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What Is Complicated Grief — and When Is It Prolonged Grief Disorder

By Markham HeidMedically Reviewed by Allison Young, MDReviewed: April 5, 2022Medically ReviewedComplicated grief is grief that continues for an extended period of time and interferes with day-to-day functioning.Getty ImagesFour years after her husband’s death, a 68-year-old woman visits her doctor because she’s having trouble sleeping. While talking with her doctor, the woman reveals that she’s been sleeping on her couch because sleeping in the bed she and her husband shared makes her miss him too much. She still blames herself and her husband’s medical team for his death, and she thinks about him “constantly” — often wishing to die so that she can be with him again.The woman’s experiences are detailed in a 2015 article in The New England Journal of Medicine, which explains what complicated grief is and how it should be managed. Complicated grief is defined as grief that is “unusually severe and prolonged” and impairs a person’s ability to live a normal life, according to the article.Psychologists estimate that approximately 10 to 20 percent of people who are grieving will develop complicated grief, according to another review on the topic. more on Grief

All About Grief What Causes It How to Cope With It and When to Get Help

“Complicated grief is now called ‘prolonged grief disorder,’” says M. Katherine Shear, MD, the author of the study in The New England Journal of Medicine and the Marion E. Kenworthy professor of psychiatry at Columbia University in New York, who studies grief and bereavement. “The difference between normal or healthy grief and prolonged grief is related to whether certain defensive responses that are a normal part of early grief become persistent and overly influential in mental functioning.”Grief, briefly defined, is the emotional reaction a person has following a loss. During the weeks and months following a loss — such as the death of a spouse or parent — almost any reaction is considered “normal.” But at a certain point, if the grief continues to interfere with a person’s life, it may be considered a diagnosable disorder.RELATED: How 2 Caregivers Are Coping With Losing a Loved One During the COVID-19 Pandemic

What Is Complicated Grief Prolonged Grief Disorder by Definition

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Based in large part on Dr. Shear’s work with people who have experienced complicated grief (Shear is also the founding director of the Center for Complicated Grief at Columbia School of Social Work), in March 2022 prolonged grief disorder was added to the next update of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, or DSM-5-TR — the formal guide that psychiatrists use to identify and diagnose mental health problems.According to the DSM-5-TR, prolonged grief disorder is defined by someone experiencing the following six criteria:
1. A death — at least 12 months ago for adults, and at least six months ago for kids — of a person who was close to the bereaved.2. Since the death, there has been a grief response characterized by one or both of the following nearly every day for at least the last month: Intense yearning or longing for the deceased personPreoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death)
3. As a result of the death, at least three of the following eight symptoms have been experienced nearly every day for at least the last month: Identity disruption (such as feeling as though part of oneself has died)Marked sense of disbelief about the deathAvoidance of reminders that the person is deadIntense emotional pain (such as anger, bitterness, or sorrow) related to the deathDifficulty with reintegration into life after the death (including problems engaging with friends, pursuing interests, or planning for the future)Emotional numbness (for example, an absence or marked reduction in the intensity of emotions, or feeling stunned) as a result of the deathFeeling that life is meaningless as a result of the deathIntense loneliness (such as feeling alone or detached from others) as a result of the death 4. The loss causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5. The duration and severity of the bereavement reaction clearly exceeds expected social, cultural, or religious norms for the individual’s culture and context. 6. The symptoms of grief are not better explained by major depressive disorder, post-traumatic stress disorder, or another mental disorder, or attributable to the physiological effects of a substance (such as medication or alcohol) or another medical condition. Shear adds that complicated grief or prolonged grief disorder is by and large defined by the extent to which grief affects someone’s life. “It’s when grief is continuing to dominate someone’s life, getting other people frustrated, and it feels like they can’t come to terms with the new reality or restore their ability to thrive,” she says. RELATED: The Top Mental Health TikTok Influencers — and Why They’re Important

Causes What Makes Grief Complicated

According to Shear’s work, some risk factors for complicated grief include: A history of mood or anxiety disordersA history of alcohol or drug abuseExperiencing multiple lossesA difficult childhood or upbringingPoor social support following a lossSerious conflicts with friends or loved onesMajor financial problems following a loss Of course, this is not a complete list. Also, the causes of complicated grief are likely multifactorial. In other words, several of these factors — along with others not mentioned here — may come together to cause complicated grief. It’s also worth pointing out that many of the criteria for prolonged grief disorder are subjective or based in part on a person’s social or cultural norms. “There is considerable cultural variation in what is regarded as ‘normal’ or ‘typical’ grief,” says Matthew Ratcliffe, PhD, professor of philosophy at the University of York in the United Kingdom, whose current research focuses on grief. He adds, however, that an extended duration of grief and an inability to accept events that have happened are often the hallmark indicators that grief may be considered “prolonged grief disorder.” RELATED: Symptoms of Depression That You Shouldn't Ignore

Managing Complicated Grief Tips for Coping

If you ask psychologists and grief counselors how they help people manage grief, the first thing you’ll hear is that it’s a highly personal and individualized process. “Experiences of grief and their course over time are highly diverse,” Dr. Ratcliffe says. Just as the experience of grief is diverse, so are the methods by which people can cope with it.That said, there is a clinically validated therapy for complicated grief — one that Shear developed. The treatment is broken down into 16 weekly sessions, and it tends to involve the following steps: Learning about grief, complicated grief, and psychotherapyKeeping a diary of one’s griefInvolving a significant other in one’s grievingWork involving interpersonal functioningWork involving one’s personal goals and self-careRevisiting the story of the death, as well as its implications and consequencesRevisiting any places and activities that one may be avoidingWorking with memories and picturesHaving an imagined conversation with the deceasedResearch in the journal Bereavement Care has found that Shear’s therapy significantly outperforms traditional psychotherapy for the treatment of complicated grief. It’s important to emphasize, once again, that experts tend not to talk about grief in terms of “normal” and “abnormal.” The term “complicated grief” doesn’t mean that someone’s method of mourning is somehow wrong. Rather, it’s an acknowledgment that some forms of grief may be especially difficult to overcome and could benefit from an expert’s attention. If you suspect that the grief you are experiencing or the grief that someone you know is experiencing may be prolonged or complicated grief — and that you or that person may benefit from professional help — seek it. Start with your therapist (if you have one) or ask your primary care provider for a recommendation. RELATED: A Psychiatrist's Guide to Finding a Mental Health Care Provider

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Editorial Sources and Fact-Checking

Shear MK. Complicated Grief. The New England Journal of Medicine. January 8, 2015.Shear MK. Complicated Grief Treatment: The Theory, Practice and Outcomes. Bereavement Care. January 1, 2010.Prigerson HG, Boelen PA, Xu J, et al. Validation of the New DSM-5-TR Criteria for Prolonged Grief Disorder and the PG-13-Revised (PG-13-R) Scale. World Psychiatry. February 2021.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). March 2022.Show LessNEWSLETTERS

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