Grief and prolonged grief disorder — criteria, differential and CGT plan (MEQ)

(i) Formulation and systems. Working diagnosis: prolonged grief disorder (DSM-5-TR). Death of a close person more than 12 months ago (16 months); daily intense yearning and preoccupation; additional symptoms including identity disruption, avoidance of reminders, difficulty reintegrating socially/occupationally, and emotional pain; clinically significant impairment; reaction exceeds typical cultural expectation for this timeframe and severity. Note ICD-11 would already have been duration-eligible after more than 6 months with longing/preoccupation, intense emotional pain, cultural excess, and impairment — name the system when quoting numbers.[3][4]

(ii) Differentials. Versus adaptive grief: persistence beyond 12 months with stalled restoration, pervasive avoidance, and impairment argue clinical PGD rather than expected mourning alone.[3][5] Versus MDD: yearning and person-linked preoccupation dominate; he denies pervasive anhedonia outside the loss narrative and global worthlessness; PHQ-9 11 warrants monitoring but full MDE not clearly established — recheck neurovegetative load, diurnal pattern, and pervasiveness at each review. Remember DSM-5 removed the bereavement exclusion: if full MDD criteria emerge, diagnose and treat MDD as well.[4][6] Also screen PTSD clusters about the crash itself (intrusions of the collision/notification) versus separation distress about the daughter.

(iii) Risk. Expand "be with her" language: frequency, intent, plan, means, preparatory acts, prior attempts, hopelessness, impulsivity, alcohol disinhibition, protective factors (partner, other children, work). Safety plan, means advice, crisis contacts, early review. Child-loss and traumatic death elevate complicated grief and risk vigilance needs.[4]

(iv) Treatment. First-line: grief-focused psychotherapy — Complicated Grief Treatment or grief-focused CBT. Name ingredients: psychoeducation on dual-process oscillation; aspirational goals for a life of meaning; revisiting the story of the death; imaginal conversation/adaptive continuing bonds; graded exposure to avoided road/photos; behavioural activation and social re-engagement; work on guilt/self-blame. Landmark RCT evidence supports CGT over IPT; optimising trial informs combination questions with citalopram when depression is present.[1][2][5] Antidepressant not automatic for pure PGD. If full MDD evolves or severe depressive comorbidity blocks therapy: example sertraline 25–50 mg orally each morning, review 1–2 weeks for activation/suicidality, titrate as tolerated, serial PHQ-9 and grief scale, several weeks at therapeutic dose. Reduce alcohol with motivational approach.[2][4]

(v) Culture and alcohol. Explore family mourning practices, religious meaning, anniversary rituals; do not shame continuing bonds. Alcohol is a maintaining factor for mood, sleep, and risk — set reduction goals and monitor withdrawal if heavy. Involve partner with consent; consider bereavement peer support alongside structured therapy.[4][5]