Complicated grief involves a persistent and long-lasting reaction to a significant loss. While for most, the sharpness of a loss subsides over the course of six months or so, those who experience complicated grief will get “stuck” in their grief process. This may occur after sudden, unexpected losses that are traumatic and more difficult to process.
What Is Complicated Grief?
Complicated grief, also known as complicated bereavement, chronic grief, or complicated grief disorder, involves experiencing symptoms of grief that intensify instead of subsiding over time. After the death of a loved one, including the loss of a parent, a miscarriage, or the loss of a child, experiencing the associated seven stages of grief is normal. While there are no specific timelines for these stages, and they can occur out of order, if someone gets “stuck” in one of these stages it may be a sign of complicated grief.
Examples of What Can “Complicate” Grief
Traumatic grief, like witnessing the death of a loved one or having to remain in a home where a death or suicide occurred, may also result in complicated bereavement. Disenfranchised grief is a term used in the context of less recognized or overt losses, such as the loss of a pet, which can be extremely traumatic and complex for many people.1,2
Complicated grief may also occur from lack of closure.3 For example, when someone experiences the loss of an abusive parent or abusive romantic partner in a relationship, it may take longer for them to process the normal stages of grief because of the trauma history associated with that person.
Symptoms of Complicated Grief
Symptoms of complicated grief may differ from typical grief in the context of severity. Complicated grieving symptoms will be experienced daily and to a disabling degree that affects one’s social life or their ability to perform at work or in school.6,7
Symptoms of complicated grief include:6,7
- Intense sorrow and longing for the deceased
- Avoidance of reminders associated with loss
- Identity and role confusion
- Feeling emotionally numb
- Lack of desire to pursue new interests
- Difficulty with trust
- Feeling bitter or angry about the loss
- Difficulty maintaining current or investing in new relationships
- Feeling that life is meaningless since the loss
- Feelings of shock, in a daze or total confusion (sometimes called grief brain)
How Is Complicated Grief Different From Regular Grief?
Complicated grief differs from the regular grief process in that symptoms will persist and impact important areas of functioning for the bereaved individual. Many people are familiar with Elisabeth Kubler-Ross’s five stages of grief model that includes the phases of denial, anger, bargaining, depression and acceptance.4
Over the past five decades, theories on grief have evolved and suggest that one can process and reprocess these stages in many different orders or not in a predetermined set of time.
Complicated Grief vs. Persistent Complex Bereavement Disorder
The main difference between complicated grief and persistent complex bereavement disorder is that prolonged grief disorder is suggested to last more than six months while persistent complex bereavement (PCBD) lasts more than 12 months.5,6 It is important to note that the DSM-5 does not currently classify PCBD as a diagnosable disorder; however, it’s under review for further study due to evolved research on complex grief.7
Complicated Grief vs. Depression
There are similarities between grief and depression, however there are differences to be aware of. Grief leads people to isolate at times, but able to still have emotional connections with others. Depression feels like you are alienated and alone, even with people around. Depression is marked by a long feeling of hopelessness, which is common with grief, however grief allows people to remember that there will be better days ahead.
Those in grief are able to feel better when consoled, however with depression, it can feel like there is nothing that can be done to help someone feel better. Depression leaves little room for positive emotions, while grief still allows positive feelings to be expressed and positive memories to be felt.
How to Identify Complicated Grief
Complicated grief can be hard to identify at times, as grief can look different for everyone. Grief, over a period of months or years following the death of a loved one, can become complicated when it becomes chronic. When this happens, people tend to find poor coping mechanisms and are fueled by negative thoughts—at this point we can safely call this complicated grief. In other words, when a person’s daily functioning, mental health, and mood are affected by grief, this is complicated grief.
Who Is at Risk For Complicated Grief?
While there are no known direct or absolute causes of complicated grief, there are risk factors and behaviors that may prolong healing from a difficult loss. Anyone of any age or stage in life is at risk of experiencing complicated grief.
The following risk factors may increase the chances for complications within the grief process:3,8
- If someone witnesses the death
- The death is considered traumatic
- Those experiencing multiple losses in a short timeframe
- If someone experiences more stressors in addition to the loss of the deceased
- Anyone with a history of negative coping or someone who is already struggling with mental health concerns
- Anyone with a limited social support network
How Can Complicated Bereavement Impact Someone’s Life?
Complicated grief interrupts the normal healing process that occurs when mourning after the loss of a significant person. The symptoms associated with complicated bereavement are complex and can have direct negative implications for many aspects of your life.
Here are some examples of symptoms from complicated grief and their consequences:
- Ongoing rumination regarding the ramification of the loss. This focus is on past regrets and “what ifs.” This prevents the bereaved from taking action to begin to move forward with healing.
- Complicated grief can create a greater and longer-lasting intensity of painful emotions like guilt, anger, bitterness, sadness, and regret. It keeps the focus on the past death of a loved one and all the negative consequences of the loss.
- CG can create a longer period of self imposed isolation. Mourners tend to not want to go to places they visited with the person who is gone or be with people that remind them of that person.
- A large part of the healing process is finding a “new normal” with new meaning and purpose in your life. Preoccupation with the person who is gone and your shared past accentuates the enormity of the loss. This dynamic makes it nearly impossible to create new life goals and purpose.
