Adjustment & Grief Disorders — SAQ

Stem

A 62-year-old man, Mr K, is brought to his GP by his daughter 14 months after the sudden death of his wife from a myocardial infarction at home. He had found her collapsed and could not resuscitate her. He describes daily, intense yearning for his wife and preoccupation with the moment of her death, which he replays constantly. He has lost 9 kg, has stopped seeing friends, has not returned to his woodworking hobby, and says "part of me died with her" and "life has no meaning anymore". He avoids going into their bedroom and avoids driving past the hospital. He retains some capacity to laugh at his granddaughter's jokes but feels emotionally numb most of the time. He has occasional passive death wishes ("I wish I could join her") but no plan or intent. He has a 20-year history of hypertension, drinks 30 units of alcohol a week (up from 10 before the death), and was started on sertraline by a locum GP 8 weeks ago with no improvement.

Questions

a) What is the most likely diagnosis? Justify your reasoning against the diagnostic criteria. (2 marks)

Prolonged grief disorder (PGD), DSM-5-TR 302.82 / ICD-11 6B42. The diagnostic criteria are met:

• It has been over 12 months since the death (DSM-5-TR adult threshold; ICD-11 requires 6 months).
• He has the gateway symptom — intense yearning/longing for the deceased, with preoccupation with the circumstances of the death.
• He has at least 3 symptom-cluster items, on most days, to a clinically significant degree: identity disruption ("part of me died with her"), intense emotional pain, difficulty reintegrating (lost friends, hobbies, weight loss), emotional numbness, avoidance of reminders (the bedroom, the hospital), and feeling that life is meaningless.
• The symptoms cause clinically significant distress and functional impairment and exceed cultural norms for bereavement.
• The picture is not better explained by MDD — he retains some capacity for pleasure (laughter), and the dominant affect is yearning rather than pervasive anhedonia. (1 mark for the diagnosis; 1 mark for justification against the criteria, including the 12-month duration and the symptom-cluster items.)

b) Distinguish this presentation from (i) normal grief and (ii) major depressive disorder (MDD). (3 marks)

(i) Normal grief vs PGD. Normal grief involves sadness that comes in waves, preserved self-esteem, and the capacity for positive memories alongside the sadness; the bereaved gradually re-engages with life over weeks to months. PGD, by contrast, is characterised by daily, intense preoccupation and yearning, identity disruption, avoidance of reminders, emotional numbness, meaninglessness, and functional impairment that persists beyond cultural norms (the 12-month DSM-5-TR / 6-month ICD-11 threshold). Mr K's daily preoccupation, identity disruption, avoidance, numbness and meaninglessness over 14 months clearly cross the PGD threshold. (1.5 marks.)

(ii) MDD vs PGD. The bedside rule: grief comes in waves; MDD is a pervasive tide. MDD is suggested by pervasive anhedonia across all domains, worthlessness, hopelessness, prominent suicidal ideation not limited to the deceased, and psychomotor retardation or agitation. Mr K retains some capacity to laugh at his granddaughter, his central affect is yearning rather than pervasive anhedonia, and his death wishes are passive and bound to joining his wife rather than reflecting global hopelessness — arguing against a primary MDD diagnosis. (Note: both can co-occur; the failure of sertraline to help also supports a primary PGD picture.) (1.5 marks.)

c) Outline your management plan for this patient. (3 marks)

1. Risk assessment. Assess suicide risk formally (passive death wishes present; alcohol is a disinhibitor and means access to lethal doses must be considered). The widower is in the highest widowhood-effect window (first 6 to 24 months). Address the alcohol use (30 units/week, doubled since the death) — motivational interviewing, brief intervention, consider community alcohol service.
2. Complicated grief therapy (CGT). The evidence-based treatment for PGD is CGT, the 16-session manualised dual-process treatment integrating loss-focused work (imaginal revisiting of the death, situational revisiting of avoided reminders — the bedroom, the hospital) with restoration-focused work (re-engagement with friends, woodworking, goals, identity). The HEAL trial (Shear, JAMA 2005) showed CGT superior to interpersonal therapy (51 percent vs 28 percent response). Refer to a clinical psychologist or specialist grief service trained in CGT.
3. Pharmacotherapy review. The sertraline started by the locum has not helped because SSRIs do not treat grief itself — they treat comorbid MDD and anxiety. Review the indication: if he does not meet MDD criteria, consider a structured taper of the sertraline while initiating CGT. If comorbid MDD is present, optimise the SSRI (sertraline titrated to 150 to 200 mg) alongside CGT. Avoid benzodiazepines long-term. (1 mark each, maximum 3.)

d) The patient asks whether he is "going mad" because he sometimes hears his wife's voice calling his name. How do you respond, and what is the clinical significance of this symptom? (2 marks)

Reassure him clearly: hearing or briefly seeing the deceased is common in normal grief and in PGD, and is not in itself a sign of psychosis or "going mad". Across cultures, sensory experiences of the deceased are reported by a substantial minority of bereaved people and are usually comforting. The symptom becomes clinically concerning (suggesting a psychotic disorder) only when it is frightening, persecutory, command in nature, complex or multimodal, accompanied by delusional beliefs, or occurring in a patient with a pre-existing psychotic history. Validate his experience, explain its normalcy, and use it as a point of engagement in CGT — the voice is part of his continuing bond with his wife, which CGT aims to integrate, not sever. (1 mark for reassurance and explanation of normalcy; 1 mark for the features that would suggest a true psychotic disorder.)