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.
^ abcdefghShear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., et al. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and anxiety, 28(2), 103-17. doi:10.1002/da.20780.
^Bonanno GA, Wortman CB, Lehman DR, et al. Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol 2002;83:1150–1164.
^DeVaul RA, Zisook S. Psychiatry: unresolved grief. Clinical considerations. J Postgrad Med 1976;59:267–271.
^DeVaul RA, Zisook S, Faschingbauer TR. Clinical aspects of grief and bereavement. Prim Care 1979;6:391–402.
^Zisook S, Shuchter S, Schuckit M. Factors in the persistence of unresolved grief among psychiatric outpatients. Psychosomatics 1985;26:497–503.
^ abcDopson CC, Harper MB. Unresolved grief in the family. Am Fam Physician 1983;27:207–211.
^ abcShear MK, Jackson CT, Essock SM, et al. Screening for complicated grief among project liberty service recipients 18 months after september 11, 2001. Psychiatr Serv 2006;57: 1291–1297.
^ abPiper WE, McCallum M, Joyce AS, et al. Patient personality and time-limited group psychotherapy for complicated grief. Int J Group Psychother 2001;51:525–552.
^Robinson T, Marwit SJ. An investigation of the relationship of personality, coping, and grief intensity among bereaved mothers. Death Stud 2006;30:677–696.
^ abOtt CH. The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Stud 2003;27:249–272.
^ abJohnson JG, Zhang B, Greer JA, PrigersonHG. Parental control, partner dependency, and complicated grief among widowed adults in the community. J Nerv Ment Dis 2007;195:26–30.
^ abVanderwerker LC, Jacobs SC, Parkes CM, Prigerson HG. An exploration of associations between separation anxiety in childhood and complicated grief in later life. J Nerv Ment Dis 2006;194:121–123.
^Prigerson HG, Shear MK, Bierhals AJ, et al. Case histories of traumatic grief. Omega 1997;35:9–24.
^Prigerson HG, Shear MK, Frank E, et al. Traumatic grief: a case of loss-induced trauma. Am J Psychiatry 1997;154:1003–1009.
^Van Doorn C, Kasl SV, Beery LC, et al. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis 1998;186:566–573.
^ abcChiu YW, Huang CT, Yin SM, Huang YC, Chien CH, Chuang HY. Determinants of complicated grief in caregivers who cared for terminal cancer patients. Support Care Cancer 2010;18:1321–1327.
^Schulz R, Boerner K, Shear K, et al. Predictors of complicated grief among dementia caregivers: a prospective study of bereavement. Am J Geriatr Psychiatry 2006;14:650–658.
^Boerner K, Schulz R, Horowitz A. Positive aspects of caregiving and adaptation to bereavement. Psychol Aging 2004;19:668–675.
^Prigerson HG, Bierhals AJ, Kasl SV, et al. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997;154:616–623.
^Chen JH, Bierhals AJ, Prigerson HG, et al. Gender differences in the effects of bereavement-related psychological distress in health outcomes. Psychol Med 1999;29:367–380.
^Boelen PA, Prigerson HG. The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study. Eur Arch Psychiatry Clin Neurosci 2007;257:444–452.
^Ott CH, Lueger RJ, Kelber ST, Prigerson HG. Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics. J Nerv Ment Dis 2007;195: 332–341.
^Lannen PK, Wolfe J, Prigerson HG, et al. Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later. J Clin Oncol 2008;26:5870–5876.
^Shear K, Monk T, Houck P, et al. An attachment-based model of complicated grief including the role of avoidance. Eur Arch Psychiatry Clin Neurosci 2007;257: 453–461.
^Cruz M, Scott J, Houck P, et al. Clinical presentation and treatment outcome of african americans with complicated grief. Psychiatr Serv 2007;58:700–702.
^Zuckoff A, Shear K, Frank E, et al. Treating complicated grief and substance use disorders: a pilot study. J Subst Abuse Treat 2006;30:205–211.
^Hardison HG, Neimeyer RA, Lichstein KL. Insomnia and complicated grief symptoms in bereaved college students. Behav Sleep Med 2005;3:99–111.
^Simon NM, Pollack MH, Fischmann D, et al. Complicated grief and its correlates in patients with bipolar disorder. J Clin Psychiatry 2005;66:1105–1110.
^Maytal G, Zalta AK, Thompson E, et al. Complicated grief and impaired sleep in patients with bipolar disorder. Bipolar Disord 2007;9:913–917.
^ abGhaffari-Nejad A, Ahmadi-Mousavi M, Gandomkar M, Reihani-Kermani H. The prevalence of complicated grief among bam earthquake survivors in iran. Arch Iran Med 2007;10:525–528.
^Shear, M. K., McLaughlin, K. A., Ghesquiere, A., Gruber, M. J., Sampson, N. A., & Kessler, R. C. (2011). COMPLICATED GRIEF ASSOCIATED WITH HURRICANE KATRINA. Depression and Anxiety, 28(8), 648-657. doi:10.1002/da.20865
^Mancini A, Prati G, Black S. Self-worth mediates the effects of violent loss on ptsd symptoms. J Trauma Stress 2010, in press.
