Complicated Grief

Overview

Losing a loved one is one of the most distressing and, unfortunately, common experiences people face. Most people experiencing normal grief and bereavement have a period of sorrow, numbness, and even guilt and anger. Gradually these feelings ease, and it’s possible to accept loss and move forward.

For some people, feelings of loss are debilitating and don’t improve even after time passes. This is known as complicated grief, sometimes called persistent complex bereavement disorder. In complicated grief, painful emotions are so long lasting and severe that you have trouble recovering from the loss and resuming your own life.

Different people follow different paths through the grieving experience. The order and timing of these phases may vary from person to person:

Accepting the reality of your loss
Allowing yourself to experience the pain of your loss
Adjusting to a new reality in which the deceased is no longer present
Having other relationships

These differences are normal. But if you’re unable to move through these stages more than a year after the death of a loved one, you may have complicated grief. If so, seek treatment. It can help you come to terms with your loss and reclaim a sense of acceptance and peace.

Symptoms

During the first few months after a loss, many signs and symptoms of normal grief are the same as those of complicated grief. However, while normal grief symptoms gradually start to fade over time, those of complicated grief linger or get worse. Complicated grief is like being in an ongoing, heightened state of mourning that keeps you from healing.

Signs and symptoms of complicated grief may include:

Intense sorrow, pain and rumination over the loss of your loved one
Focus on little else but your loved one’s death
Extreme focus on reminders of the loved one or excessive avoidance of reminders
Intense and persistent longing or pining for the deceased
Problems accepting the death
Numbness or detachment
Bitterness about your loss
Feeling that life holds no meaning or purpose
Lack of trust in others
Inability to enjoy life or think back on positive experiences with your loved one

Complicated grief also may be indicated if you continue to:

Have trouble carrying out normal routines
Isolate from others and withdraw from social activities
Experience depression, deep sadness, guilt or self-blame
Believe that you did something wrong or could have prevented the death
Feel life isn’t worth living without your loved one
Wish you had died along with your loved one

When to see a doctor

Contact your doctor or a mental health professional if you have intense grief and problems functioning that don’t improve at least one year after the passing of your loved one.

Causes

It’s not known what causes complicated grief. As with many mental health disorders, it may involve your environment, your personality, inherited traits and your body’s natural chemical makeup.

Diagnosis

Grieving is a highly individual process for each person, and determining when normal grief becomes complicated grief can be difficult. There’s currently no consensus among mental health experts about how much time must pass before complicated grief can be diagnosed.

Complicated grief may be considered when the intensity of grief has not decreased in the months after your loved one’s death. Some mental health professionals diagnose complicated grief when grieving continues to be intense, persistent and debilitating beyond 12 months.

There are many similarities between complicated grief and major depression, but there are also distinct differences. In some cases, clinical depression and complicated grief occur together. Getting the correct diagnosis is essential for appropriate treatment, so a comprehensive medical and psychological exam is often done.

Risk factors

Complicated grief occurs more often in females and with older age. Factors that may increase the risk of developing complicated grief include:

An unexpected or violent death, such as death from a car accident, or the murder or suicide of a loved one
Death of a child
Close or dependent relationship to the deceased person
Social isolation or loss of a support system or friendships
Past history of depression, separation anxiety or post-traumatic stress disorder (PTSD)
Traumatic childhood experiences, such as abuse or neglect
Other major life stressors, such as major financial hardships

Complications

Complicated grief can affect you physically, mentally and socially. Without appropriate treatment, complications may include:

Depression
Suicidal thoughts or behaviors
Anxiety, including PTSD
Significant sleep disturbances
Increased risk of physical illness, such as heart disease, cancer or high blood pressure
Long-term difficulty with daily living, relationships or work activities
Alcohol, nicotine use or substance misuse

Prevention

It’s not clear how to prevent complicated grief. Getting counseling soon after a loss may help, especially for people at increased risk of developing complicated grief. In addition, caregivers providing end-of-life care for a loved one may benefit from counseling and support to help prepare for death and its emotional aftermath.

Talking. Talking about your grief and allowing yourself to cry also can help prevent you from getting stuck in your sadness. As painful as it is, trust that in most cases, your pain will start to lift if you allow yourself to feel it.
Support. Family members, friends, social support groups and your faith community are all good options to help you work through your grief. You may be able to find a support group focused on a particular type of loss, such as the death of a spouse or a child. Ask your doctor to recommend local resources.
Bereavement counseling. Through early counseling after a loss, you can explore emotions surrounding your loss and learn healthy coping skills. This may help prevent negative thoughts and beliefs from gaining such a strong hold that they’re difficult to overcome.

