Prolonged Grief Disorder: Symptoms, Causes, & Treatments

What Is Prolonged Grief Disorder?

While “normal” grief fades with time, prolonged grief remains strong and may even intensify. Prolonged grief also includes other unusual symptoms that can occur soon after the death or build slowly over time. They affect the person’s ability to maintain relationships or function normally at work or at home. Due to its broader effects on daily life, prolonged grief has also been called complicated grief. 

Prolonged Grief Disorder as a Diagnosis

Prolonged grief disorder was recently added as an official diagnosis to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).^1,2 It clarifies the differences between grief versus depression. Certain symptoms of grief, such as yearning and pining, are not characteristic of depression, but are typical of grief.

PGD’s inclusion in the DSM-5 will allow mental health clinicians to bill insurance companies for treatment. It will also encourage funding for research into effective pharmacological treatments.

Symptoms of Prolonged Grief Disorder

The experience of prolonged grief is similar to the typical experience of grief for at least the first six months. For that reason, a person wouldn’t be diagnosed with prolonged grief disorder unless a minimum of six months have passed since the death of their loved one.⁴ Beyond that, it isn’t unusual to continue to experience intense sorrow, preoccupation with the person who died, or focus upon the circumstances of the death. An exception, however, could be if a person is in denial of the loss for six months or more.

Continuous yearning and longing for the deceased is also a typical experience, even after six months. In order to be considered prolonged grief, additional symptoms must be present.

Symptoms of prolonged grief disorder include:¹

• Feeling intense and constant longing for the deceased
• Intense sadness that remains intense after six months
• Being unable to focus on anything other than the death or how it occurred
• A sense of emptiness or numbness that won’t let up
• An inability to accept the fact that the death is permanent
• Feeling bitter or angry about the loss
• Becoming irritable or easily frustrated
• Avoiding reminders of the person who died
• Feeling that life is meaningless or pointless without the loved one
• Feeling alone, detached from friends and family
• Feeling unable to trust friends or family
• Having difficulty remembering the happy times with the deceased
• Blaming yourself for what happened to the person who died
• Being unable to enjoy life and the activities you used to enjoy
• Having a wish to be with the deceased, and related suicidal thoughts
• An increase in substance use/abuse, including heavy drinking

Prolonged Grief Disorder vs. Persistent Complex Bereavement Disorder

Research indicates that PGD and persistent complex bereavement disorder are essentially the same, and that the distinction has been mostly a matter of semantics.³ Prolonged grief disorder has been an official diagnosis in the International Classification of Diseases-11 (ICD-11) since its last publication in May 2019. The recent addition of prolonged grief disorder to the DSM-5 aligns it with the ICD-11.⁴

Prior to this year, the development team of the DSM-5 was using the label of persistent complex bereavement disorder to describe the same disorder as a “condition for further study.”⁵

Prolonged Grief Disorder Vs. Depression

There can be overlap between people with prolonged grief and depression. However prolonged grief disorder is generally triggered by a traumatic loss or death of a significant other and is not caused by heredity. Complicated grief can last a long time. It is an intense yearning for the person that is now gone. The way this type of grief is experienced is influenced by previous psychiatric history, and environmental factors such as available support, and the nature of the loss. PGD can be treated with therapy to help learn coping mechanisms to work through grief.

Depression is a diagnosed mood disorder that can be caused by chemical changes in the brain. For example people who are depressed have lower amounts of serotonin in their brain. Another cause of depression is a smaller hippocampus which also regulates mood, energy, memory, and learning. There can be a hereditary component linking depression between family members. It can be treated with therapy focusing on causes and ways to cope and recognize changes in mood. Medication management can also be used to help stabilize mood so therapy can be more effective.

Prolonged Grief Disorder Vs. PTSD

PGD and Post Traumatic Stress Disorder (PTSD) are similar in that they both are the result of a traumatic and stressful life event. PTSD can be triggered by violence, abuse, or witnessing a traumatic event. They both can include major losses. Common emotions shared by people with these diagnoses can include anger, guilt, fear and anxiety. Yearning is not a prominent emotion experienced by people with PTSD.

PTSD is usually treated with therapy helping those suffering to learn skills to regain control over their lives and the disabling emotions they are experiencing. PTSD treatment helps people to reframe thoughts that are creating tumultuous emotions and erratic behaviors. PTSD can harm relationships because of its symptoms and disruptive nature.

Causes of Prolonged Grief

Any loss might result in prolonged grief, but some kinds are particularly difficult and have a higher risk of leading to prolonged grief disorder. Extremely difficult loss situations include the loss of a parent, loss of a child, and loss of a spouse. Any violent or unexpected death, including murder or suicide, creates a risk for prolonged grief, too. Traumatic loss and traumatic grief are particularly difficult to work through.

The stages of grief might occur in any order and they might be repeated throughout the whole grieving process. If the feelings don’t lessen over time, you get “stuck” in a stage or go back again to a previous stage, it could lead to prolonged grief.

How Long Is Too Long to Grieve?

