The recent addition of prolonged grief disorder (PGD) to the ICD-11 and the DSM-5-TR has brought changes in what many mental health experts consider to be best practice in bereavement care. Because PGD is newly recognized as an official mental disorder, clinicians may be unfamiliar with current approaches to its detection, diagnosis and treatment. Here we provide answers to common questions that have arisen regarding: a) the settings in which clinicians are likely to encounter a person meeting criteria for PGD; b) who typically initiates help-seeking and the receptivity of those with PGD to treatment from mental health professionals; c) how to distinguish PGD from typical grief as well as from major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) secondary to bereavement; d) implications of diagnostic criteria for treatment; and e) how to apply criteria to ensure their cross-cultural sensitivity and validity.

Where might clinicians encounter someone who might be diagnosed with PGD? Although the age of the mourner has proven inversely associated with PGD risk, older adults are more likely to experience the death of a spouse or partner – a kinship relationship to the deceased person posing elevated PGD risk¹. Therefore, geriatricians serve populations at high risk for PGD. Moreover, due to a high concentration of deaths, nursing homes, assisted living facilities, cancer clinics, hospices and palliative care services, hospitals (particularly intensive care units), war zones, and places where natural or man-made disasters occur, are settings in which clinicians are likely to encounter persons – surviving family and friends – at elevated risk of PGD.

Counter to the claim that those who meet criteria for PGD are uninterested in treatment, our research revealed that 100% of the bereaved respondents who met criteria for PGD indicated that they would be interested in receiving treatment for it². However, though they might be interested in treatment, few bereaved individuals with PGD actually seek help³. In a study of bereaved caregivers of patients who died of cancer, we found that, despite 71% of caregivers with PGD reporting increased suicidality, only 43% reported accessing mental health services following the patient's death – a rate significantly below those for bereaved study participants diagnosed with MDD or PTSD³.

Anecdotally, our Cornell Center for Research on End-of-Life Care is frequently contacted by concerned family members seeking treatment for someone whom they believe has PGD. These people typically describe a situation in which their bereaved family member has struggled with grief for many years, been diagnosed with MDD or PTSD, and received treatment for those disorders to no avail. Such experiences are consistent with results which prompted our initial interest in grief – findings from a randomized controlled trial demonstrating that an antidepressant (i.e., nortriptyline) alone and together with psychotherapy addressing role transitions (i.e., interpersonal psychotherapy), while effective for symptoms of late-life bereavement-related depression, did not prove effective for the resolution of grief symptoms⁴. These findings highlight the need to distinguish PGD from MDD among mourners, and to identify effective treatments for the reduction of symptoms of distressing and disabling grief. Currently, many psychotherapeutic interventions, particularly cognitive behavioral therapies (CBTs)⁵, have proven efficacious for reducing PGD symptoms.

How can a clinician determine whether a bereaved person's grief response is ordinary or pathological? Diagnostic criteria for PGD found in the ICD-11 or DSM-5-TR require responses that, while seemingly normal, at severe levels and after six or twelve months from the loss (depending on whether ICD-11 or DSM-5-TR criteria are applied), identify mourners at risk of enduring distress and dysfunction. Missing the deceased person and loss of interest in socializing and concentration at work are not abnormal in the initial months following a significant interpersonal loss. Beyond the first anniversary of the death, however, it is surprisingly rare (4-15%⁶) for bereaved individuals to yearn intensely for the deceased person throughout the day (a preoccupation with thoughts of the deceased making it difficult to focus and engage in usual activities); feel disturbingly detached from others; be agonizingly alone; and lack a sense of meaning, purpose and identity without the deceased person. Individuals who survive a significant other's death from natural causes who exhibit these thoughts and feelings beyond the first anniversary of the death should be evaluated for PGD.

Differences between PGD and MDD focus on the distinction between the deceased person-specific trigger in PGD versus a generalized sense of sadness and pessimism about present and future outcomes in MDD. Yearning for the deceased person is specific to PGD and is not present in MDD (nor PTSD). In PTSD, avoidance is focused on fear of a life-threatening event either to oneself or a significant other and helplessness to prevent harm. In PGD, avoidance is focused on disbelief and lack of emotional and cognitive acceptance of the fact that the loved one has died.

