Skip to main content Accessibility help

Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients

  • C. Mauro (a1), M. K. Shear (a2) (a3), C. F. Reynolds (a4) (a5), N. M. Simon (a6) (a7), S. Zisook (a8) (a9), N. Skritskaya (a2), Y. Wang (a1), B. Lebowitz (a8), N. Duan (a10), M. B. First (a11), A. Ghesquiere (a12), C. Gribbin (a2) and K. Glickman (a13)...



Persistent complex bereavement disorder (PCBD) is a protracted form of grief included in DSM Section 3 indicating a need for more research. Two other criteria sets [prolonged grief disorder (PGD) and complicated grief (CG) disorder] are also currently in use by researchers. This study evaluates rates of diagnosis of each proposed criteria set in a clinical sample of bereaved individuals participating in clinical research.


Two groups in which persistent grief was judged to be present or absent completed an assessment instrument that included items needed to diagnose PCBD as well as PGD and CG. One group included grief treatment-seeking participants in our multicenter National Institute of Mental Health (NIMH)-sponsored study who scored ⩾30 on the Inventory of Complicated Grief (ICG) and the other comprised bereaved adults enrolled in clinical research studies who scored <20 on the ICG. Rates of diagnosis were determined for proposed PCBD, PGD and CG criteria.


PCBD criteria diagnosed 70 [95% confidence interval (CI) 64.2–75.8] % of the grief treatment-seeking group, PGD criteria identified 59.6 (95% CI 53.4–65.8) % of these individuals and CG criteria identified 99.6 (95% CI 98.8–100.0) %. None of the three proposed criteria identified any cases in the bereaved comparison group.


Both proposed DSM-5 criteria for PCBD and criteria for PGD appear to be too restrictive as they failed to identify substantial numbers of treatment-seeking individuals with clinically significant levels of grief-related distress and impairment. Use of CG criteria or a similar algorithm appears to be warranted.


Corresponding author

*Address for correspondence: M. K. Shear, M.D., Columbia School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, USA. (Email: A previous presentation of this research was given at the American Psychiatric Association Annual Meeting, Toronto, Ontario, 17 May 2015.


