When Mourning Does Not End: Identifying and Treating Complicated Grief

There are few more devastating events than loss of a loved one, especially under sudden, unnatural, or traumatic circumstances. While bereavement is a normal response to a serious loss, it is different from depression — although the two can coexist — and when it becomes prolonged or disabling, it is sometimes called “complicated grief (CG).”¹

“The loss of a loved one triggers a grief reaction and a process of adapting to that loss,” Natalia Skritskaya, PhD, Clinical Psychologist and Research Scientist at the Center for Complicated Grief, Columbia School of Social Work, New York, told Psychiatry Advisor.

Grief is “intensely painful,” but it is “generally a self-limiting process.”² “For most people, the intensity of grief diminishes gradually over time and they are able to adapt to the loss, restore their functioning, and go on with their lives,” Dr Skritskaya said. “But for a minority of bereaved people, this does not happen, and the intense reaction of acute grief persists — potentially indefinitely, becoming a chronic persistent condition where that initial pain of loss continues.”

When this takes place, the individual experiences “prolonged suffering and debility, as well as susceptibility to general medical deterioration, major depression, substance abuse, and suicidal thoughts and behavior,”¹ as well as anger and difficulty trusting others.³

Nomenclature of “Complicated Grief”

A variety of terms other than CG have been used to identify this condition, including “prolonged grief disorder,” “unresolved grief,” “pathological grief,” and “persistent complex bereavement disorder,” which is the diagnosis used in DSM-5.^4,5  All of these terms suggest that the “grief is unusually intense, lasts well beyond the period expected by social and cultural norms, and is accompanied by impairments in daily functioning.”²

“In complicated grief, also called prolonged grief, the intense acute reaction persists, potentially indefinitely,” according to Dr Skritskaya. “The most frequent time period for this that we have seen in our clinical trials is 2 years post-loss, but we have also seen people who remained in the state of bereavement as much as 5 years post-loss, and others for whom it has been decades where that initial pain of loss continues.”

The DSM-IV⁶ excluded a first-time diagnosis of major depressive disorder (MDD) during the first 6 months of bereavement, however this “exclusion” was eliminated in DSM-5⁴ because severe MDD can be triggered by bereavement or the two conditions may coexist. The issue was hotly debated because of the concern that normal grief might become pathologized.⁷ However, although “we must not ‘medicalize’ normal grief, neither should we ‘normalize’ the serious disorder of major depression simply because it occurs in the context of recent bereavement.”⁷

Current DMS-5 criteria for persistent complex bereavement disorder are listed in Table 1.

“The terminology going forward is likely to be ‘prolonged grief disorder,’ which will be used by the WHO in the 11^th edition of the ICD,” Dr Skritskaya said. (Table 2)

For the sake of simplicity and consistency, however, this article will use the term complicated grief (CG).

Risk Factors for Complicated Grief

Several studies have pointed to a greater prevalence of complicated grief in women vs men,⁸ although “I don’t think we fully understand the reasons for this,” Dr Skritskaya commented. She suggested that biological, social, and cultural components might all be contributors.

Some research has suggested that loss of a loved one to suicide or violence, or loss of a child, increase the risk. Additional risk factors are listed in Table 3.

“I would like to emphasize that, although losing a loved one to suicide is a major risk factor for prolonged grief, not everyone who loses a loved one to suicide develops this condition. Like any other risk factor, this just increases the risk,” Dr Skritskaya said.

She added that people are very individual in how they react to loss, and certain patterns of thinking can “derail” the process of adaptation.

“When a person is trying to rewrite the reality of a loss and has trouble accepting what happened, that reaction is natural. If you have lost a loved one, no one wants it to happen, so the initial reaction is to protest and think of all the ways that this really didn’t have to happen,” she observed.

But “if the person gets too caught up in this process and in trying to find answers to the questions of ‘why’ and ‘how’ it happened, it can become maladaptive.”