Because the core symptom in PGD is yearning, there are similarities with diagnostic criteria for addictive disorders. For example, PGD symptoms of yearning, anger, and protest of separation from the source of reward resemble the craving and withdrawal symptoms of substance use disorder. These similarities suggest that persons at risk of PGD are those for whom the deceased person was a primary source of love, support, security, identity and validation; that is, a source of psychological reward. They also suggest that interventions – both psychosocial and pharmacological – which blunt reward derived from the deceased person (e.g., naltrexone) might reduce yearning and promote an openness to interacting with living others who might fill social voids, thereby reducing symptoms of PGD and promoting bereavement adjustment more broadly⁷.

Lastly, while we consider grief a universal human (but not uniquely human, given evidence of its presence in other mammalian species – e.g., elephants, monkeys, voles) response to separation from a significant other, we also acknowledge important cultural influences on the form that grief responses take. What may be considered normal or expected in one culture (e.g., prohibitions on dating or dress) may be regarded as abnormal in another. Linguistic differences may affect the ability to assess symptoms (e.g., if a language has no words or imperfect synonyms for the PGD criteria). The ICD-11 and DSM-5-TR note a “cultural caveat” whereby judgments about normal versus pathological grief reactions are considered within the mourner's cultural context⁸.

The Grief and Bereavement Cultural interview⁹ has been developed to assist clinicians in factoring in the role of culture in making a PGD diagnosis. Statistical techniques such as item response theory can be used to determine which items provide the most unbiased information with respect to an underlying grief “attribute” within a specific culture or language. Both clinical and data analytic techniques should be employed to ensure cross-cultural reliability and precision in the application of the PGD criteria.

In conclusion, PGD is a new mental disorder that clinicians may not know how to detect, diagnose or treat. We have briefly addressed some of the most common questions asked by clinicians about assessing PGD, and offered guidelines for intervening to ensure consistency with current best practices in bereavement care.

最近，ICD-11 和 DSM-5-TR 中增加了长期悲伤障碍 (PGD)，这给许多心理健康专家认为的丧亲护理最佳实践带来了变化。由于 PGD 被新近认定为一种官方精神障碍，临床医生可能不熟悉当前的检测、诊断和治疗方法。在这里，我们提供了以下常见问题的答案：a) 临床医生可能会遇到符合 PGD 标准的人的环境； b) 谁通常主动寻求帮助，以及PGD患者对心理健康专业人员治疗的接受程度； c) 如何将 PGD 与典型的悲伤以及继发于丧亲之痛的重度抑郁症 (MDD) 和创伤后应激障碍 (PTSD) 区分开来； d) 诊断标准对治疗的影响； e) 如何应用标准来确保其跨文化敏感性和有效性。

临床医生可能会在哪里遇到可能被诊断为 PGD 的人？虽然哀悼者的年龄已被证明与 PGD 风险呈负相关，但老年人更有可能经历配偶或伴侣的死亡——与死者的亲属关系会导致较高的 PGD 风险¹ 。因此，老年科医生为PGD高危人群提供服务。此外，由于死亡人数集中，疗养院、辅助生活设施、癌症诊所、临终关怀和姑息治疗服务、医院（特别是重症监护病房）、战区以及发生自然或人为灾害的地方都是设置场所其中临床医生可能会遇到 PGD 风险较高的人（幸存的家人和朋友）。

与“符合 PGD 标准的人对治疗不感兴趣”的说法相反，我们的研究显示，100% 符合 PGD 标准的丧亲者受访者表示他们有兴趣接受治疗² 。然而，尽管他们可能对治疗感兴趣，但很少有患有 PGD 的丧亲者真正寻求帮助³ 。在一项针对癌症死亡患者家属的护理人员的研究中，我们发现，尽管接受 PGD 的护理人员中 71% 的人自杀倾向有所增加，但只有 43% 的人员表示在患者死亡后接受了心理健康服务——这一比例明显低于丧亲人员的研究参与者诊断患有 MDD 或 PTSD ³ 。

