Complicated grief is grief that lasts longer and is more intense than a culture may consider typical. It may disrupt someone’s daily life, alter their sense of identity, and cause frequent, strong emotions, such as longing, anger, or loneliness.

In 2021, the American Psychiatric Association (APA) added complicated grief, or prolonged grief disorder, to an updated version of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The International Classification of Diseases (ICD-11) lists a similar condition.

However, the concept of complicated grief as a medical diagnosis is controversial. In a 2018 study of over 2,000 mental health professionals, only 24.8% thought prolonged grief disorder should be a separate diagnosis in the ICD-11.

In this article, we will look at what complicated grief is, its symptoms, and how it compares to other emotional states and conditions. We will also explain how professionals diagnose and treat prolonged grief disorder and when to seek support.

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“Complicated grief” is a term for grief that is more intense or lasts longer than a culture may consider typical. According to the APA, it may cause someone to become preoccupied by their loss in a way that disrupts daily life.

This is a common reaction to a bereavement in the early stages of mourning. However, the National Cancer Institute suggests that grief typically begins to come in waves or bursts after this point, causing temporary longing or sadness that comes and goes.

A person with complicated grief may feel their loss all the time, though, long after the initial mourning period. They may feel part of themselves has died, along with the loved one.

According to a 2022 article, complicated grief may affect up to 7–10% of people who experience bereavement.

Some health organizations recognize complicated grief as a medical diagnosis.

The APA included prolonged grief disorder in the newest edition of the DSM-5. The ICD-11 uses the same terminology. Earlier diagnoses included prolonged bereavement disorder and persistent complex bereavement disorder.

Not all experts agree that complicated grief is a mental health condition, though.

In a 2020 study of 2,088 German mental health professionals, less than half felt the benefits of including the diagnosis in the ICD-11 outweighed the disadvantages, and 32.9% said the disadvantages outweighed the advantages.

Study participants suggested that the diagnosis might pathologize grief, turning it into an illness rather than a normal experience. This could create stigma.

Participants also emphasized that social norms surrounding grief differ across cultures, meaning that what one culture considers a pathology might be typical in another.

Some evidence suggests that people who have experienced bereavement also have mixed feelings about the diagnosis. A 2020 survey of people who had lost partners found that while some welcomed it as a recognition of how significant grief can be, others criticized the inclusion of specific time frames for grief.

Additionally, it is unclear how common complicated grief truly is. In one study of people who lost loved ones in the September 11 terrorist attacks in 2001, 43% met the criteria for complicated grief 2.5 to 3.5 years later.

This may suggest that long lasting grief is more common than scientists estimate. More research is necessary to confirm or disprove this.

According to the APA, potential signs of prolonged grief disorder include:

  • Reintegration difficulties: Usually, after a loss, people gradually reenter their daily lives and begin resuming their typical activities. The APA states that those with complicated grief have difficulty with this, affecting their work, school, and relationships.
  • Avoidance: A person may avoid reminders that their loved one has died, or people and places that remind them of the loss.
  • Emotional pain: A person may have intense feelings of sadness, loneliness, and yearning. Sometimes this emotional pain may affect their physical health. A 2018 paper notes that complicated grief is associated with high blood pressure, headaches, and lower quality of life.
  • Acute grief symptoms: With “typical grief,” a person has an initial phase of active, acute grieving that may consume much of their life. They may cry frequently or feel sad very often. Complicated grief causes acute grief symptoms to last longer. Some acute grief symptoms include:
    • intense longing for the person who has died
    • intense sadness
    • frequent crying
    • having difficulty thinking about anything other than the grief

A person does not need to wait for grief to become overwhelming before seeking help. A therapist can help them discuss their feelings in a safe space and process what has happened.

This does not mean someone must forget about the loss, but with support, they can learn to manage how it makes them feel.

A person can consider seeking help if:

  • grief disrupts their daily life
  • they feel consistently sad, lonely, or hopeless
  • they feel they do not have someone to talk to, or do not have adequate support

Rarely, grief can cause a life threatening condition known as Takotsubo cardiomyopathy. Some refer to it as “broken heart syndrome.” It is not a heart attack, but the symptoms are similar and include chest pain and shortness of breath.

People who experience these symptoms should seek emergency care. Tell the doctor about the grief since this may help with diagnosing the condition.

People with intense grief may sometimes have suicidal thoughts. If a person is thinking about suicide, they should seek help right away.

