Persistent Complex Bereavement Disorder/ Complicated Grief: Symptoms, Causes, Diagnosis and Treatment

Complicated grief, also known as prolonged grief disorder or persistent complex bereavement disorder, is characterized by an intense, prolonged mourning process that significantly impairs daily functioning. Unlike normal grief, which gradually diminishes over time, complicated grief persists for months or even years, often marked by overwhelming sadness and an inability to accept the loss of a loved one. 

The symptoms of complicated grief include intense sorrow and longing for the deceased, persistent preoccupation with thoughts of the loss, difficulty accepting the death, and avoidance of reminders associated with the loved one. According to Mughal S et al.’s 2023 study, “Grief Reaction and Prolonged Grief Disorder,” individuals experience emotional detachment from others, feelings of bitterness or hopelessness, and a significant decline in their ability to engage in daily activities or find joy. 

Several factors contribute to the development of complicated grief. According to Eisma, M. C et al.’s 2023 study, “Adult Attachment and Prolonged Grief,” the risk factors of complicated grief include experiencing an unexpected or violent death, having a close or dependent relationship with the deceased, and lacking a support system. 

Diagnosing complicated grief is challenging due to its subjective nature. Mental health professionals consider a diagnosis when the intensity of grief remains debilitating beyond 12 months post-loss. A comprehensive evaluation is necessary to differentiate complicated grief from other mental health disorders like major depression or PTSD, which often co-occur.

Treatment for complicated grief primarily involves psychotherapy tailored specifically for this condition, often referred to as complex grief therapy. This therapeutic approach helps individuals process their emotions, develop coping strategies, and gradually integrate their loss into their lives. 

While there is limited research on pharmacological treatments specifically for complicated grief, antidepressants are prescribed if clinical depression is also present. Joanne Cacciatore from the School of Social Work, Associate Professor, Arizona State University, Phoenix, suggests that support from friends, family, and support groups will further aid individuals in navigating their grief journey.

What is Complicated Grief?

Complicated grief is a mental health condition defined by an intense, prolonged form of grief that disrupts an individual’s daily functioning and ability to move forward after a significant loss, according to a 2018  study entitled “Complicated grief” published in the Biological Sciences Journal written by Nakajima, S. et al. Unlike normal grief, which eases over time, complicated grief lasts for months or even years after the loss of a loved one. 

Symptoms include overwhelming sadness, preoccupation with the deceased, difficulty accepting the loss, and emotional numbness. Individuals experience intense yearning for the deceased and find themselves avoiding reminders of the loss or ruminating on thoughts of guilt or anger related to the death. This condition often manifests when the bereaved cannot integrate their loss into their ongoing life, leading to prolonged distress and dysfunction.

According to a 2012 study entitled “Complicated grief in late life” written by  Miller, M. D et al. and published in the Dialogues in Clinical Neuroscience Journal, complicated grief is relatively common, affecting a significant portion of those who experience bereavement. Research suggests that approximately 10-20% of bereaved individuals develop complex grief symptoms that meet clinical criteria. 

The American Psychiatric Association has recognized this condition in its DSM-5 under the term “prolonged grief disorder,” indicating its prevalence and the need for clinical attention. Factors contributing to the development of complicated grief include unexpected or traumatic deaths, close relationships with the deceased, and a lack of social support during the grieving process.

Experiencing complicated grief is distressing; individuals often describe feeling as though a part of themselves has died along with their loved one. They struggle with emptiness and meaninglessness, leading to social withdrawal and isolation. 

The emotional pain is so severe that it interferes with daily activities such as work or maintaining relationships. Many report a sense of disbelief regarding their loss and feel trapped in their grief, unable to move forward or find joy in life. This persistent emotional turmoil underscores the importance of recognizing and addressing complicated grief through appropriate therapeutic interventions.

What is the difference between normal grief and complicated grief?

The difference between normal grief and complicated grief lies in the duration and intensity of the symptoms experienced following a loss according to Zisook S et al.’s 2009 study ” Grief and Bereavement ” published in the World Psychiatry Journal. Normal grief, often called uncomplicated grief, is a natural response characterized by a range of emotional reactions such as sadness, anger, and confusion, which typically ebb and flow over time. 

This form of grief allows individuals to gradually adapt to their loss, often leading to eventual acceptance and reintegration into daily life. In contrast, complicated grief is marked by prolonged and intense mourning that persists beyond six months, significantly impairing an individual’s ability to function. Symptoms of complicated grief include persistent longing for the deceased, difficulty accepting the loss, and intrusive thoughts related to the death. 

What are the Symptoms of Complicated Grief?

The symptoms of complicated grief are intense sorrow, feelings of unworthiness, avoidance of reminders, and denial of the loss, according to Zisook S et al.’s 2017 study entitled “Complicated Grief, published in the Focus Am Psychiatr Publication.

The symptoms of complicated grief include:

• Intense sorrow: Individuals often experience overwhelming sadness and longing for the deceased, which persists long after the initial mourning period has ended. This emotional pain is debilitating and interferes with daily life.
• Feelings of unworthiness: Those suffering from complicated grief struggle with a diminished sense of self-worth, feeling as though part of them has died along with their loved one. This leads to hopelessness and a lack of meaning in life.
• Avoidance: A common symptom is the avoidance of places, people, or activities that trigger memories of the deceased. This manifests as withdrawing from social interactions or avoiding situations that remind them of their loss.
• Denial: Many individuals find it difficult to accept the reality of their loved one’s death, often exhibiting disbelief or emotional numbness. This denial prevents them from moving forward and accepting their new reality.

Recognizing these symptoms is important for seeking appropriate support and treatment, which include therapy or support groups aimed at helping individuals process their grief more healthily.

What are the Causes of Complicated Grief?

The causes of complicated grief are multifaceted, encompassing the death of a loved one, environmental factors, and inherited personality traits, according to Shear, M. K. et al.’s 2012 study titled “Grief and Mourning Gone Awry,” published in the Dialogues in Clinical Neuroscience Journal.

The death of a loved one is a primary trigger, mainly when the loss is sudden, violent, or traumatic, such as in accidents or illnesses. Such circumstances lead to intense feelings of longing and preoccupation with the deceased, making it difficult for individuals to accept the reality of their loss. 

Environmental factors, including social isolation and lack of support networks, exacerbate grief responses. Individuals who are alone or lack close relationships struggle more significantly with their grief, as they have fewer resources to process their emotions and seek help.

What are the risk factors for complicated grief?

The risk factors for complicated grief include mental health, unexpected loss, miscarriage, divorce, traumatic childhood experiences, and a history of depression, according to Zisook, S et al.’s 2009 study entitled “Grief and bereavement,” published in the World Psychiatry Journal.

The following are the risk factors of complicated grief.

• Mental Health Conditions: Individuals with a history of mood or anxiety disorders, such as depression or bipolar disorder, are at a higher risk of developing complicated grief following a loss.
• Unexpected Loss: Grief becomes complicated when the loss occurs unexpectedly, such as through suicide or accident, leading to intense feelings of shock and disbelief.
• Miscarriage: The loss of pregnancy leads to profound grief, mainly if the individual has solid hopes and emotional attachments to the unborn child, increasing the risk for complicated grief.
• Divorce: The end of a significant relationship triggers complicated grief, especially if the individual feels unresolved emotions or if the separation is contentious.
• Traumatic Childhood Experiences: Individuals who have faced trauma in childhood have unresolved emotional issues that complicate their grieving process when faced with loss.
• Past History of Depression: A prior history of depression predisposes individuals to experience prolonged and complicated grief after losing a loved one, as they struggle more with emotional regulation and coping mechanisms.

Recognizing these factors facilitates timely interventions and support for those grappling with complicated grief. 

What are the complications of complicated grief?

The complications of complicated grief include mental health, unexpected loss, miscarriage, divorce, traumatic childhood experiences, and a history of depression, according to Zisook, S., & Shear, K. (2009). In “Grief and bereavement: What psychiatrists need to know.” publsihed by World Psychiatry.

The complications of complicated grief are listed below.

• Mental Health Conditions: Individuals with a history of mood or anxiety disorders, such as depression or bipolar disorder, are at a higher risk of developing complicated grief following a loss.
• Unexpected Loss: Grief becomes complicated when the loss occurs unexpectedly, such as through suicide or accident, leading to intense feelings of shock and disbelief.
• Miscarriage: The loss of a pregnancy leads to profound grief, particularly if the individual has strong hopes and emotional attachments to the unborn child, increasing the risk for complicated grief.
• Divorce: The end of a significant relationship triggers complicated grief, especially if the individual feels unresolved emotions or if the separation is contentious.
• Traumatic Childhood Experiences: Individuals who have faced trauma in childhood have unresolved emotional issues that complicate their grieving process when faced with loss.
• Past History of Depression: A prior history of depression predisposes individuals to experience prolonged and complicated grief after losing a loved one, as they struggle more with emotional regulation and coping mechanisms.

Recognizing these factors facilitates timely interventions and support for those grappling with complicated grief. 

How is complicated grief diagnosed?