有趣的是，我们的康奈尔临终关怀研究中心经常有相关的家庭成员联系，为他们认为患有 PGD 的人寻求治疗。这些人通常会描述这样一种情况：他们的失去亲人的家庭成员多年来一直在悲伤中挣扎，被诊断患有抑郁症或创伤后应激障碍，并接受了这些疾病的治疗但无济于事。这些经历与促使我们最初对悲伤产生兴趣的结果一致——一项随机对照试验的结果表明，单独使用抗抑郁药（即去甲替林）并与解决角色转换的心理治疗（即人际心理治疗）一起使用，同时对晚期症状有效。 -生活中与丧亲之痛相关的抑郁症，并未被证明对解决悲伤症状有效⁴ 。这些发现凸显了在哀悼者中区分 PGD 和 MDD 的必要性，并确定有效的治疗方法来减少令人痛苦和丧失能力的悲伤症状。目前，许多心理治疗干预措施，特别是认知行为疗法 (CBT) ⁵已被证明可有效减少 PGD 症状。

临床医生如何确定失去亲人的人的悲伤反应是正常的还是病态的？ ICD-11 或 DSM-5-TR 中发现的 PGD 诊断标准要求反应虽然看似正常，但在丧失后 6 或 12 个月后达到严重水平（取决于 ICD-11 或 DSM-5-TR 标准）被应用），识别有遭受持久痛苦和功能障碍风险的哀悼者。在严重的人际关系丧失后的最初几个月里，思念死者、失去社交兴趣和工作注意力都不是异常现象。然而，在死亡一周年之后，令人惊讶的是，失去亲人的人很少^会整天强烈地思念死者（全神贯注于对死者的思念，因此很难集中注意力并参与其中）日常活动）；感到与他人的疏离感令人不安；孤独得令人痛苦；在没有死者的情况下缺乏意义、目的和身份感。对于重要他人因自然原因死亡而幸存的个人，如果在死亡一周年之后仍表现出这些想法和感受，则应接受 PGD 评估。

PGD​​ 和 MDD 之间的差异集中于 PGD 中死者特定触发因素与 MDD 中对当前和未来结果的普遍悲伤和悲观感之间的区别。对死者的思念是 PGD 特有的，MDD（或 PTSD）中不存在。在创伤后应激障碍（PTSD）中，回避集中于对自己或重要他人面临生命威胁的事件的恐惧以及对防止伤害的无助。在 PGD 中，回避主要集中在对亲人去世这一事实的怀疑以及缺乏情感和认知上的接受。

由于PGD的核心症状是渴望，因此与成瘾性疾病的诊断标准有相似之处。例如，PGD 的渴望、愤怒和对与奖励来源分离的抗议的症状类似于物质使用障碍的渴望和戒断症状。这些相似之处表明，对于那些将死者视为爱、支持、安全感、身份和认可的主要来源的人来说，面临 PGD 风险的人；也就是说，心理奖励的来源。他们还建议，通过心理社会和药物干预来削弱死者的奖励（例如纳曲酮），可能会减少渴望并促进与可能填补社会空白的活着的人互动的开放性，从而减少PGD症状并促进丧亲之痛。更广泛的调整⁷ ．

最后，虽然我们认为悲伤是一种普遍的人类（但不是唯一的人类，因为有证据表明悲伤也存在于其他哺乳动物物种中——例如大象、猴子、田鼠）对与重要他人分离的反应，但我们也承认文化对其形式的重要影响悲伤的反应。在一种文化中可能被视为正常或预期的事情（例如，约会或着装的禁令）在另一种文化中可能被视为异常。语言差异可能会影响评估症状的能力（例如，如果一种语言没有适合 PGD 标准的单词或同义词）。 ICD-11 和 DSM-5-TR 指出了一个“文化警告”，即在哀悼者的文化背景下考虑对正常与病理性悲伤反应的判断⁸ 。

悲伤和丧亲文化访谈⁹旨在帮助临床医生在进行 PGD 诊断时考虑文化的作用。项目反应理论等统计技术可用于确定哪些项目提供了有关特定文化或语言中潜在悲伤“属性”的最公正的信息。应采用临床和数据分析技术来确保 PGD 标准应用的跨文化可靠性和精确度。

总之，PGD 是一种临床医生可能不知道如何检测、诊断或治疗的新型精神障碍。我们简要回答了临床医生提出的有关评估 PGD 的一些最常见问题，并提供了干预指南，以确保与当前丧亲护理的最佳实践保持一致。