Similarly, “it is normal to push pain away because no one wants to feel pain, but if this type of ‘pushing away’ is the main response to grief and used as the primary coping tool, it can backfire in the long run and the grief can become prolonged.”

Differential Diagnosis

Dr Skritskaya explained that CG is a “distinct condition” and differs from depression and anxiety, as well as posttraumatic stress disorder (PTSD), which are the most common differential diagnoses — although there is some overlap.⁹

“Both grief and depression are characterized by sadness, but if you look more closely at the symptoms, you see the difference,” she said.

In grief, the sadness centers on the loss of a loved one and the person is sad because the loved one is no longer here, while in depression, “sadness is more about the feeling of failure, not being good at things, and being more self-focused,” she pointed out.

Moreover, the types of ruminative thinking — especially feelings of guilt — are different in depression than in grief. “In grief, guilt feelings are more often related to the death and surrounding events and are tied to the loss of the relationship. The person feels, ‘I should have done more.’ In depression, on the other hand, the person is more likely to feel guilty or self-critical about not being a good person in general or being unable to do things right.”

Although both depression and grief can be characterized by apathy and anhedonia, these are more pervasive in depression than in grief,” Dr Skritskaya noted.

Similarly, Dr Skritskaya continued, there is overlap between PTSD and prolonged grief, but “at the center of the grief reaction, there is loss — the absence of someone who was valued — while in PTSD, there has been trauma and presence of a threat.” Although avoidance is common to both conditions, it more related to loss in CG and to fear for survival in PTSD. Additionally, many people experiencing CG seek proximity to the loved one by looking at the deceased’s belongings or photographs, wearing the deceased’s clothing, or going to the cemetery frequently. These are not typical symptoms of PTSD.

Dr Skritskaya noted that the upcoming ICD will categorize PTSD and complicated grief in the same category, as stress or trauma-related conditions. “But in CG, the reaction is to loss — the absence of someone who was valued — while in PTSD, it is the presence of a threat.”

She emphasized that it is important to differentiate between normal grief, CG, MDD, and PTSD because these conditions respond to different treatments. (Tables 4 and 5)

Diagnosing Complicated Grief

Several assessment instruments are found to be helpful in diagnosing CG. These include the 19-item Inventory of Complicated Grief (ICG), which has shown good internal consistency and test-retest reliability.”¹⁰ In particular, it is designed to distinguish between normal vs pathological grief reactions.¹⁰ The Brief Grief Questionnaire (BGQ) is a shorter instrument, more suited to settings where clinicians have time constraints when working with clients.

[http://complicatedgrief.columbia.edu/wp-content/uploads/2016/05/BGQ.pdf]

Targeted Psychotherapy

Dr Skritskaya pointed to short-term complicated grief treatment (CGT) as the “most extensively tested and evidence-based treatment for CG.”^11,12

“CGT is a 16-session intervention, based to some extent on CBT [cognitive behavioral therapy] but one might say it has been influenced by ‘third-wave’ CBT approaches, incorporating a more dialectical and acceptance-oriented approach,” Dr Skritskaya said.

CGT also “incorporates attachment perspective theory, because we view that perspective as very helpful in understanding grief, since grief comes from the loss of a close relationship. Additional strategies incorporated from other approaches include motivational interviewing [MI] as well as interpersonal therapy,” she said.

CGT is “designed to remove impediments to adaptation and facilitate natural adaptive processes,” with adaption having both a “loss focus” and a “restoration focus.” It includes “some exposure components, situational visiting, MI, and psychoeducation, normalizing reactions, explaining grief, and giving guidance about what is helpful and what strategies could backfire,” Dr Skritskaya noted.

CGT is constructed around 7 “core themes:”¹

• Understanding/accepting grief
• Managing emotional pain and monitoring symptoms
• Thinking about the future
• Strengthening ongoing relationships
• Telling the story of the death (sometimes called “restorative retelling)
• Learning to live with reminders
• Connecting to memories

Ideally, clinicians should refer the client to a CGT specialist; however, they can implement treatment themselves, with time limitations and frequency based on practice setting.