- There is a loss of identity when a person you had a close relationship with has died. For example, when a husband dies the spouse is no longer a wife and this is very disruptive and disorienting in terms of self identity.
Common Co-Occurring Disorders
Complicated grief can be overlooked or mistaken for common mental-health disorders like depression. If left untreated, grief can certainly devolve into a depressive disorder over time. People with complicated grief may experience intrusive thoughts, sleep disturbances or even suicidal ideation.8
Those who struggle with substance misuse are also at risk of experiencing prolonged grief due to a history of poor coping with life stressors.9 It is important that those who think they are experiencing complicated grief seek professional, clinical support to receive a proper diagnosis based on presenting symptoms and circumstances of the loss.
There are a number of additional disorders that are associated with complicated grief, such as:
- Acute stress disorder or adjustment disorder
- Major depressive disorder (MDD)
- Generalized anxiety disorder (GAD)
- Personality disorders
- Panic disorder
How to Cope With Complicated Grief
It’s important to acknowledge your grief and be present in difficult moments, as painful as they may feel. It’s common for psychotherapists to describe grief as emotional “waves” that can hit suddenly and be extremely impactful. Remember, complicated grief disorder is complex, chronic and, at times, ambiguous, and confusing. Accept that you can get better, you’re allowed to feel sad, and you can heal.
Here are six ways to cope with complex grief:
- Remind yourself that what you’re feeling is OK: What you’re feeling is nearly incomprehensible, but it’s OK to feel pain and sadness. It may be easier to write these feelings out in a grief journal instead of expressing them verbally.
- Identify supports: Stay connected to family, friends, and community members you trust and continue to invest time in those relationships.
- Explore new ways to cope: Shocking and unprepared loss can sometimes make us forget how to use normal coping mechanisms. It is important to recognize when what normally would help us to adapt or cope is no longer working.
- Set limits and boundaries: Recognize what you are capable of and what can maybe wait. You and your loved ones may need all of your strength and focus right now, and that’s OK. Recognize unhealthy supports too and distance yourself from who or what is holding you back from healing.
- Recognize wishful thinking or other unhelpful thought patterns: As much as we may want to imagine the possibility of a different outcome, being stuck in constant rumination is likely what is keeping you from healing.
- Consult with professionals: See your provider for medication management if needed or ask for a referral for specialty services.
Can Complex Grief Be Prevented?
There are some people who are at higher risk for complex grief. Risk factors include:
- People with a previous history of depression.
- The closeness of the relationship with the person who is lost and the nature of the loss.. The closer the relationship the greater the sense of loss.
- Sudden traumatic losses like car accidents, the death of a child, or a suicide also increase the risk of complex grief.
While complicated grief may not be able to be fully prevented, the quicker a mental health professional who specializes in grief therapy is engaged to offer treatment the better the prognosis for the bereaved. People in these higher-risk populations should have access to prompt grief therapy treatment to help mitigate the severity and extent of their complex grief symptoms.
Getting a Complicated Grief Diagnosis
Mental health diagnoses like complicated grief must be made by a mental health specialist who is licensed with at least a master’s degree level of training. This diagnosis can be made by mental health practitioners such as psychologists, licensed clinical social workers, psychiatrists, and licensed professional counselors.
There is an instrument called the Inventory of Complicated Grief (ICG) created by Holly G. Prigerson, PhD, in 1995. It was designed to detect symptoms of grief “to be distinct from bereavement-related depression and anxiety and to predict long-term functional impairments.”(10 This questionnaire is designed to be given in a face-to-face interview, and can identify symptoms and their severity and frequency for the past month.
Here are some examples of questions from the ICG:11
- Was the loss traumatic for you?
- Do you ever try to avoid reminders that _____ is gone?
- To what extent do you feel like the future holds no meaning or purpose without ____?
- Do you ever feel disbelief over _____’s death?
The complete Inventory of Complicated Grief can be found here.
When a Therapist or Grief Counselor Can Help
After a loss, it’s normal to experience a period of shock, disbelief, and denial that lasts for days or weeks. When you feel ready to start processing, that’s a good time to start seeking therapeutic services with an experienced provider. Conversely, if you or a loved one appears to be experiencing symptoms of a mental-health crisis after a loss, research what crisis services are available in your community.
How to Find a Therapist
Finding the right therapist can feel challenging and overwhelming, and there are many types of grief counseling and grief therapy available. An online therapist directory is a great place to start looking for certified grief counselors, psychologists, social workers and marriage and family therapists who can provide clinical services related to grief and loss.
Complicated grief is difficult to process but there are ways to move forward in life and begin to heal. It may be difficult to support a loved one as they experience complicated grief, especially if symptoms reach a certain level of severity (like difficult physical symptoms of grief). Seeking professional support is critical in receiving a proper diagnosis and appropriate plan for treatment.
For Further Reading
- Helpful Books About Loss and Grief
- The Center for Complicated Grief
- Heartbeat: Survivors After Suicide
- NAMI: National Alliance on Mental Health
- Association for Death Education and Counseling
- SAMHSA’s National Helpline: 1-800-662-HELP (4357)