Adjustment & Grief Disorders — Viva

Q1: First principles — what is the difference between normal grief, adjustment disorder, and prolonged grief disorder? (3 min)

Examiner: A junior doctor tells you she is unsure when to diagnose "grief", when "adjustment disorder", and when "prolonged grief disorder". Take me through the three categories and the boundaries between them.

Expected answer:

• Normal grief (bereavement) is the universal, adaptive human response to the loss of a loved one. It is characterised by sadness that comes in waves, preserved self-esteem, the capacity for positive memories alongside the sadness, longing without pervasive meaninglessness, and gradual re-engagement in life over weeks to months. Most bereaved people do not need psychiatric treatment; bereavement support, education and watchful waiting are sufficient. Wittouck's 2011 meta-analysis confirms preventive interventions for uncomplicated bereavement are not effective — do not medicalise normal grief.

• Adjustment disorder (DSM-5-TR) is a maladaptive reaction to an identifiable stressor that is disproportionate to the stressor (with cultural/contextual judgement), causes functional impairment, does not meet criteria for another mental disorder (MDD, GAD, PTSD), and is not normal bereavement. Onset is within 3 months of the stressor; resolution is within 6 months of the stressor (or its consequences) ending. It is, by definition, a sub-threshold, time-limited diagnosis of exclusion. Subtypes: depressed mood, anxiety, mixed anxiety and depressed mood (commonest), disturbance of conduct, mixed disturbance of emotions and conduct, unspecified.

• Prolonged grief disorder (PGD, DSM-5-TR 302.82 / ICD-11 6B42) is the 7 to 10 percent of bereaved people whose grief becomes stuck, intense, preoccupying and disabling. Since the death (at least 12 months ago in adults, 6 months in children per DSM-5-TR; 6 months per ICD-11), the person has intense yearning/longing OR preoccupation with the deceased or the circumstances of death, plus at least 3 of identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reintegrating, emotional numbness, meaninglessness, loneliness — impairing, exceeding cultural norms, and not better explained by another disorder. The treatment is complicated grief therapy (CGT).

Follow-up: The boundaries — grief vs adjustment disorder, and grief vs PGD. The first boundary: adjustment disorder excludes normal bereavement by definition; if the stressor is the death of a loved one and the picture is grief-like, it is normal grief (or PGD if criteria are met), not adjustment disorder. The second boundary: the duration threshold (12 months DSM-5-TR adults; 6 months ICD-11) plus the symptom profile (yearning rather than waves of sadness, identity disruption, meaninglessness) distinguish PGD from normal grief.

Q2: The classic differential — grief vs major depressive disorder (3 min)

Examiner: A senior colleague says, "you can't diagnose depression in someone who is grieving — it's just grief." Reconcile that with the DSM-5, and then tell me the bedside features that distinguish the two.

Expected answer:

• The colleague is wrong under DSM-5. In 2013, DSM-5 removed the bereavement exclusion from MDD — a bereaved person who meets full MDD criteria HAS major depressive disorder and should be treated for it. Bereavement is now an aetiological context, not a competing diagnosis. (The change was controversial: critics feared over-diagnosis of normal grief as MDD, but the rationale is that withholding effective treatment from a bereaved person with MDD is itself harmful.)

• The bedside distinguishing features, reproduced verbatim:

  • Grief: sadness in waves (pangs); preserved self-esteem; positive memories alongside the sadness; longing for the deceased; guilt, when present, is focused on the deceased or the death; the capacity for pleasure in non-loss activities is preserved.
  • MDD: pervasive anhedonia across all domains; worthlessness; hopelessness; psychomotor retardation or agitation; prominent suicidal ideation not limited to the deceased; marked functional impairment.
  • A useful rule: grief comes in waves; depression is the tide that does not go out. Ask explicitly: "Between the sad moments, can you still enjoy things?" "Do you feel you are a worthwhile person?" "Is the sadness always there, or does it come and go?"

• Both can coexist. PGD and MDD are distinct syndromes but commonly co-occur (especially after the loss of a child or violent death). Diagnose and treat both.