More information and a treatment manual are available at:

Professionals

Pharmacotherapy for CG

Pharmacologic interventions are typically not helpful as monotherapy for CG. A study of individuals who experienced CG who were taking either antidepressants alone, [receiving] CGT alone, or a combination of medication and CGT found a higher dropout rate among those receiving medication alone, compared to those receiving CGT alone, and all participants in CGT experienced improvement in grief symptoms, suicidal ideation, grief-related impairment, avoidance, and maladaptive beliefs.^11,12 However, adjunctive antidepressant therapy can be helpful for some clients.⁹ 

Step-by-Step

When working with clients who are experiencing grief, the recommended approach¹ is to:

• Recognize if CG is present
• Discuss the diagnosis with the client
• Provide/refer clients to appropriate therapy
• Invite the client to share the narrative of his/her relationship with the deceased loved one and the death
• Explore the client’s grief experience
• Assess for potential suicide risk
• Screen for frequently comorbid conditions, (eg, MDD, PTSD, and substance use disorders)

An important component of working with CG is active listening and establishing a therapeutic alliance. These enable further work that builds on the relationship and connection, Dr Skritskaya said. “Compassion and understanding are the foundation for working with CGD, as with acute grief, and when those are present, other components of treatment will follow.”

References

1. Iglewicz A, Shear MK, Reynolds CF III, Simon N, Lebowitz B, Zisook S. Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice. Depress Anxiety. 2020 Jan;37(1):90-98. doi:10.1002/da.22965
2. Zisook S, Reynolds CF III. Complicated grief. Focus (Am Psychiatr Publ). 2017;15(4):12s-13s. doi:10.1176/appi.focus.154S14.
3. Fields SA, Johnson WM, Mears J. How to treat complicated grief. J Fam Pract. 2018 Oct;67(10):637-640.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5^th edition). Washington, DC, 2013.
5. Mauro C, Shear MK, Reynolds CF, Simon NM, Zisook S, Skritskaya N, et al. Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients. Psychol Med. 2017 Mar;47(4):608-615. doi:10.1017/S0033291716002749
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text Revision). Washington, DC, 2013.
7. Pies RW. The bereavement exclusion and DSM-5: An update and commentary. Innov Clin Neurosci. 2014;11(7-8):19-22.
8. Lundorff M, Bonanno GA, Johannsen M, O’Connor M. Are there gender differences in prolonged grief trajectories? A registry-sampled cohort study. J Psychiatr Res. 2020 Oct;129:168-175. doi:10.1016/j.jpsychires.2020.06.030
9. Maercker A, Znoj H. The younger sibling of PTSD: similarities and differences between complicated grief and posttraumatic stress disorder. Eur J Psychotraumatol. 2010;1:10.3402/ejpt.v1i0.5558. doi:10.3402/ejpt.v1i0.5558
10. Jordan AH, Litz BT. Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Prof Psychol Res Pr. 2014;45(3):180–187. doi:10.1037/a0036836
11. Shear MK, Reynolds CF III, Simon NM, et al. Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial. JAMA Psychiatry. 2016;73(7):685-694. doi:10.1001/jamapsychiatry.2016.0892
12. Zisook S, Shear MK, Reynolds CF, et al. Treatment of complicated grief in survivors of suicide loss: A HEAL report. J Clin Psychiatry. 2018 Mar/Apr;79(2):17m11592. doi:10.4088/JCP.17m11592

Table 1

DSM-5 Diagnostic Criteria for Persistent Complex Bereavement-Related Disorder

Death of a loved one followed by…

≥1 of the following symptoms, occurring on most days for ≥12 months after the loss Yearning/longing for loved oneEmotional pain, intense sorrowPreoccupation with the deceasedPreoccupation with the circumstances of the death

AND

≥6 of the following clinically significant symptoms, occurring on most days for ≥12 months after the loss Difficulty accepting loss Marked difficult accepting the deathDisbelief/numbness over the lossInability to have positive memories of the loved oneAnger/bitterness related to the lossSelf-blameExcessively avoiding reminders of the loved onDesire to reunite with the loved oneLoss of trust in others since the deathLoneliness/detachmentFeeling that life is empty and meaningless without the deceased, belief that one cannot function without the deceasedDiminished sense of identityLack of pursuit of interests/hobbies

The disturbances cause clinically significant distress or impairment

The bereavement reaction is out of proportion to or inconsistent with cultural/religious norms

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5^th edition).Washington, DC, 2013.

