Complicated grief is considered when an individual’s ability to resume normal activities and responsibilities is continually disrupted beyond six months of bereavement. Six months is considered to be the appropriate point of CGD consideration, since studies show that most people are able to integrate bereavement into their lives by this time.
The symptoms of complicated grief are mentioned in the most-recently-proposed diagnostic criteria; they include maladaptive thoughts and behaviors related to the death or the deceased, continuous emotional dysregulation about the death, social isolation and suicidal ideation.
Causes and predictors
Although more research is needed to determine the multiple pathways to complicated grief disorder, preexisting conditions (such as major depression, PTSD, and sleep disorders) are thought to exacerbate the interruption of the natural healing process.
There are some known predictive characteristics for CGD. An individual is at risk for CGD if they are:
The person has been bereaved (i.e. experienced the death of a loved one) for at least six months
At least one of the following symptoms of persistent, intense, acute grief has been present for a period longer than is expected by others in the person’s social (or cultural) environment:
Persistent intense yearning or longing for the person who died
Frequent intense feelings of loneliness, or that life is empty or meaningless without the person who died
Recurrent thoughts that it is unfair, meaningless or unbearable to live when a loved one has died, or a recurrent urge to die in order to find (or join) the deceased
Frequent preoccupying thoughts about the person who died; e.g. thoughts or images of the person intrude on activities or interfere with functioning
At least two of the following symptoms are present for at least one month:
Frequent, troubling rumination about the circumstances (or consequences) of the death (concerns about how or why the person died, about not being able to manage without their loved one, thoughts of having let the deceased person down, etc.)
Recurrent feeling of disbelief or inability to accept the death
Persistent feeling of shock; feeling stunned, dazed or emotionally numb since the death
Recurrent feelings of anger or bitterness related to the death
Persistent difficulty trusting or caring about other people, or envy of others who have not experienced a similar loss
Frequently experiencing pain (or other symptoms) that the deceased person had, hearing the voice of (or seeing) the deceased person
Experiencing intense emotional or physiological reactivity to memories of the person who died or to reminders of the loss
Changes in behavior due to avoidance (or its opposite, excessive proximity-seeking—refraining from going places, doing things, or having contact with things that are reminders of the loss; feeling drawn to reminders of the person—wanting to see, touch, hear or smell things to feel close to the person who died). Both symptoms may coexist in the same individual.
Duration of symptoms and impairment of at least one month
Symptoms cause clinically significant distress or impairment in social, occupational or other major areas of functioning, where impairment is not explicable as a culturally appropriate response
CGD is relatively unresponsive to antidepressants or interpersonal psychotherapy; however, recent studies support the use of CG-targeted psychotherapy (similar to PTSD-targeted psychotherapy). Other methods of psycho-pharmacological treatment are under investigation.
CGD and bereavement-related adjustment disorder
Although the DSM-5 work groups have suggested using "adjustment disorder, specified as bereavement-related" to diagnose complicated grief, opposing opinions contend that this does not fit the nature of CGD and is an inappropriate diagnosis for those suffering from CGD.
Medicalizing (or misdiagnosing) normal grief
Following the DSM-5 work groups’ recommendation to remove the bereavement-exclusionary criteria, there is some concern that the addition of CGD may increase the possibility of medicalizing the grieving process. However, proponents of CGD claim that with proper clinical assessment only those with abnormally incapacitating levels of grief will receive this diagnosis and benefit from treatment. Furthermore, despite the possibility of diagnosis-related stigma the clinical necessity for treatment is a priority for those suffering from CGD.
Cultural norms for grief
An individual’s culture plays a large role in determining an inappropriate pattern of grief, and it is necessary to consider cultural norms before reaching a CGD diagnosis. There are cultural differences in expected emotional levels, their expression and duration; the external symptoms of grief differ in non-Western cultures, presenting increased somatization.
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