Without you in my arms, I feel an emptiness in my soul. I find myself searching the crowds for your face. I know it’s an impossibility, but I cannot help myself. — Nicholas Sparks
Grief is an emotional response to the loss of someone or something that is important to us. It is a natural and expected process that we all experience at some point in our lives. However, not all grief is the same. Some individuals may experience what is known as complicated grief, a condition where the grieving process becomes prolonged and debilitating. It is estimated that 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder (Szuhany et al., 2021).
Grief
Grief is a universal and normal human response to the loss of someone or something that is important to us. According to Kübler-Ross’s (1969) five-stage model, the grieving process typically involves denial, anger, bargaining, depression, and acceptance. However, it is important to note that not everyone experiences these stages in the same order or to the same degree. The duration and intensity of grief also vary from person to person and can last for weeks, months, or even years.
Complicated Grief
Complicated grief is a condition in which the grieving process becomes prolonged and debilitating. It is characterized by intense and persistent feelings of longing, yearning, and sadness for the deceased. Complicated grief is often associated with difficulty accepting the loss, preoccupation with the deceased, and a sense of disbelief or anger. Symptoms of complicated grief may include feelings of emptiness or numbness, difficulty sleeping or eating, and a loss of interest in everyday activities (Shear et al., 2011).
Causes of Complicated Grief
Complicated grief is a relatively new concept in the field of psychology, and researchers are still exploring the factors that contribute to its development. Research suggests complicated grief is associated with several risk factors, including the nature of the loss, the individual’s attachment style, and the availability of social support. Additional factors that influence the course of the grief process include the nature of the relationship with the deceased, the circumstances of the death, and the individual’s coping mechanisms (Hawton, 2007; Shear et al., 2011).
Specifically, individuals who experience a sudden or traumatic loss of a loved one through suicide, homicide, or other traumatic events may be at greater risk of developing complicated grief. Similarly, individuals who had a close and dependent relationship with the deceased or who have an insecure attachment style may also be at greater risk (Prigerson et al., 2009). Additionally, individuals who have a history of depression and anxiety or who lack social support may be more vulnerable to complicated grief.
Diagnosis of Complicated Grief
One of the challenges in diagnosing complicated grief is differentiating it from other mental health conditions such as major depression or post-traumatic stress disorder (PTSD). Individuals with complicated grief may experience symptoms such as feelings of guilt or self-blame, intrusive thoughts or memories of the deceased, and a loss of meaning or purpose in life. These symptoms may overlap with symptoms of depression, anxiety disorders and/or PTSD, making it difficult to distinguish between these conditions. However, researchers have proposed diagnostic criteria for complicated grief, which may help to improve the accuracy of diagnosis and treatment (Prigerson et al., 2009).
ICD-11 Diagnosis — Prolonged Grief Disorder
The International Classification of Diseases, Eleventh Revision (ICD-11) is a medical classification system developed and published by the World Health Organization (WHO) to provide a standardized method of classifying diseases, disorders, and other health-related conditions. The ICD-11 is the most recent version of the classification, which was released in 2018. The system is used by healthcare providers and researchers worldwide to facilitate consistent and accurate recording, reporting, and analysis of health information. It includes codes for various health conditions, including physical and mental health disorders, injuries, and causes of death.
A new diagnosis of Prolonged Grief Disorder was approved by the World Health Organization in 2018, and included in ICD-11. The diagnosis criteria require the presence of a persistent and all-encompassing grief reaction, characterized by feelings of longing for the deceased or an ongoing preoccupation with the deceased, along with intense emotional pain, such as sadness, guilt, anger, denial, blame, difficulty in accepting the death, feeling of losing a part of oneself, inability to experience positive mood, emotional numbness, and difficulty engaging in social or other activities (World Health Organization, 2018).
DSM-5-TR — Persistent Complex Bereavement Disorder
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR) is a publication by the American Psychiatric Association that provides a standard classification system for mental health disorders in the United States. The DSM-5-TR includes descriptions, symptoms, and other criteria for diagnosing mental health disorders, such as depression, anxiety, and schizophrenia, among others. It is widely used by clinicians, researchers, insurance companies, and others to identify and classify mental health conditions. The DSM-5-TR was published in 2022 and represents the most recent revision to the DSM series, which has been in use since 1952.
With the DSM-III revision, published in 1980, uncomplicated bereavement was recognized as a condition that was receiving clinical attention. Since that time further interest in complicated grief developed, leading to further research and, ultimately, the introduction of Prolonged Grief Disorder in the DSM-5-TR. The DSM-5-TR includes a specific diagnosis for PCBD, which is generally referred to as complicated grief in common language.
According to the DSM-5-TR, PCBD is characterized by persistent and severe grief reactions that interfere with everyday functioning with a persistence longer than might be expected based on social, cultural, or religious norms. For the clinical diagnosis of PCBD, the loss of a loved one had to have occurred at least one year ago for adults, and at least six months ago for children and adolescents.
Specifically, the grieving individual must have experienced at least three of the following symptoms nearly every day for at least the last month prior to the diagnosis:
- Identity disruption (such as feeling as though part of oneself has died)
- Marked sense of disbelief about the death
- Avoidance of reminders that the person is dead
- Intense emotional pain (such as anger, bitterness, sorrow) related to the death
- Difficulty with reintegration (such as problems engaging with friends, pursuing interests, planning for the future)
- Emotional numbness (absence or marked reduction of emotional experience)
- Feeling that life is meaningless
- Intense loneliness (feeling alone or detached from others)
(American Psychiatric Association, 2022)
Treatment of Complicated Grief:
Treatment for complicated grief typically involves psychotherapy, such as cognitive-behavioral therapy or interpersonal therapy. These approaches aim to help individuals process their grief, develop coping skills, and reduce symptoms of depression and anxiety. Some therapists may also use techniques such as mindfulness meditation or exposure therapy to help individuals confront their feelings and memories related to the loss. Medications such as antidepressants may also be used in conjunction with therapy to manage symptoms of depression or anxiety. Treatment for complicated grief is often tailored to the individual’s specific needs and may involve a combination of different approaches. While there is no one-size-fits-all approach to treating complicated grief, research suggests that early intervention is key to preventing the condition from becoming chronic (Shear et al., 2011).
Grief is a natural and normal response to loss. While grief is a universal experience, complicated grief is a condition that can become prolonged and debilitating. Understanding the difference between grief and complicated grief is important for individuals who may be struggling with prolonged grief reactions. Treatment for complicated grief typically involves psychotherapy and/or medications and is tailored to the individual’s specific needs. With appropriate treatment and support, individuals experiencing complicated grief can learn to manage their symptoms and find ways to move forward with their lives.
References:
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing. https://www.psychiatry.org/psychiatrists/practice/dsm
Hawton K. (2007). Complicated grief after bereavement. BMJ (Clinical research ed.), 334(7601), 962–963. https://doi.org/10.1136/bmj.39206.507488.BE
Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C., Neimeyer, R. A., Bonanno, G. A., Block, S. D., Kissane, D., Boelen, P., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS medicine, 6(8), e1000121. https://doi.org/10.1371/journal.pmed.1000121
Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N., Meert, K., Schiff, M., O’Connor, M. F., First, M., … Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and anxiety, 28(2), 103–117. https://doi.org/10.1002/da.20780
Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Focus (American Psychiatric Publishing), 19(2), 161–172. https://doi.org/10.1176/appi.focus.20200052
World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). https://icd.who.int/en
Zisook, S., Shear, K., & Kendler, K. S. (2007). Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry: official journal of the World Psychiatric Association (WPA), 6(2), 102–107.
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