Suicide prevention

If you know someone at immediate risk of self-harm, suicide, or hurting another person:

  • Ask the tough question: “Are you considering suicide?”
  • Listen to the person without judgment.
  • Call 911 or the local emergency number, or text TALK to 741741 to communicate with a trained crisis counselor.
  • Stay with the person until professional help arrives.
  • Try to remove any weapons, medications, or other potentially harmful objects.

If you or someone you know is having thoughts of suicide, a prevention hotline can help. The National Suicide Prevention Lifeline is available 24 hours per day at 800-273-8255. During a crisis, people who are hard of hearing can use their preferred relay service or dial 711 then 800-273-8255.

Click here for more links and local resources.

Grief affects people differently, so there can be a lot of variation in the emotions, physical symptoms, and impact of grief between two individuals. Because of this, there is no firm definition of typical grief.

It is also worth bearing in mind that research into grief is still fairly new, and there are many things researchers still do not know.

That said, the current definition of complicated grief has some distinctive features that set it apart. These include:

  • Intensity: Immediately following a loss, there is an acute phase of grief during which a person may feel very sad, lost, confused, and overwhelmed by feelings of yearning for the person who has died. They may have trouble eating or sleeping, or have physical symptoms such as pain and dizziness. When these symptoms last much longer than the immediate aftermath of a loss, a doctor may consider this complicated grief.
  • Duration: According to the APA, an adult must have experienced the death of a loved one at least 12 months earlier to receive a diagnosis of prolonged grief disorder. For children and teens, the loss must have occured at least 6 months earlier. In effect, this means a person must have experienced the grief for at least this amount of time in order to meet the criteria.
  • Disruption of daily life: Immediately following a loss, daily functioning may be challenging. A person may feel overwhelmed by sadness. Over time, a person may learn to live with the loss and think of or miss the person more periodically. When grief disrupts daily life and functioning for a long time, on an ongoing basis that lasts at least a month, a doctor may consider this complicated grief.

Sometimes bereavement can trigger depression. However, complicated grief and depression are different. While both can cause intense sadness or feelings of isolation, the focus of these feelings tends to be different.

In people who are grieving, the emotions focus on a lost loved one. They may arise if a person remembers the person as they go about their day. In prolonged grief, this is pervasive and frequent.

People with depression may have more generalized feelings, such as hopelessness, guilt, or worthlessness. The feelings may be directed inward, at themselves, rather than centering on the person they have lost.

Alternatively, someone with depression may experience a lack of emotion rather than intense emotion. They may not have much motivation or enthusiasm for things they once enjoyed.

An article by the APA notes that the differences between people who are grieving and people with depression are visible on brain scans. In those who are grieving, feelings of connection to their deceased loved one activate the reward centers of the brain. This does not happen in people who only have depression.

However, it is possible to have both complicated grief and depression at the same time.

A 2021 systematic review and meta-analysis of 23 prior studies on grief found a 63% co-occurrence rate for depression. The rate for anxiety was 54%, and the rate for post-traumatic stress disorder (PTSD) was 49%.

Researchers are not sure why some people develop prolonged grief, and others do not. Different studies have identified various risk factors. Some include:

  • a loved one dying in a way that is sudden, painful, violent, or otherwise traumatic
  • the nature of the relationship with the departed loved one, as closer relationships may inspire more grief
  • denial or difficulty accepting the death
  • avoidance of difficult emotions, which may prevent someone from processing what has happened
  • a negative view of the self and the world

A therapist can diagnose prolonged grief based on someone’s symptoms. Because there are similarities between prolonged grief, depression, and PTSD, they may ask someone a series of questions to try and distinguish between them.

Once a therapist understands someone’s symptoms and their impact, they will help a person work through their feelings in talk therapy.

Some therapists specialize in grief therapy. There is also a specific form of talk therapy for complicated grief, known as complicated grief treatment.

Other options include cognitive behavioral therapy specifically adapted for grief and graded exposure therapy, which may help people who feel they must avoid people, places, or things associated with the loss.

For those with depression, antidepressants may help reduce the symptoms. However, medication generally does not help with grief itself, which impacts the brain differently.

Complicated grief can be extremely painful.

Compassion for oneself and support from others can help. With time, a person can learn to process their grief and begin to improve their quality of life.

People who are experiencing any type of grief can seek help from a mental health professional.