Bereavement in later life — structured clinical viva

Working formulation: likely prolonged grief disorder 13 months after spousal death with stalled restoration and meaning collapse. Confirm DSM-5-TR criteria (adult ≥12 months, yearning/preoccupation, additional symptoms, impairment, cultural-norm judgement). Screen carefully for comorbid MDD and for culturally congruent continuing bonds versus psychosis. Family request for diazepam is the wrong default — prioritise safety, practical supports, and grief-focused psychotherapy.[1][2][6]

Nosology. Adaptive grief is expected and not a disorder. DSM-5-TR PGD: death ≥12 months ago (adults), yearning or preoccupation, ≥3 additional symptoms, impairment, exceeds cultural norms. ICD-11: more than 6 months, longing/preoccupation, intense emotional pain, exceeds norms, impairment. Name the system you are using.[2][6]

Differential. PGD = separation distress about the person. MDD = pervasive low mood/anhedonia, global worthlessness; can be diagnosed during bereavement when full criteria met. Sensing the deceased may be a continuing bond — assess insight and other psychotic features before labelling psychosis. Exclude delirium and evolving dementia with attention testing and collateral.[4][6]

Mechanisms. Dual process model: oscillation between loss-oriented and restoration-oriented coping; pathology as stuck oscillation with avoidance and failed re-engagement (bowls club, empty chair rituals).[3]

Risk. Suicide and self-neglect, alcohol, living alone, means. Widowhood elevates mood/anxiety morbidity and has broader health/mortality pathways — practical supports are clinical care.[5][8]

Treatment. First-line PGD: CGT/CBT. Shear 2014 elderly RCT — CGT superior to grief-focused IPT. Ingredients: psychoeducation, aspirational goals, revisiting death story, imaginal conversation, graded exposure, restoration activation. Optimising trial informs citalopram as adjunct for co-occurring depression, not a replacement for therapy. Avoid long-term benzodiazepines (falls, dependence, blocked grief work).[1][7]