Hide All
Bui, E, Mauro, C, Robinaugh, DJ, Skritskaya, NA, Wang, Y, Gribbin, C, Ghesquiere, A, Horenstein, A, Duan, N, Reynolds, C, Zisook, S, Simon, NM, Shear, MK (2015). The Structured Clinical Interview for Complicated Grief: reliability, validity, and exploratory factor analysis. Depression and Anxiety 32, 485492.
Cozza, SJ, Fisher, JE, Mauro, C, Zhou, J, Ortiz, CD, Skritskaya, N, Wall, MM, Fullerton, CS, Ursano, RJ, Shear, MK (2016). Performance of DSM-5 persistent complex bereavement disorder criteria in a community sample of bereaved military family members. American Journal of Psychiatry 173, 919929.
First, MB (2016). Adopting a continuous improvement model for future DSM revisions. World Psychiatry 15, 223224.
Folstein, MF, Folstein, SE, McHugh, PR (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189198.
Horowitz, MJ, Siegel, B, Holen, A, Bonanno, GA, Milbrath, C, Stinson, CH (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry 154, 904910.
Kersting, A, Brahler, E, Glaesmer, H, Wagner, B (2011). Prevalence of complicated grief in a representative population-based sample. Journal of Affective Disorders 131, 339343.
Luciano, M (2015). The ICD-11 beta draft is available online. World Psychiatry 14, 375376.
Maercker, A, Brewin, CR, Bryant, RA, Cloitre, M, Van Ommeren, M, Jones, LM, Humayan, A, Kagee, A, Llosa, AE, Rousseau, C, Somasundaram, DJ, Souza, R, Suzuki, Y, Weissbecker, I, Wessely, SC, First, MB, Reed, GM (2013). Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry 12, 198206.
Marwit, SJ (1991). DSM-III-R, grief reactions, and a call for revision. Professional Psychology: Research and Practice 22, 7579.
Meert, KL, Shear, K, Newth, CJ, Harrison, R, Berger, J, Zimmerman, J, Anand, KJ, Carcillo, J, Donaldson, AE, Dean, JM, Willson, DF, Nicholson, C, Eunice Kennedy Shriver National Institute of Child H, Human Development Collaborative Pediatric Critical Care Research N (2011). Follow-up study of complicated grief among parents eighteen months after a child's death in the pediatric intensive care unit. Journal of Palliative Medicine 14, 207214.
Mundt, JC, Marks, IM, Shear, MK, Greist, JH (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. British Journal of Psychiatry 180, 461464.
Nakajima, S, Shirai, A, Maki, S, Ishii, Y, Nagamine, M, Tatsuno, B, Konishi, S (2009). Mental health of the families of crime victims and factors related to their recovery. Seishin Shinkeigaku Zasshi 111, 423429.
Nasreddine, ZS, Phillips, NA, Bedirian, V, Charbonneau, S, Whitehead, V, Collin, I, Cummings, JL, Chertkow, H (2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society 53, 695699.
Prigerson, HG, Frank, E, Kasl, SV, Reynolds, CF III, Anderson, B, Zubenko, GS, Houck, PR, George, CJ, Kupfer, DJ (1995 a). Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry 152, 2230.
Prigerson, HG, Horowitz, MJ, Jacobs, SC, Parkes, CM, Aslan, M, Goodkin, K, Raphael, B, Marwit, SJ, Wortman, C, Neimeyer, RA, Bonanno, G, Block, SD, Kissane, D, Boelen, P, Maercker, A, Litz, BT, Johnson, JG, First, MB, Maciejewski, PK (2009). Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine 6, e1000121.
Prigerson, HG, Maciejewski, PK, Reynolds, CF III, Bierhals, AJ, Newsom, JT, Fasiczka, A, Frank, E, Doman, J, Miller, M (1995 b). Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry Research 59, 6579.
Prigerson, HG, Shear, MK, Jacobs, SC, Reynolds, CF III, Maciejewski, PK, Davidson, JR, Rosenheck, R, Pilkonis, PA, Wortman, CB, Williams, JB, Widiger, TA, Frank, E, Kupfer, DJ, Zisook, S (1999). Consensus criteria for traumatic grief. A preliminary empirical test. British Journal of Psychiatry 174, 6773.
Shear, K, Frank, E, Houck, PR, Reynolds, CF III (2005). Treatment of complicated grief: a randomized controlled trial. JAMA 293, 26012608.
Shear, KM, Jackson, CT, Essock, SM, Donahue, SA, Felton, CJ (2006). Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatric Services 57, 12911297.
Shear, MK (2015). Clinical practice. Complicated grief. New England Journal of Medicine 372, 153160.
Shear, MK, Reynolds, CF III, Simon, NM, Zisook, S, Wang, Y, Mauro, C, Duan, N, Lebowitz, B, Skritskaya, N (2016). Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry 73, 685694.
Shear, MK, Simon, N, Wall, M, Zisook, S, Neimeyer, R, Duan, N, Reynolds, C, Lebowitz, B, Sung, S, Ghesquiere, A, Gorscak, B, Clayton, P, Ito, M, Nakajima, S, Konishi, T, Melhem, N, Meert, K, Schiff, M, O'Connor, MF, First, M, Sareen, J, Bolton, J, Skritskaya, N, Mancini, AD, Keshaviah, A (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety 28, 103117.
Shear, MK, Wang, Y, Skritskaya, N, Duan, N, Mauro, C, Ghesquiere, A (2014). Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry 71, 12871295.
Simon, NM (2013). Treating complicated grief. JAMA 310, 416423.
Simon, NM, Wall, MM, Keshaviah, A, Dryman, MT, Leblanc, NJ, Shear, MK (2011). Informing the symptom profile of complicated grief. Depression and Anxiety 28, 118126.
Zisook, S, Shear, K (2009). Grief and bereavement: what psychiatrists need to know. World Psychiatry 8, 6774.


Type Description Title
Supplementary materials

Mauro supplementary material
Table S1

 Word (72 KB)
72 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed