Evidence-Based Reviews

Recognizing and treating complicated grief

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Timing and severity of symptoms can help identify this distinct syndrome



Nearly 2.5 million persons die each year in the United States.1 For the bereaved, these deaths may be among the most painful and disruptive events they will experience. In this article, we evaluate the growing body of research on complicated grief (CG)—which also has been called prolonged grief, chronic grief, traumatic grief, and pathological grief—with an emphasis on how to identify CG and distinguish it from other adaptive and maladaptive reactions to the loss of a loved one. In addition, we review empirical evidence on treating CG, including psychotherapy, pharmacotherapy, and combined treatment approaches.

The bereavement-specific syndrome we refer to as CG currently is being reviewed for possible inclusion in DSM-5 as an official diagnosis. At press time, proposals for DSM-5 included a bereavement-related adjustment disorder within the new Trauma- and Stressor-Related Disorders category, as well as a provisional diagnosis of CG entitled Persistent Complex Bereavement-Related Disorder, which, upon acceptance, would be listed in Section III.2

What is ‘normal’ grief?

Grief is highly variable across individuals and time and may range from an absence of distress to severe and persistent pain and anguish. There’s no simple definition of “normal grief.” However, as clinicians, it’s necessary to understand the range of usual reactions. We recommend 2 considerations when evaluating grief reactions.

First, be aware that grief encompasses a range of cognitions, emotions, and behaviors. It may range from a relative lack of painful thoughts and emotions to intense and disruptive sadness, loneliness, anger, guilt, intrusive thoughts, difficulty concentrating, preoccupation with loss, social withdrawal, and a sense of being overwhelmed by the loss and its consequences. In the months after a loss, bereaved individuals may look for the deceased in a crowd, speak to them, or even experience auditory or visual hallucinations of the deceased. Nonetheless, positive feelings such as relief, peace, and happiness also are common following a loss.3 Moreover, laughter and smiling when discussing a lost loved one predicts reductions in grief symptoms over time.4 Overall, grief research suggests that, far from proceeding along standard and uniform stages,5 grief is complex and comprises a broad spectrum of thoughts, feelings, and behaviors that vary within and among individuals.

Second, note that in the absence of complications, grief progresses. For those who experience elevated levels of distress, the pain and disruption of loss initially may feel overwhelming but will subside in intensity over time for most individuals.5 This is not to say that an individual will never again feel sadness or longing for the deceased; elements of grief are likely to remain. Although the trajectory of grief symptoms varies among individuals and may progress in fits and starts, over time grief becomes more intermittent, less interfering, and is balanced with a sense of interest and purpose in life.

What is CG?

As research on grief experiences has grown, there’s increasing recognition that a minority of bereaved individuals experience more extreme grief symptoms that cause substantial, persistent distress and impairment despite the passage of many months or years. Shear et al6 proposed a set of CG diagnostic criteria (Table) in which a cluster of symptoms of intense and persistent separation distress are defined as core symptoms. Similar to other psychiatric diagnoses, the symptoms must be associated with significant distress or impairment.


Proposed diagnostic criteria for complicated grief

Symptom domainCriteria
Separation distressThe patient has ≥1 of the following 4 symptoms:
1) Persistent, intense yearning or longing for the deceased
2) Frequent feelings of intense loneliness or emptiness
3) Recurrent negative thoughts about life without the deceased or recurrent urge to join the deceased
4) Preoccupying thoughts about the deceased that impair daily functioning
ThoughtsThe patient has ≥2 of the following 8 symptoms:
1) Rumination about circumstances of the death
2) Frequent disbelief or inability to accept the death
Feelings3) Persistent feeling of being shocked, stunned, or emotionally numb since the death
4) Recurrent feelings of anger or bitterness regarding the death
5) Difficulty trusting or caring about others since the loss
6) Experiencing pain or other somatic symptoms the deceased person had, hearing the voice of the deceased, or seeing the deceased person
7) Intense emotional reactions to memories of the deceased
Behaviors8) Excessive avoidance or excessive preoccupation with places, people, and things related to the deceased or death
Source: Adapted from reference 6

Assessing CG symptoms

Among those with persistent elevated distress, a CG diagnosis must be considered in the context of the individual’s social and cultural environment, time since the loss, and duration of symptoms. The hallmark symptom of CG is separation distress with a focus of cognitive, behavioral, and emotional symptoms on the loss and its consequences. CG is associated with substantial distress, functional impairment, and an increased risk for suicide. See the Box for a case study.


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