Persistent Complex Bereavement Disorder: Signs, Symptoms, & Treatments

What Is Persistent Complex Bereavement Disorder?

Persistent complex bereavement disorder, sometimes called complicated grief, will look like an exaggerated grief reaction following the death of a loved one. Like other people who have recently experienced the death of a loved one, people with PCBD will display symptoms of sadness and despair, but these will exceed what is typical of grief in terms of severity.¹

Not only will the intensity of symptoms appear extreme, the duration of symptoms will tend to last much longer than an expected period of grief. Rather than symptoms softening and alleviating with time, PCBD signs will continue and may even worsen as the weeks and months pass.

Persistent Complex Bereavement Disorder’s Status as a Diagnosis

Persistent complex bereavement disorder’s status as an official mental health disorder is a bit unclear. The American Psychiatric Association (APA) compiles a list of currently recognized conditions in the text called the Diagnostic and Statistical Manual of Mental Disorders. Currently, in its fifth revision, the DSM-5 prominently features persistent complex bereavement disorder (PCBD) as one of the “Conditions for Further Study.”¹

Before the APA can add the condition, experts must study it further. It is likely that PCBD will achieve status as a full mental health condition in future versions of the DSM, but for now, people with these symptoms and mental health professionals should avoid the label. The APA reports that persistent complex bereavement disorder is not intended for clinical use.¹

Symptoms of Persistent Complex Bereavement Disorder

A person with persistent complex bereavement disorder will have uncomfortable levels of sadness, confusion, anger, denial, and yearning triggered by the loss of their loved one, but when someone has endured a meaningful loss, it’s challenging to differentiate between typical and problematic grief. They may not view their symptoms as odd or abnormal, despite the negative toll of these grief symptoms on physical and mental health.

The proposed symptoms of persistent complex bereavement disorder are numerous and specific to ensure that typical grief reactions do not become pathologized by mental health professionals or others. The experience of PCBD must be disproportionate with the expected grief reactions based on age, culture, and religion.¹

The individual must experience at least one of the following PCBD symptoms:¹

• Continuous feelings of yearning and longing for the deceased person.
• Intense sorrow, sadness, and emotional pain connected to the death
• Being preoccupied with the person who died by excessively thinking, talking, and writing about them.
• Being stuck thinking and talking about the circumstances of the death. Again, children may show this through play and behavior that centers around the death and the possible death of others.

These symptoms are not enough to receive the PCBD diagnosis, though. To have persistent complex bereavement disorder, a person must show at least six of the following symptoms:¹

• An inability to accept the death as permanent
• Disbelief or emotional numbness triggered by the loss
• Struggling to remember positive and happy memories of the person
• Feeling very bitter and angry about the death
• Feeling bad about self or blaming self for what happened
• Avoiding any and all possible reminders of the loss and the person who died
• A desire to die as well in order to be reunited with the dead
• Trouble trusting or believing others since the death
• Feeling alone and disconnected from others
• Feeling that life is meaningless or that they cannot survive without the dead
• Struggling to find their own role in life without the loved one
• Lack of interest in pursuing friendships, activities, or healthy coping skills after the death

The present symptoms must occur most of the time for at least one year for adults and six months for children. They must cause a major disturbance in the person’s daily life and functioning.

Normal Grief Vs. Complex Bereavement

Grief is a normal and anticipated reaction to a significant loss. In cases of normal grief, after weeks or months people are able to move forward with a “new normal” in their lives. PCBD does not dissipate even after an extended period of time and has an additional component with feeling an extreme yearning for the person who is gone.

Here are some other similarities and differences between normal grief and persistent complex bereavement disorder:

• In both types of grief people may feel sadness, cry, have trouble with sleep, lack of energy, loss of appetite. They both may include diminished concentration and daily functioning. These symptoms are more severe and last longer in cases of PCBD.
• In instances of complex bereavement the responses to the loss does not diminish with time. Symptoms often can get worse. Symptoms of PCBD must persist  or worsen for at least 12 months for adults and at least 6 months for children and adolescents to be diagnosed as PCBD.
• PCBD offers limited or no moments of relief. It is a constant state of debilitation and longing for the person who is gone. There is an ongoing denial or disbelief regarding the loss of the person and the relationship.
• Social connections with trusted, supportive friends and family can help comfort those experiencing normal grief. In instances of PCBD there is a reluctance to engage in these relationships. Social interactions tend not to offer support or comfort to the bereaved because there is such an intense preoccupation with the person who is gone.

Causes of Persistent Complex Bereavement Disorder

Experts are uncertain about what causes persistent complex bereavement disorder, but the emergence of symptoms is usually related to the person’s personality, their genetics, and their relationship to the deceased.² One person could have a perfectly common and expected reaction to a loss, while another person in a very similar situation could display numerous signs and symptoms of PCBD.

