Background     The majority of individuals experience normal grief after the death of a loved one (see Fast Fact #32). However, about 10-20% of bereaved individuals experience a persistent, debilitating phenomenon referred to as complicated grief (CG) (1). Complicated grief has also been referred to as prolonged or pathologic grief (2); and in the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM V), CG was relabeled as Persistent Complex Bereavement Disorder (3).

Risk Factors     CG is principally considered an attachment disorder (1). Insecure attachment styles (excessive dependency, compulsive care-giving, defensive separation) are correlated with CG. Additionally, supportive marital relationships (characterized as security-enhancing, confiding and emotionally supportive) are correlated with CG after the loss of a spouse suggesting that the loss of a spouse who provides emotional stability and security may lead to an exacerbated grief reaction (4).  Other risk factors include weak parental bonding in childhood, childhood abuse and neglect, female gender, low perceived social support, and low preparation for the loss (1,5).

Impact on Health     CG is associated with mental and physical health problems including depression, hypertension, work and social impairment and reduced quality of life. Additionally, CG increases an individual’s risk of suicide and suicidal behavior (7).

Diagnosis     CG shares characteristics with major depressive disorder (suicidal ideation, preoccupation with worthlessness) and post-traumatic stress disorder (re-experiencing intrusive thoughts of the deceased, avoidance of reminders of the deceased and emotional numbness).  However these are separate entities differentiated by precipitating events, risk factors, course of illness and response to intervention (2). The precise diagnostic criteria for CG are currently being debated (5). Commonly agreed upon characteristics include: 

• yearning, pining, or longing for the deceased
• trouble accepting the death
• feeling uneasy about moving on with one’s life
• inability to trust others since the death
• excessive bitterness or anger about the death
• persistent feeling of being shocked, stunned, or emotionally numb since the death
• frequent intense feelings of loneliness
• feeling that life is empty or meaningless without the deceased (refraining from doing things/going places that remind one of the loss)
• frequent preoccupying thoughts about the person that died

Symptoms must cause marked dysfunction in social, occupational or other important domains. The duration of symptoms required to meet criteria for CG has not been defined and varies between six to twelve months after the death (1, 5).

Screening   The following Brief Grief Questionnaire is a 5-item screening tool scored on a 0-2 Likert scale (‘not at all,’ ