Although not officially recognized as a mental health condition, persistent complex bereavement disorder is characterized by intense and lasting symptoms following the death of a loved one. As many as 4.8% of people will experience persistent complex bereavement disorder, but acknowledging the issue and working with mental health professionals can decrease the intensity and duration of grief effects.1
Persistent Complex Bereavement Disorder: Status as a Diagnosis
Persistent complex bereavement disorder’s status as an official mental health disorder is a bit cloudy. 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
PCBD is currently not a diagnosis that anyone should receive from a professional. The situation becomes more complicated, though. 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
Signs of Persistent Complex Bereavement Disorder
Persistent complex bereavement disorder, sometimes called complicated grief, will look like an exaggerated grief and loss 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.
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, irritabile, 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
People with PCBD may note some indirect effects and complications from the condition like:2
- Depression
- Anxiety
- Suicidal thoughts and actions
- Drastic changes in sleep
- Increased rates of alcohol use, smoking, or substance abuse
Someone who is drinking more could be using the alcohol as a way to manage symptoms of their grief and loss. With time, the substance use will only create more problems.
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 a person has endured a meaningful loss, it is challenging to differentiate between typical and problematic grief. They may not view their symptoms as odd or abnormal, despite the negative toll these symptoms have on their 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
Persistent complex bereavement disorder always begins with a death.
Since the death, the individual must experience at least one of the following PCBD symptoms:1
- Continuous feelings of yearning and longing for the deceased person. Children may show this yearning through play and other behaviors involving a person leaving and then returning
- 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. 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.
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 individual’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 very 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.
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.
The treatment of persistent complex bereavement disorder will focus on goals like:3
- Decreasing the grief symptoms
- Experiencing and releasing uncomfortable emotions
- Being mindful and aware of wanted emotions
- Building a healthy, lasting connection to the deceased
- Accepting the permanence of the loss
- Avoiding isolation and re-engaging in the social relationships
- Fostering healthy outlets, hobbies, and activities
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
Therapy
Once the professional delivers the educational component, psychotherapy for persistent complex bereavement disorder can commence. Like with many other mental health conditions, cognitive behavioral therapy (CBT) will act as a first-line treatment, but other available options could yield positive results.
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.
Common Type of Therapies
CBT offers consistent success with a broad range of mental health disorders and works well for PCBD symptoms. CBT helps the person understand how their thoughts, feelings, and behaviors are all interdependent, and by identifying and changing problematic thoughts, the person can change their feelings. As many as 70% of people treated with CBT for complicated grief benefit from treatment.3
Another helpful therapy style is called 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 symptoms.4
A third therapy style called complicated grief treatment or traumatic grief therapy blends aspects of CBT and interpersonal therapy together. This approach helps 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
More than half (51%) of people who completed complicated grief treatment reported improved symptoms, compared to only 28% of people who improved with interpersonal therapy.4 Even with the potential benefit, complicated grief treatment is challenging and taxing on the individual, which leads many to leave the program before treatment concludes.
Intended Treatment Outcome & Timeline
No matter the specific style of therapy used, all psychotherapy options will have similar goals for the person in need. Therapy for PCBD will aim to help the individual:2
- Learn about complicated grief and its treatment
- Adjust to the loss and arrive at new goals
- Become less distressed and avoidant of thoughts of the deceased
- Boost coping skills
- Move away from guilt and shame surrounding the loss
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: Best Options
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 can expand this information. These small trials show:3
- Tricyclic antidepressants like desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor) offered some benefit
- Selective serotonin reuptake inhibitors (SSRIs) including escitalopram (Lexapro) and paroxetine (Paxil) could reduce symptoms
In coming years, new research will be needed to better establish possible medication uses for complicated grief and persistent complex bereavement disorder.
Lifestyle Changes
Therapy and medication are professional options to better manage symptoms of PCBD, but some lifestyle changes available at home can help to complement the other treatments. Lifestyle changes are often free and devoid of adverse effects, which makes that worth a try for anyone dealing with grief issues.
Some of the best lifestyle changes to help manage the symptoms of persistent complex bereavement disorder include the following.4
Improve Physical Health to Improve Mental 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.
Address the 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.
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 cancelling plans and use these opportunities to seek the support all people need.
Reinvest Your Energy
Grieving is hard. It 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 endeavours. Redirecting this energy can create a lot of good for the world.
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 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 in the relationship, so people should 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.
Practical Ways to Cope with Persistent Complex Bereavement Disorder
Coping skills always improve the situation with healthy coping skills creating lasting change and unhealthy coping skills triggering short-term benefits and long-term troubles. Coping skills for persistent complex bereavement disorder can drastically improve symptoms, no matter the situation.
Some effective ways to cope with persistent complex bereavement disorder include the following:6
Acknowledging the Loss and 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.
Building 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.
Connecting 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.
Staying 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.
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
Additional Resources
The topics of death, dying, grief, and loss are important to the world of mental health because they are universal. All people have experience with death, but not everyone needs to endure the discomfort of persistent complex bereavement disorder.
Wonderful groups are fighting the battle against the condition, including:
- Association for Death Education and Counseling
- The Center for Complicated Grief
- The National Foundation for Grieving Children, Teens, and Families
- Online Therapist Directory: Sort therapists by specialty, cost, availability and more. Watch intro videos and see articles written by the therapists you’re considering working with. When you’ve found a good match, book an online therapy appointment with them directly.
Are you ready to connect with a therapist but feel a little overwhelmed by all your options? Speak with one of Choosing Therapy’s Client Navigators. Client Navigators are mental health professionals who will listen to what you’re looking for in a therapist and help pair you with the best possible fit. Getting started is free, easy, and confidential.