Treatment

Your doctor or mental health professional considers your particular symptoms and circumstances in determining what treatment is likely to work best for you.

Psychotherapy

Complicated grief is often treated with a type of psychotherapy called complicated grief therapy. It’s similar to psychotherapy techniques used for depression and PTSD, but it’s specifically for complicated grief. This treatment can be effective when done individually or in a group format.

During therapy, you may:

Learn about complicated grief and how it’s treated
Explore such topics as grief reactions, complicated grief symptoms, adjusting to your loss and redefining your life goals
Hold imagined conversations with your loved one and retell the circumstances of the death to help you become less distressed by images and thoughts of your loved one
Explore and process thoughts and emotions
Improve coping skills
Reduce feelings of blame and guilt

Other types of psychotherapy can help you address other mental health conditions, such as depression or PTSD, which can occur along with complicated grief.

Medications

There’s little solid research on the use of psychiatric medications to treat complicated grief. However, antidepressants may be helpful in people who have clinical depression as well as complicated grief.

Coping and support

Although it’s important to get professional treatment for complicated grief, these strategies also may help you cope:

Stick to your treatment plan. Attend therapy appointments as scheduled and practice skills learned in therapy. If needed, take medications as directed.
Practice stress management. Learn how to better manage stress. Unmanaged stress can lead to depression, overeating, or other unhealthy thoughts and behaviors.
Take care of yourself. Get enough rest, eat a healthy diet and take time to relax. Exercise regularly. Physical activity can help relieve stress, depression and anxiety. Don’t turn to alcohol or recreational drugs for relief.
Reach out to your faith community. If you follow religious practices or traditions, you may gain comfort from rituals or guidance from a spiritual leader.
Socialize. Stay connected with people you enjoy being around. They can offer support, a shoulder to cry on or shared laughter to give you a little boost.
Plan ahead for special dates or anniversaries. Holidays, anniversaries and special occasions can trigger painful reminders of your loved one. Find new ways to celebrate, positively reminisce or acknowledge your loved one that provide you comfort and hope.
Learn new skills. If you were highly dependent on your loved one, for example, to handle the cooking or finances, try to master these tasks yourself. Ask family, friends or professionals for guidance, if necessary. Seek out community classes and resources, too.
Join a support group. You may not be ready to join a support group immediately after your loss, but over time you may find shared experiences comforting and you may form meaningful new relationships.

Preparing for your appointment

You may start by contacting your doctor. After your initial appointment, your doctor may refer you to a mental health professional who can help diagnose your symptoms and provide a treatment plan.

You may want to ask a trusted family member or friend to be present for your appointment, if possible, to help you remember key information.

Here’s some information to help you prepare for your appointment.

What you can do

Before your appointment, make a list of:

Any symptoms you’ve been experiencing and for how long. Your doctor will want to know the extent to which these symptoms are affecting your daily life, including work and personal relationships.
Your key personal information, especially any additional major stress or change you’ve experienced since your loved one died, such as serious illness, significant family disruptions or financial problems.
Medical information, including other physical or mental health conditions with which you’ve been diagnosed.
All medications, vitamins, herbs or other supplements you’re taking, and the dosages.
Questions you’d like to ask your doctor.

References

Conditions for further study: Persistent complex bereavement disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed May 4, 2021.
Shear MK, et al. Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis. https://www.uptodate.com/contents/search. Accessed May 4, 2021.
Shear MK, et al. Complicated grief in adults: Treatment. https://www.uptodate.com/contents/search. Accessed May 4, 2021.
Grief, bereavement, and coping with loss (PDQ) ― Health professional version. National Cancer Institute. https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-hp-pdq. Accessed May 4, 2021.
Seeking help and support for grief and loss. American Cancer Society. https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/depression-and-complicated-grief.html. Accessed May 4, 2021.
Shear MK. Complicated grief. New England Journal of Medicine. 2015;372:153.
Grief and bereavement. American Cancer Society. https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/grieving-process.html. Accessed May 4, 2021.
Doering BK, et al. Treatment for complicated grief: State of the art science and ways forward. Current Opinion in Psychiatry. 2016;29:286.
National Suicide Prevention Lifeline. https://suicidepreventionlifeline.org. Accessed May 4, 2021.
Jordan AH, et al. Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice. 2014;45:180.