Evidence-Based Reviews

Recognizing and treating complicated grief

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Many individuals with CG remain undiagnosed and untreated for years despite high levels of distress and impairment and high risk for negative consequences such as suicide.7 Accordingly, there’s a need for greater CG screening. Clinically useful tools for assessing CG include a brief, 5-item dimensional screening assessment6 and the patient-rated Inventory of Complicated Grief.8

Distinguishing complicated and uncomplicated grief. Exhibiting CG symptoms in the first several months after a loss does not mean an individual has or will develop CG. Most bereaved adults report painful thoughts and emotions in the weeks and months following the loss, including distressed yearning, waves of intense grief, persistent and intrusive thoughts, images related to the death, somatic distress, and a feeling of being disconnected from others. For most individuals, the intensity of this response diminishes within 6 to 18 months after the loved one’s death.5 Although the optimal length of time to wait before establishing a diagnosis remains debatable, the earliest CG should be diagnosed is 6 months after a loss.

It’s common for grief to occasionally rise in intensity for days or weeks. This surge may occur many months or years after the loss, even in people who exhibited relatively little distress or impairment. In particular, anniversaries, holidays, or periods of stress may trigger increased grief intensity. However, these surges typically subside naturally within a short time. Accordingly, CG should be diagnosed only when symptoms persist for >1 month.

CG vs other post-loss disorders. CG, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) often are comorbid in bereaved adults. Simon et al9 found 72% of CG patients in a treatment- seeking sample reported a lifetime history of MDD and 53% reported a lifetime history of PTSD. However, CG can be distinguished from these disorders. In the same study, 25% of CG patients had no other axis I diagnosis.9 After accounting for comorbid disorders, researchers associated CG severity with work and social impairment. These findings provide clear evidence for the incremental validity of CG—ie, a CG diagnosis gives clinicians additional information that predicts impairment above and beyond other disorders. However, future research needs to further examine CG and its overlap and differentiation from MDD and PTSD.

Distinguishing CG and MDD. Intense yearning or preoccupation with the deceased is a common symptom of CG but not MDD. In addition, CG symptoms possess intentionality. For example, emotional distress such as sadness and anger are prominent features of both CG and MDD. However, in CG, these symptoms are specific to the loss or circumstances of the loss, whereas in MDD they generally are more nebulous and generalized. Similarly, CG entails proximity seeking related to the deceased, and avoidance of reminders of the deceased, whereas MDD includes a more general social withdrawal and anhedonia.

Distinguishing CG and PTSD. CG and loss-related PTSD are distinguished by the predominant emotions and focus of concern associated with each disorder. The predominant emotion in PTSD is fear, whereas in CG it is sadness and longing. In PTSD, intrusive thoughts and memories associated with the trauma generally are associated with the event itself and produce an ongoing sense of threat.10 Avoidance in PTSD is intended to reduce this threat feeling. By contrast, in CG, intrusive memories focus on the deceased or the circumstances of the death, and avoidance is aimed at preventing painful reminders of the loss or its permanence. Importantly, both syndromes may be present.

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Unable to move on: A case study of complicated grief

Mr. C, age 67, presents to a local emergency department (ED) with his daughter. His daughter reports that he has not been himself since his wife died in a car accident 2 years ago. He continues to live in the house he shared with his wife, despite not needing the extra space and being unable to maintain it. Although Mr. C and his daughter used to talk about her mother a great deal, she says she now tries to avoid the subject because it upsets him. More recently she became concerned when Mr. C began to tell her that his life was meaningless without his wife. He said he frequently thinks about taking his own life to end his pain and loneliness.

Mr. C tells the ED psychiatrist he feels an intense wave of grief and loneliness every morning when he realizes his wife is not with him. He often stays in bed for hours, longing for her and thinking about their time together. At times, he thinks he hears her voice downstairs but when he searches for her, she is not there. Mr. C has been unable to go through his wife’s belongings, and feels nothing should be moved in their home. He will look at her photos, yet avoids other reminders of her (eg, partaking in their favorite hobbies, going to their favorite restaurants). He feels bitter and angry about his wife’s death, and becomes agitated when describing the car accident that took her life. Mr. C feels guilty for not being with his wife when she died. He assures the psychiatrist that he loves his children, but says he feels increasingly distant from them and doesn’t understand how they can move on after their mother’s death.

Mr. C reports symptoms consistent with a diagnosis of complicated grief. Further assessment is appropriate to determine if his symptoms are severe enough to warrant treatment.

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