There are no rules for how long a person should grieve. It’s different for everyone and influenced by several factors, including the ability to adapt to change and how much change is happening in other parts of that person’s life. The specific circumstances surrounding the death also affect the time needed for grief to fade. For example, grief that follows a traumatic or violent death can be particularly difficult.

A general conclusion about how long grief “should” last is anywhere from six months to four years.^5,6 It’s still regular grief as long as the symptoms aren’t becoming more severe or strange, such as talking about the loved one as if they’re still alive. One study shows that feelings of intense grief and mourning peak between four and six months, and decline over the next two years.⁷

Can Prolonged Grief Cause a Loss of Identity?

Prolonged grief is usually related to the loss of a significant person. In conjunction with this loss is the loss of that relationship. For example, in the death of a spouse/partner, your identity as a wife, husband, or partner is lost as well. That can be an important and large aspect of how you view yourself. Grief experts note that the severity of someone’s PGD symptoms is linked to the extent to which the loss was considered to be part of someone’s identity.⁸

How to Cope With Prolonged Grief

Coping with prolonged grief takes effort and some degree of hope that you will feel relief in time. Since grief occurs in emotional “waves,” you will probably have periods of time when the grief is less intense, and other times when it feels overwhelming. There are various ways to cope with grief; some will work better than others for each individual.

Ways to cope with prolonged grief include:⁹

1. Identify supportive people in your life and stay involved with them: this will help you manage the sense of loneliness or isolation that can follow the loss of a loved one
2. Set clear boundaries for yourself: this includes acceptance that you may not feel up to all of your usual commitments, whether in work or social life. It is important to be kind to yourself and make your own emotional well-being a priority when coping with prolonged grief.
3. Consider pursuing a new hobby or interest: it might be difficult to maintain the activities you once enjoyed with the company of your loved one. It can be helpful to start a new hobby or activity for your enjoyment, whether it’s done as an individual or as part of a group.
4. Be mindful of any wishful thinking about the deceased: it is natural to miss a loved one, but it isn’t helpful to dwell on what it might be like if they were still with you
5. Honor the deceased at particular times of the year, such as the anniversary of their birth or death: establishing grief rituals can be a way to keep them in your memories at especially important times like death anniversaries while moving on with your life more generally
6. Accept your loss and the natural sadness that follows: give yourself safe times and places to grieve deeply. Letting yourself have these feelings will eventually allow them to lift and become less heavy.
7. Sort through their belongings and donate whatever you don’t need: by donating items such as clothing, books, or sporting equipment, you will be able to benefit others and facilitate your own process of letting go
8. Ask for help from a mental health professional: most mental health professionals are experienced with providing grief counseling

When a Therapist or Grief Counselor Can Help

In the weeks following loss of a loved one, many people experience shock, disbelief, and denial. If you’re having difficulty getting through your day and functioning at work or home, a grief counselor can help. There’s no need to wait to find out if symptoms lessen or if they become worse. If you’ve been struggling for over six months without improvement, it’s even more important to seek help from a professional.

There are various types of grief counseling available.

• Cognitive behavioral therapy (CBT) has been successful in the treatment of symptoms of prolonged grief with studies showing that 70% of people treated with CBT benefit.¹⁰
• A second type of grief counseling involves interpersonal therapy. In this form of grief therapy, the person’s relationship with the deceased becomes better understood so symptoms can be resolved.¹¹
• A third type of grief counseling combines parts of CBT with interpersonal therapy for greater effectiveness than interpersonal therapy alone.¹¹

You can get online help to find a therapist by asking your primary care provider for a referral or by using an online therapist directory where you can search by specialty and location.

How to Help a Loved One With Prolonged Grief Disorder

There are many things you can do to support a loved one suffering from prolonged grief and help them cope with the pain, including:

• Be available to quietly listen without judgment. Many people tend to self isolate while grieving. Creating availability to listen can be a huge source of comfort and support. The person grieving may need to talk but might not know who to turn to. They may be fearful of being judged by how they are coping (or not coping) with the loss.
• Use the name of the person that has died. Many people try to avoid using the deceased person’s name for fear of upsetting the one who is grieving. Using the name of the deceased with the grieving person offers comfort and helps them to know that the person remains present in the thoughts of others.
• Offer help in concrete ways. Follow through on gestures like buying groceries, cooking meals, helping with childcare. If you have a skill, like understanding insurance claims, then use it to offer to help. These gestures can make a huge difference.
• Be a good friend and observer in your contact with a friend. Look for signs and symptoms getting worse. Watch for  symptoms like increased depression, possible suicide ideation, or increased debilitation. Encourage them to get help from a mental health professional specializing in grief and loss.

Final Thoughts

Prolonged grief is hard to deal with, but there are ways to move forward in life and find meaning again. Each individual grieves in their own unique way, and all types of loss are difficult. There are some types of losses which are particularly difficult for many people. These types of losses create a higher risk of grief which is long lasting and becomes more complex with time. Grief counseling has been shown to be very effective in resolving the symptoms of prolonged grief.