How Much Grief is Too Much?
August 19, 2026
Overview
Prolonged Grief Disorder (PGD) was added to the DSM-5-TR in 2022. A diagnosis of PGD is deemed medically appropriate for adults experiencing certain grief symptoms for longer than a year (and for children, longer than six months) in a way that can impair social functioning. The inclusion of PGD as a mental health condition has resulted in controversy. A closer examination of grief and PGD is an important public health issue because death grief, like aging, is something that almost everyone will experience, and yet despite the negative health outcomes that can result when grief support is inadequate or nonexistent, it receives little to no attention.
In honor of National Grief Awareness Day, which seeks to de-stigmatize grief, I’d like to talk about Prolonged Grief Disorder (PGD) which was added to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) in 2022. At the time, it did not catch my attention. If it had, I would have read the debates surrounding this new diagnostic category with the seeming “objectivity” of a professional; that is, as someone possessing no lived experience with death grief. At the time, I probably would have come down on the side of the diagnostic benefits, e.g., legal protections, insurance coverage, better targeted treatments.
But that was the old me. I recently wrote about my own concerns, shared by others, that the addition of PGD contributes to the pathologization of a very basic human experience. Even so, a closer examination of grief and PGD is an important public health issue because death grief, like aging, is something that almost everyone will experience, but receives too little attention. Moreover, like debates on other diagnostic additions, there can be reasonable disagreement on this issue.
A diagnosis of PGD is deemed medically appropriate for adults experiencing certain grief symptoms for longer than a year, and for children, longer than six months, in a way that can impair social functioning. These symptoms include longing for and thoughts of the dead person almost daily for at least a month along with symptoms like feeling like a part of yourself has died, disbelief, intense “anger, bitterness, sorrow,” emotional numbness, and deep loneliness. Such symptoms should raise alarms, considering, for example, the well-known health harms of social isolation (often a companion of deep loneliness). These felt physical states can also pile up triggering other health conditions. A PGD diagnosis also requires that the intensity of symptoms “clearly exceeds social, cultural, or religious norms for the individual’s culture and context.”
Some defenders of PGD have characterized its critics into two categories. The existential critics who argue that PGD fails to recognize “grief as a foundational emotion connecting humans to love and death.” And diagnostic critics who argue that PGD reduces “universal human experiences . . . to medical categories.” Both actually raise existential questions on how to understand the experience of death grief.
One of the problems with PGD is that it provides bright-line answers to the following question: how much grief is too much? Considering that a higher risk of PGD is associated with sudden unexpected violent deaths (murder or suicide), loss of a person who one has a close relationship with (spouse, child), and the grossly disproportionate loss of a parent experienced by children of color during the COVID-19 pandemic due to structural and other forms of racism, it would be surprising if PGD symptoms (e.g., disbelief, intense anger, numbness) abated within such a short timeline (e.g., six months or a year). These are all highly traumatizing events. Are years of cycling through such emotions really abnormal, signaling a maladaptive grief experience?
Another problem is the assertion that PGD can be diagnosed by identifying symptoms that “clearly exceed[] social, cultural, or religious norms for the individual’s culture and context.” This builds in vague criteria for measuring grief, thus inviting bias and stereotyping, a well-known problem in the medical profession (particularly when people do not conform to or identify with mainstream culture).
This points to a deeper issue. PGD places the pathology on the individual instead of where it often belongs: the dominant social, cultural, and other norms imposed on grief and by extension the griever. Given the dearth of paid time off allotted in the U.S., much less designated time off to grieve, it is clear that dominant Western cultural norms provide little if any space for grief. This indicates that these norms represent the true cultural context that determines what constitutes “normal” grief. But why must grief conform to norms which are fundamentally flawed?
Studies have shown that social and cultural norms around grief are harmful and arbitrary. One analysis found that a diagnosis of PGD was not more publicly stigmatizing compared to a person experiencing PGD symptoms without a diagnosis, thus concluding that adding a PGD diagnosis did not add more stigma. One way to interpret this is that a PGD diagnosis does no harm. But another way of reading this is that it reveals that the pre-existing stigma contained in people’s expectations of what kind of grief is socially acceptable runs deep. Even people’s intentions to provide “social support” can be shaped by “perceptions of the appropriateness of the grief reaction.” Specifically, “[p]eople expect fewer grief-related symptoms and more recovery-related behavior over time; the experience of severe grief reactions more than two years after loss is a clear violation of these assumptions leading to more negative social reactions.” Vague norms about what is excessive invites harmful beliefs about when a person’s grief is “too much.”
Instead of challenging social expectations around grief, PGD adopts them into its diagnostic criteria. Getting rid of PGD as a diagnosis will not solve these problematic norms, but the issues inherent in this diagnostic framework are not minor. PGD shapes the grief experience by defining what is “normal” versus “disordered” grief against measurements that are themselves disordered. There is also the potential to downplay so-called “normal” grief, as if it is not that bad, which is untrue.
There is a benefit to PGD, which is that it calls attention to the need for better grief treatments. The problem is that treatments often require money and health insurance. Yet we are living in a time when people are rapidly losing health insurance through Medicaid’s new federally mandated disenrollmentvia wholesale cutting out of previously qualified individuals, work requirements, and onerous administrative burdens. Thus, even if better grief treatments are created, this does not prevent replicating existing health disparities due to inequitable systems.
Considering this context, what is needed to fill the gaps is for organizations to provide free services. This means expanding access to traditional treatments like free group or individual therapy to people who are un/underinsured. More creative treatments are also needed, which can include creating opportunities for connection that vary (meditation, pickleball, volleyball, sound baths, book clubs, writing clubs, free public pools). The key is to be intentional and to ensure that healing modalities are easy, cost-free, and diverse: healing can be movement, rest, talking, listening—it depends on the person, or even the day.
Public health departments already offer health services, and they can also provide grief services. They can advocate for reforms to the social determinants of health that impact grief including more paid time off, de-stigmatizing grief through policy and organizational change, educating the public on the health impacts of grief, and the health benefits of providing free services. Community partners can do the same and draw on their expertise to make these services relevant and accessible.
We must turn our attention to cultural norms that impose maladaptive restrictions on grief and replace them with adaptive healing structures. That is something that is truly in the interest of the public’s health. For some, a PGD diagnosis may be a relief. I am not arguing for a universal experience. Instead, I want to shift the conversation. Normalizing grief does not prevent creating better interventions that help people heal when, and if, they are ready.
How much grief is too much? The question we should be asking is: why is there so little room for grief? Let’s examine the underpinnings of what I’m calling, Impatient Grief Disorder (IGD)—the features of which I have sketched above: the imposition of time limits, an intolerance for grief, and the stripping away of access to health services. What does it say about our cultural context that returning to “normal” one year after a death is healthy? How much does IGD exacerbate people’s grief symptoms?
To help console grievers, Aaron Freeman offers a physicist’s explanation about what happens after death, saying “according to the law of conservation of energy, not a bit of you is gone; you are just less orderly.” Shouldn’t those that love them continue to be less orderly too? What could be more normal than that?
This article was written by April Shaw, Deputy Director, Health Equity, Network for Public Health Law. The Network promotes public health and health equity through non-partisan educational resources and technical assistance. These materials are provided solely for educational purposes and do not constitute legal advice. The Network’s provision of these materials does not create an attorney-client relationship with you or any other person and is subject to the Network’s Disclaimer. Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.