^Mitchell AM, Kim Y, Prigerson HG, Mortimer-Stephens M. Complicated grief in survivors of suicide. Crisis 2004;25:12–18.
^ abVessier-Batchen M, Douglas D. Coping and complicated grief in survivors of homicide and suicide decedents. J Forensic Nurs 2006;2:25–32.
^Melhem NM, Day N, Shear MK, et al. Traumatic grief among adolescents exposed to a peer’s suicide. Am J Psychiatry 2004; 161:1411–1416.
^Keesee NJ, Currier JM, Neimeyer RA. Predictors of grief following the death of one’s child: the contribution of finding meaning. J Clin Psychol 2008;64:1145–1163.
^Meert KL, Thurston CS, Thomas R. Parental coping and bereavement outcome after the death of a child in the pediatric intensive care unit. Pediatric Critical Care Medicine 2001;2:324–328.
^Murphy SA. The loss of a child: sudden death and extended illness perspectives. In: Stroebe M, Hansson RO, Schut H, Stroebe W, editors. Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association; 2008.
^ abTomarken A, Holland J, Schachter S, et al. Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology 2008;17:105–111.
^Anderson WG, Arnold RM, Angus DC, Bryce CL. Posttraumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med 2008;23: 1871–1876.
^Siegel MD, Hayes E, Vanderwerker LC, et al. Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008;36:1722–1728.
^Currier JM, Holland JM, Neimeyer RA. Sense-making, grief, and the experience of violent loss: toward a mediational model. Death Stud 2006;30:403–428.
^Forstmeier S, Maercker A. Comparison of two diagnostic systems for complicated grief. J Affect Disord 2007;99:203–211.
^Kersting A, Kroker K, Horstmann J, et al. Complicated grief in patients with unipolar depression. J Affect Disord 2009;118:201–204.
^Kersting A, Kroker K, Steinhard J, et al. Complicated grief after traumatic loss: a 14-month follow up study. Eur Arch Psychiatry Clin Neurosci 2007;257:437–443.
^Langner R, Maercker A. Complicated grief as a stress response disorder: evaluating diagnostic criteria in a german sample. J Psychosom Res 2005;58:235–242.
^Parkes CM. Symposium on complicated grief. OMEGA 2005–2006;52:1–7.
^Stroebe M, Schut H. Complicated grief: a conceptual analysis of the field. OMEGA 2005–2006;52:53–70.
^Morina N, Rudari V, Bleichhardt G, Prigerson HG. Prolonged grief disorder, depression, and posttraumatic stress disorder among bereaved kosovar civilian war survivors: a preliminary investigation. International Journal of Social Psychiatry 2010;56:288–297.
^Prigerson H, Ahmed I, Silverman GK, et al. Rates and risks of complicated grief among psychiatric clinic patients in karachi, pakistan. Death Stud 2002;26:781–792.
^Schaal S, Elbert T, Neuner F. Prolonged grief disorder and depression in widows due to the rwandan genocide. Omega (Westport) 2009;59:203–219.
^Laor N, Wolmer L, Kora M, et al. Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes. J Nerv Ment Dis 2002;190:824–832.
^Bonanno GA, Papa A, Lalande K, et al. Grief processing and deliberate grief avoidance: a prospective comparison of bereaved spouses and parents in the united states and the People’s Republic of China. J Consult Clin Psychol 2005;73:86–98.
^Ito M. Complicated grief among general Japanese population: validity and reliability of Brief Grief Questionnaire. Presentation World Congress of Behavioral and Cognitive Therapies, Boston, MA; 2010.
^Nakajima S, Shirai A, Maki S, et al. Mental health of the families of crime victims and factors related to their recovery. Seishin Shinkeigaku Zasshi 2009;111:423–429.
^Fujisawa D, Miyashita M, Nakajima S, Ito M, Kato M, Kim Y. Prevalence and determinants of complicated grief in general population. J Affect Disord 2010;127:352–358.
^Pasternak RE, Reynolds III CF, Schlernitzauer M, et al. Acute open-trial nortriptyline therapy of bereavement-related depression in late life. J Clin Psychiatry 1991;52:307–310.
^Reynolds 3rd CF, Miller MD, Pasternak RE, et al. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry 1999;156:202–208.
^Shear MK, Frank E, Foa E, et al. Traumatic grief treatment: a pilot study. Am J Psychiatry 2001;158:1506–1508.
^Shear K, Frank E, Houck PR, Reynolds 3rd CF. Treatment of complicated grief: a randomized controlled trial. J Am Med Assoc 2005;293:2601–2608.
^Shear, M. K. (2011). BEREAVEMENT AND THE DSM5. Omega-Journal of Death and Dying, 64(2), 101-118. doi:10.2190
^Wakefield and First, 2012 Wakefield JC, First MB. Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?. World Psychiatry 2012; 11: 3-10.
^Horwitz, A. V., & Wakefield, J. C. (2007). The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. Oxford University Press.