Table 2

ICD-11 Criteria for the Diagnosis of Prolonged Grief Disorder

A persistent and pervasive grief response characterized by longing for/persistent preoccupation with the deceased and accompanied by intense emotional pain sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, inability to have a positive mood, emotional numbness, or difficulty in engaging with social or other activities

A grief response that has persisted for an abnormally long period of time after the loss, clearly exceeding expected social, cultural, or religious norms; this category excludes grief responses within 6 months after the death and for longer periods in some cultural contexts

A disturbance that causes clinically significant impairment in personal, family, social, educational, occupational, or other important areas of functioning

Eisma MC, Rosner R, Comtesse H. ICD-11 Prolonged grief disorder criteria: Turning challenges into opportunities with multiverse analyses. Front Psychiatry. 2020;11:752. doi:10.3389/fpsyt.2020.00752

Table 3

Risk Factors for the Development of Complicated Grief

Relationship to Loss	Risk Factors
Pre-loss	Female sexPreexisting trauma (especially childhood trauma)Prior lossesInsecure attachmentPreexisting mood and anxiety disordersPreexisting mental illnessNature of the relationship (eg, loss of a child)Substance use disorders
Loss-related	Relationship and caregiver roles (spouses, mothers of dependent children, caretakers for chronically ill)Nature of the death itself (eg, violent, sudden, prolonged, suicide, drug-related)
Peri-loss	Social circumstances (eg, lack of family or community support)Lack of resources following the deathPoor understanding of the circumstances of the death (ie, lack of information about the death)Interferences with natural health process (eg, inability to follow usual cultural practices of death/mourning, alcohol of substance use)Major financial problems following the deathSerious conflicts with family/friends

Simon NM. Treating complicated grief. JAMA. 2013;310(4):416-423. doi:10.1001/jama.2013.8614

Table 4

Distinguishing Grief from Major Depressive Episodes

Grief	Major Depressive Episode
Emptiness/feeling loss	Persistent depressed moodAnhedonia
Decreases in intensity over days and weeksOccurs in waves	More persistent most of the dayTypically occurs every day
Self-derogatory thoughts (if present) related to perceived failings vis-à-vis the deceased	Self-critical and persistent ruminationsFeelings of worthlessness
Thoughts about death/dying typically focused on deceased and possibility of “joining them”	Thoughts of death/dying more typically focused on ending one’s own life (eg, due to sense of worthlessness, being undeserving of life, or unable to cope with pain of depression

Parkes CM. Complicated grief in the DSM-5: Problems and solutions. Arch Psychiatr Ment Health. 2020; 4: 048-051. doi:10.29328/journal.apmh.1001019

Table 5

Distinguishing Complicated Grief from Posttraumatic Stress Disorder

Complicated Grief

Posttraumatic Stress Disorder

Yearning symptoms Preoccupation with the deceased/circumstances of deathVoluntary thoughts about the about deceasedAvoidance of reminders of the lossFailure to adaptEmotional numbingFocus on the deceased

Involuntary/intrusive thoughtsAvoidance or efforts to avoid distressing memoriesAnxious hyperarousalRecurrent involuntary distressing memories of traumaDissociative reactionsFlashbacksNightmaresAggressionPhysiological reactions to reminders of the traumaInability to remember important aspects of the traumaAvoidance of distressing thoughts or feelings related to the traumaAvoidance of external reminders of the traumaFocus on threat

Jordan AH, Litz BT. Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Prof Psychol Res Pr. 2014;45(3):180–187. doi:10.1037/a0036836