime soon with Jesus and Moses at his side .
Okay , how long did that last ?
It's been a while since my grandfather passed , but I'd say it seemed to last for a few months and then somehow we didn't hear about it anymore .
Okay , well , it sounds a little bit like brief psychotic disorder . That disorder involves a short-term breakdown in a person's connection to reality . It's often brought on by significant stress In this case , maybe your grandfather's passing .
Right .
And symptoms like delusions arise suddenly , but tend to resolve within one month . Of course , before you make this diagnosis , it's really important to take the person's cultural and religious background into consideration when determining whether the belief is delusional .
Okay . Well what about prolonged grief disorder ?
Well , psychotic symptoms can occur with prolonged grief disorder , but that's not part of the diagnostic criteria . You may see it , but it's not required to make the diagnosis . And at any rate , the duration of your dad's belief or delusion didn't last long enough to qualify for a diagnosis of prolonged grief disorder .
And you didn't mention any other symptoms , so it sounds like it was just one symptom related to grief that you know resolved itself .
Okay , well , thanks , stacey . How about a wrap up ?
Sure , All right . Prolonged grief disorder involves an intense yearning for the deceased , preoccupation with the loss and significant impairment in functioning that , for adults , persists beyond 12 months after the death , or , for children and adolescents , six months after the death .
Several symptoms must be present most days , including trouble accepting the death , avoidance of reminders , overwhelming emotions , difficulty reengaging in life , emotional numbness , a loss of purpose and profound loneliness due to the absence .
In contrast , uncomplicated bereavement is characterized by sadness that gradually subsides over time as the grieving person adjusts to life without the deceased and functioning largely remains intact . The duration and severity of symptoms are the critical factors in distinguishing between normal grief and pathological grief that requires clinical intervention .
Mm-hmm . Well , thanks for tuning in today . Everybody , Join us next time as we tackle another tricky diagnosis . It's in there .