Follow-up: What about a bereaved person who has intense yearning at 3 months — is that PGD? No — at 3 months intense yearning is entirely normal and expected. PGD requires 12 months (DSM-5-TR adults) or 6 months (ICD-11). Diagnosing PGD at 3 months pathologises normal grief.

Q3: Prolonged grief disorder — the diagnosis and its treatment (3 min)

Examiner: Take me through the diagnostic criteria for prolonged grief disorder and its first-line treatment, with the evidence.

Expected answer:

• DSM-5-TR criteria (302.82 / F43.81), reproduced verbatim. Since the death of a loved one (at least 12 months ago in adults; 6 months in children and adolescents), the person has, on more days than not, intense yearning/longing for the deceased, or intense preoccupation with the deceased or the circumstances of the death (the gateway symptom), plus at least 3 of: identity disruption; marked disbelief about the death; avoidance of reminders; intense emotional pain; difficulty with reintegration into life; emotional numbness; feeling that life is meaningless; intense loneliness — causing clinically significant distress or impairment, exceeding cultural/religious/social norms, and not better explained by another mental disorder. ICD-11 (6B42) uses a 6-month duration criterion across all ages.

• The treatment is complicated grief therapy (CGT) — a 16-session manualised individual psychotherapy developed by Katherine Shear and colleagues, organised around the Stroebe-Schut Dual Process Model. It integrates:

  • Loss-focused work — imaginal revisiting (the patient retells the story of the death in detail, repeatedly, with therapist guidance); situational revisiting (graded real-world exposure to avoided reminders); addressing maladaptive beliefs about the death, the deceased, or one's role in it.
  • Restoration-focused work — re-engagement with life: setting personal goals, rebuilding identity and roles, restoring relationships and activities, considering the future.
  • Restoration of oscillation — the therapist actively works to restore the alternating movement between loss- and restoration-orientation that has failed in PGD.

• The evidence. The HEAL trial (Shear et al., JAMA 2005) randomised 95 participants to CGT or interpersonal therapy (IPT): CGT response 51 percent vs IPT 28 percent, with the largest effect in those with comorbid depression. A subsequent three-site trial replicated this; combined CGT plus citalopram was particularly effective when comorbid depression was present. Internet-based CGT (Kersting) and brief CBT for PGD (Boelen) also have evidence.

• Pharmacotherapy. SSRIs do not treat grief itself but are first-line for comorbid MDD or anxiety. There is no evidence that an SSRI alone treats the core yearning/preoccupation of PGD. Avoid long-term benzodiazepines — they impair grief processing.

Follow-up: Why does standard CBT or IPT not work as well as CGT? Standard CBT and IPT do not target the core mechanism of PGD — the failure of oscillation between loss- and restoration-oriented coping, and the avoidance of the death narrative. CGT uses imaginal revisiting (an exposure technique borrowed from trauma therapy) to integrate the reality of the death, plus situational revisiting of avoided reminders, plus active restoration work — directly addressing the three maintaining processes identified by Boelen (failure to integrate the loss, negative appraisals, anxious avoidance).

Q4: Atypical and special presentations (3 min)

Examiner: Tell me about grief in three populations where the presentation is atypical and easy to miss — children, older adults, and patients with serious medical illness.

Expected answer:

• Children and adolescents. Children grieve behaviourally rather than verbally: regression (bedwetting, separation anxiety, clinging), behavioural disturbance (oppositionality, conduct problems, school refusal), decline in school performance, somatic complaints, and play that re-enacts the loss. Adolescents may present with irritability, risk-taking, substance use, or conduct disturbance rather than tearful sadness. Magical thinking is common — the child may believe they caused the death by wishing it or by misbehaviour; they need explicit reassurance that they are not responsible. Explain death honestly and concretely, avoiding euphemisms like "passed away" or "gone to sleep" (which young children may interpret literally and become fearful of sleep). Maintain routine; involve school; answer the same questions repeatedly (children process loss iteratively). A bereaved child is at greatest risk when the surviving parent is impaired; involve CAMHS if severe or prolonged. Adjustment disorder with disturbance of conduct is more common in boys.