Complicated grief is diagnosed using criteria established in the DSM-5-TR, according to Eisma MC et al.’s 2023 study entitled ”Prolonged grief disorder in ICD-11 and DSM-5-TR,”  published in the Austrailian NZ Journal Psychiatry Journal. To meet the diagnostic criteria, an individual must have experienced the death of a loved one at least 12 months prior (or 6 months for children and adolescents). 

The diagnosis requires evidence of intense yearning or preoccupation with thoughts of the deceased, occurring daily for at least a month.

What are the Treatments for Complicated Grief?

The primary treatments for complicated grief are Cognitive Behavioral Therapy (CBT), Exposure Therapy, Medication, and Support Groups, as reviewed in Szuhany, K. L. et al.’s 2020 study entitled “Prolonged Grief Disorder” published in the Journal of Life Long Learning in Psychiatry. 

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy is a structured, goal-oriented psychotherapy that focuses on identifying and changing negative thought patterns and behaviors associated with grief. It typically includes techniques such as cognitive restructuring, behavioral activation, and skills training to help individuals process their loss and re-engage with life. CBT is particularly effective for complicated grief as it addresses the avoidance of reminders related to the deceased, which prolonged grief symptoms.

According to the Journal of Lifelong Learning in Psychiatry, in 2021, CBT reduces symptoms of complicated grief, and about 70% of participants experience improvement after treatment.

Exposure Therapy

Exposure therapy is a specific type of CBT that involves gradually confronting the memories and reminders of the deceased in a controlled manner. This approach helps individuals process their grief by reducing avoidance behaviors and desensitizing them to painful memories. 

The therapy includes recounting the story of the death or engaging in activities that remind them of the deceased. Evidence suggests that exposure therapy leads to better psychological outcomes for individuals with complicated grief, improving social functioning and overall quality of life.

Medication

Medication, particularly antidepressants, is prescribed to help manage co-occurring symptoms such as depression or anxiety in individuals experiencing complicated grief. While medications do not specifically target grief symptoms, they alleviate associated feelings of sadness and hopelessness, enabling individuals to engage more fully in therapeutic processes. 

Support Groups

Support groups provide a communal setting where individuals share their experiences and feelings related to their loss. These groups often foster a sense of belonging and understanding among participants who have faced similar losses. They are beneficial in combating the isolation usually felt by those experiencing complicated grief. 

 Addressing complicated grief often requires a multifaceted approach involving psychotherapy, medication, and community support to facilitate recovery and reintegration into daily life.

How do you manage complicated grief?

Managing complicated grief involves self-care and therapeutic support. Connecting with others is important; reaching out to family members and friends provides emotional support and helps alleviate feelings of isolation. Engaging in conversations about your feelings allows for shared understanding and validation, which can be incredibly healing. 

Can you prevent complicated grief?

Yes, you can prevent complicated grief, although it requires proactive measures and support, according to Wittouck C et al.’s 2011 study entitled, “The Prevention and Treatment of Complicated Grief,” published in the Clin Psychol Rev Journal. Engaging in open conversations with mental health professionals shortly after a loss helps individuals process their emotions and establish coping strategies, which mitigate the risk of developing complicated grief. Building a robust support system of family and friends is important, as social connections provide comfort and understanding during the grieving process.

How long does complicated grief last?

Complicated grief lasts at least 12 months following the death of a loved one for adults and at least 6 months for children and adolescents, according to  Shear MK, Simon N, et al. 2011 study entitled. “Complicated Grief And Related Bereavement  Issues For DSM-5. Depression and Anxiety, published in the PubMed Journal. Unlike normal grief, which tends to diminish over time, complicated grief symptoms persist indefinitely, leading to ongoing emotional distress and functional impairment. 

The American Psychiatric Association recognizes that individuals suffering from complex grief experience overwhelming feelings of sorrow and difficulty accepting the reality of their loss long after the initial mourning period has passed. Research by World Psychiatry (2009), “Grief and bereavement: what psychiatrists need to know” by Sidney ZIsook, indicates that while most bereaved individuals begin to adapt within the first six months, a significant minority, approximately 7% to 10% develop prolonged grief symptoms that warrant clinical intervention.

How is complicated grief different from depression?

Complicated grief is different from depression due to the underlying causes, according to Aoyama M et al’s 2018 study titled. “Factors associated with possible complicated grief and major depressive disorders” published in Psychoncology Journal.

Complicated grief arises precisely from the loss of a loved one and is characterized by intense, prolonged mourning that hinders recovery and the ability to resume daily life.  In contrast, major depressive disorder (MDD) is a clinical condition that occurs independently of any specific emotional trigger and is often linked to chemical imbalances in the brain.