depression, eating disorder, substance abuse and the many other conditions given attention and definition as diagnoses within this psychiatric compendium of human distress. Grief itself is an entirely normal response to the loss of someone (and in a broader definition, something) to whom (or which) we are greatly attach-ed. In the context of bereavement, grief has been described as the price we pay for love and is nearly as universal as death itself. Moreover, the ability to mourn one’s losses can promote adaptation to a world crucially and irreversibly changed by the death of another. We are left to navigate shifting emotions, realign our attachment to the deceased without relinquishing it and subtly or substantially revise our own sense of purpose and identity as we make meaning of the loss, and our own lives in its wake. Nothing in this is inherently disordered. Even if it is disorderly; it is simply the normative and variegated way we reconstruct our worlds in the aftermath of bereavement.

    Except when we don’t. A large and scientifically impressive body of research across cultures documents that, for a small subset of the bereaved (perhaps 5-10 percent) very little reconstruction ensues in the months, and sometimes years, following the death of a loved one. Instead, the bereaved may find themselves adrift in a seemingly endless sea of despair, preoccupied with the circumstances of a traumatic death or corrosive and unresolved relationship issues with the deceased. They may report feelings of drowning in anguish, being lost in unfulfilled yearning, or consumed by guilt, anger or hopelessness – little of which attenuates as months meld into years.

    The real effects of this suffering are obvious enough to those close to a mourner, as they find themselves struggling interminably to show up for their partners, parent their children, maintain friendships or perform adequately in the workplace – all to an extent and duration that greatly exceeds their community’s cultural norms. When these conditions persist largely unchanged a year or more following the loss – posing documented risk of suicide, substance abuse and serious illness –both the American Psychiatric Association and the World Health Organization concur that a diagnosis of PGD may be indicated. Genuine grief may persist long beyond one-year.

    Individuals may continue to experience periodic waves of significant sadness and missing, mingled with nostalgia and gratitude for their loved one’s ongoing contribution to their life for the rest of their days. However, the constructive integration of grief into life deepens, rather than cheapens, it and we may even live with greater purpose and intention, and greater compassion for ourself and others.

    Such a pattern of growing through grief does not deny its painfulness. Instead, it takes it

as a prompt to review and revise one’s values and choices, and affirm a life that remains

significant and is still beautiful. This image of a life changed by loss has a very different

trajectory than the one captured in the DSM 5-TR. But, crucially, PGD is only one formulation

of this painful and protracted form of distress. Like all diagnoses and all abstractions, we

use to orient to life and its challenges – for example, justice, human rights, crime, chance

and freedom, – prolonged grief disorder is a social construction, no more or less “real”

than any other. 

    Granted, there is ample evidence that the relatively few bereaved people it describes suffer grave consequences, but this condition could, in other contexts, be formulated in other terms, perhaps as a crisis of meaning, a dark night of the soul, a rupture in the network of social relations or a neurological event.

    Each such construction would carry its own implications for understanding and supporting the bereaved, and none could claim absolute “validity” in a sense that invalidated the others. Stated differently, diagnoses included are useful for some purposes and not others and should be judged on the grounds of their pragmatic viability, rather than their epistemological validity, per se.

    The relevant questions therefore include in what ways might a PGD diagnosis be helpful and harmful (as all social constructions will serve some purposes and not others) and who benefits and who suffers if this social construction is adopted? These are complex issues that merit serious attention, and they do not have simple answers.

    In the case of PGD, a diagnosis could have pragmatic benefits in opening the door to relevant, professional care in many cultural and economic contexts, without requiring the rationalization of misdiagnoses – generic depression or anxiety states, for example. Specifically, a PGD concept of a mourner’s distress could highlight some of what is distinctive in incapacitating grief, focusing attention usefully on the disruption of an attachment bond and a world of meaning unique to the precipitating loss.

    But it is likely to have a downside, including empowering professional healers (and especially physicians) at the possible expense of informal caregivers and supporters and perhaps contribute to a broader western trend to construe distress in merely pharmacological terms, rather than intrinsically existential ones.

    All of this suggests that responsible and critical analysis of the impact of such discourses for good as well as ill, is called for in the years to come. None of this resolves the suffering entailed by many forms of loss, or intense, life-limiting forms of suffering in which bereaved people occasionally become stuck, often for the rest of their lives.         With or without a diagnostic label, these extreme and intractable states of suffering call for humane and informed attention from all professionals or non-professionals, who respect both the legitimacy of grief and the human capacity for resilience in the wake of tragic loss.