• Older adults. Grief may present with somatisation (new physical complaints), cognitive complaints (the pseudodementia of depression — distinguish from true neurocognitive disorder), social withdrawal mistaken for dementia, refusal to eat or take medications, or self-neglect. The widowhood effect (increased all-cause mortality in the first 6 months, especially in men) is most visible here. Comorbid physical illness and polypharmacy complicate management — avoid TCAs (anticholinergic, falls, cardiac) and prefer sertraline for comorbid depression. Address practical supports (meals, transport, finances, social contact), sensory impairment and pain. Hearing or seeing the deceased is very common in this group and is not in itself pathological.

• Patients with serious medical illness. Anticipatory grief is common — the patient grieving the loss of function, role, future, body integrity (in oncology, dialysis, post-MI, post-stroke, post-amputation, motor-neuron disease, after an HIV or cancer diagnosis). Adjustment disorder is frequent. Address both the psychological reaction and the underlying illness; treat comorbid MDD/anxiety actively; involve the medical team; respect the patient's autonomy and pace.

Follow-up: A 70-year-old widower presents 5 days after his wife's death with collapse and chest pain at the funeral. What are you thinking? Takotsubo (stress) cardiomyopathy — "broken heart syndrome". ~90 percent female, typically post-menopausal, triggered by acute intense emotional stress. ECG: deep T-wave inversion and QT prolongation; mild troponin rise; echocardiography: apical ballooning with basal hyperkinesis; coronary angiography: no obstructive disease. Manage supportively (beta-blocker, ACE inhibitor, diuretics for heart failure); most recover within weeks. This is the most dramatic physical complication of acute bereavement.

Q5: Risks, complications and controversies (3 min)

Examiner: What are the most important complications of grief and PGD, and what is the controversy around the very existence of PGD as a diagnosis?

Expected answer:

• Complications.

  • Suicide — bereavement is an independent suicide risk factor; bereaved parents and older widowers are at highest risk; PGD itself is associated with overt suicidality independent of comorbid depression (Szanto et al., 2006). Screen every bereaved patient for suicidal ideation.
  • Progression to MDD, GAD, PTSD — adjustment disorder is a risk factor for these.
  • Substance use disorder — alcohol, sedative, opioid self-medication.
  • Takotsubo cardiomyopathy and increased cardiovascular events in the first weeks.
  • Immune suppression and increased infection/mortality in the first 6 months of widowhood.
  • Family and parenting disruption — an impaired bereaved parent is a safeguarding concern; bereaved children are themselves at risk.
  • Chronicity — untreated PGD persists for years and predicts future MDD, substance use, cardiovascular disease, reduced quality of life.

• The controversy — should PGD be a diagnosis at all?

  • Critics argue that medicalising grief pathologises a universal human experience, risks over-prescribing (especially SSRIs), and imposes a Western, time-bound framework on a culturally variable process. They point to the historic over-diagnosis of depression in the bereaved and the risk of undermining natural community and family mourning.
  • Proponents counter that the 7 to 10 percent of bereaved people with disabling, persistent symptoms unresponsive to reassurance deserve recognition, research and reimbursed, evidence-based treatment (CGT); that PGD is reliably distinguishable from normal grief and from MDD on structured assessment; and that withholding treatment from this group is its own harm.
  • The DSM-5-TR's conservative 12-month threshold (vs ICD-11's 6-month) reflects this compromise, designed to reduce false-positive diagnosis during the first year of normal grief. The requirement to compare with cultural, religious and social norms further guards against pathologising culturally normative mourning.

Follow-up: What does Wittouck's 2011 meta-analysis tell us about preventive interventions in bereavement? Preventive interventions for uncomplicated bereavement are NOT effective — universal grief counselling does not reduce rates of PGD. Only indicated interventions, delivered to those who have already developed PGD (i.e., CGT), have evidence of benefit. This is a strong argument against medicalising normal grief and for reserving specialist intervention for the ~7 to 10 percent who develop PGD.