Though the causes are unclear, there are several risk factors that will contribute to the emergence of persistent complex bereavement disorder and other complicated grief reactions.

Risk factors for PCBD include:²

• The death being unexpected or violent
• The death being a murder or suicide
• Having a very close or dependent relationship to the person
• Social isolation or being cut off from a support system
• A history of mental health disorders like depression, separation anxiety, and post-traumatic stress disorder (PTSD)
• A history of abuse and neglect during childhood
• Serious life stressors like having to move, financial issues, or medical problems

People who are more prone to avoiding symptoms of PCBD will have protective factors that are unlike the risk factors. If the person has a supportive network, a history of wellness, low life stress, and high stability, they are more likely to escape the effects of PCBD.

Common Comorbid Disorders

There are several other diagnoses that can be made in conjunction with persistent complex bereavement disorder. The most common is major depressive disorder. (MDD). There is much overlap in the symptoms of PCBD and MDD. They include feelings of sadness, episodes of anger and irritability, inability to experience pleasure in anything, and disrupted appetite and sleep.

Other diagnoses can be made simultaneously with PCBD, including post traumatic stress disorder (PTSD) and generalized anxiety disorder. The diagnosis of PTSD can occur after a traumatic event. For example, the sudden loss of a loved one resulting from a heart attack, car accident, or murder can lead to PTSD. Recovery from these types of events is more challenging and can take longer because of the unexpected and dramatic nature of the loss. Substance use disorders can also occur with PCBD, as people who have limited support and coping mechanisms may turn to alcohol and/or drugs because they feel that they cannot cope with their loss.

Outward Signs of Persistent Complex Bereavement Disorder

Beyond the intense and long-lasting grief symptoms, a person with PCBD will display more troubling manifestations, with the potential for bizarre, odd, and unexpected thoughts, feelings, and behaviors. These symptoms may build slowly over time or could emerge rapidly following the death. These effects could severely impact the person’s ability to work, go to school, function at home, and maintain their relationships.¹

Common indicators of persistent complex bereavement disorder include:¹

• Preparing meals or setting places at the table for the deceased person
• Saying that there is no reason to live without the loved one
• Stating that they are unsure who they are now that the loved one has died
• Appearing very angry, irritable, and aggressive towards others
• Talking about the loved one like they are still alive
• Refusing to complete tasks involved with the death
• Isolating from friends, family, or meaningful activities

Some people with persistent complex bereavement disorder may report having intense periods of seeing, hearing, smelling, or feeling their loved one, which could trigger either happiness or sadness.

In some situations, a person with PCBD may complain of bodily illness like pain, fatigue, or digestive issues. These complaints may reflect the death of their loved one. For example, if the loved one died of a heart attack, the person may complain of tightness in their chest, pain in their left arm, and shortness of breath.¹

Treatment of Persistent Complex Bereavement Disorder

Psychotherapy and, to a lesser degree, medications are effective treatments for persistent complex bereavement disorder. Engaging in treatment may seem uncomfortable or unnecessary, but it can help the individual process and resolve their grief. With less grief, the person can feel better and function well.

Whenever a diagnosis of PCBD or complicated grief is noted, the first step in the treatment process is for the mental health evaluator to provide the person with education regarding the condition’s signs, symptoms, and prognosis. The professional should communicate the idea that grief is healthy, but the individual’s response is unhealthy.³

Common Types of Therapy

Once the professional delivers the educational component, psychotherapy for persistent complex bereavement disorder can commence. Clinicians like professional counselors, social workers, therapists, and psychologists may deliver therapy in settings such as schools, community agencies, doctors’ offices, and in the home.

Here are common types of therapy for PCBD:

• Cognitive behavioral therapy (CBT): Like with many other mental health conditions, CBT will act as a first-line treatment, but other available options could yield positive results
• Interpersonal therapy: This therapy style helps by exploring the person’s relationship with the deceased and inspecting issues including disagreements, transitions, and grief to resolve unwanted symptoms⁴
• Grief therapy for complicated or traumatic grief: This blends aspects of CBT and interpersonal therapy together, helping the client move forward with a two-step process: First, adjusting to the loss by focusing on the mourning, then restoring satisfaction and happiness in life by improving the person’s functioning.⁴
• Grief counseling: This is another therapeutic option that helps people deal with the issue of loss, grief, complicated grief, and persistent complex bereavement disorder.

Durations of treatment always vary based on the individual’s needs and symptoms, but therapy options can quickly improve symptoms. A typical course of CBT for PCBD usually takes 16 to 25 weeks. A round of interpersonal therapy could be completed in as little as eight weeks.³

Medication For PCBD

Unlike other mental health disorders, experts do not view medication as a successful method of treating persistent complex bereavement disorder. The research looking at the benefits of medication for PCBD is limited, and currently, there is little evidence that shows any medications help significantly.²

Some smaller studies have shown that using antidepressants can have a positive impact on complicated grief symptoms, so perhaps future studies will expand this information.³

How to Get Help For Persistent Complex Bereavement Disorder

Getting help for persistent complex bereavement disorder is a simple process. Find the nearest mental or physical health professional and communicate your concerns in person or over the phone. If they cannot address your symptoms and situations, they will refer you to an experienced professional.

Always be clear about your stressors, symptoms, and experience to get the needed level of care. Be sure to let them know that your condition is beyond typical grief and mourning, so they grasp the urgency of your needs.

How to Find a Therapist

If you’re ready to find the right therapist, you can begin your search in an online therapist directory. This allows you to narrow your search by location, cost, expertise, and more. You might also consider consulting with a primary care provider, or asking loved ones if they have any recommendations for therapists.

How to Get Help For a Loved One With Persistent Complex Bereavement Disorder

Someone with persistent complex bereavement disorder experiences a range of intense and lasting symptoms related to the death, which makes the process of getting help for a loved one with the condition challenging. Approaching the situation with frustration and anger will only create a rift, so lean towards love, patience, support, and understanding.

Grieving and mourning are personal experiences, and normal grief can look quite differently, depending on the person. Before anyone can get help for someone with PCBD, they must have a basic understanding of typical grief and loss reactions versus complicated grief.

With this understanding, a person can monitor their loved ones for indications of PCBD and communicate their concerns. Discuss the idea that even typical grief can benefit from counseling, and that you would be happy to help set up an appointment or attend the visit with them.

Throughout the process, let the person know that they are not at fault for their complicated experience with grief. Persistent complicated bereavement disorder is a problem that comes with little warning.

8 Ways to Cope With Persistent Complex Bereavement Disorder

Coping with grief and loss, including persistent complex bereavement disorder can drastically improve symptoms, no matter the situation. Specific skills include acknowledging and accepting the loss, building new habits, connecting with others, and staying in the present.⁴

Here are eight ways to cope with persistent complex bereavement disorder:⁶

1. Acknowledge the Loss & Your Feelings

Denying and pushing away your feelings of grief and loss is never a good idea because they will always reemerge. Plan to spend some time each day remembering the loved one and recalling pleasant memories, while accepting the sadness you feel.

2. Build New Habits

The loss could leave a huge hole in your life and daily routine, so rather than longing for the past, experiment with new habits and behavior patterns to find movement in your day to avoid stagnation.

3. Connect With Others

Grieving can be a lonely and isolating experience, but spending time with others is essential. Online, in person, friends, or support groups—any option can help you feel cared for and loved.

4. Stay In the Present

The intense sadness of grief can make people yearn for the past, dread the future, and ignore the present. By taking a “one day at a time” approach, you can find periods of joy, happiness, and accomplishment during the day.

5. Improve Physical Health

When people are grieving, there is a tendency to lose sight of their physical health, leading to weight gain, lack of activity, and poor sleep. By shifting energy towards increased exercise, improved diet, and a better sleep schedule, a person can reap the benefits of physical health, including self-esteem, confidence, and empowerment.

6. Address Your Thoughts

Grief and persistent complex bereavement disorder make people’s thoughts less accurate and more irrational. A person can substantially improve their psychological state by investigating their thoughts, scanning for errors, and searching for more appropriate patterns. The process is complicated so ask a friend for assistance.

7. Balance Your Social Life

A big part of you will want to be alone, which is healthy, but spending too much time alone can lead to isolation and increased depression. Work to bring balance to your social life by scheduling plans, meetings, and gatherings with people you love. Avoid canceling plans and use these opportunities to seek the support all people need.

8. Reinvest Your Energy

Grieving takes tremendous focus and effort. At some point, though, you will have to reinvest your energy towards the future’s hope, rather than the past’s sadness. People find purpose with social activities, volunteering, and other new endeavors. Redirecting this energy can create a lot of good for the world.

Persistent Complex Bereavement Disorder Statistics

Tracking statistics on persistent complex bereavement disorder is a new process, since the condition does not have full recognition, yet.

Still, some interesting persistent complex bereavement disorder statistics exist, like:^1,3

• 4.8% of people will experience persistent complex bereavement disorder symptoms
• Yearning for the deceased is the most common symptom – reports by 88% of people surveyed
• Complicated grief symptoms are most common in women over 60
• 70% of people treated with CBT for complicated grief report benefit from treatment, compared with 51% who used complicated grief therapy and 28% who completed interpersonal therapy
• 13% of people with complicated grief attempt suicide at least once

Final Thoughts on Persistent Complex Bereavement Disorder

We will all lose a loved one at some point in our lives; unfortunately, it’s one of the most common, yet distressing experiences people can face. If you or someone you love is dealing with the effects of persistent complex bereavement disorder, know that you’re not alone. Help is out there in the form of therapy and support from your loved ones.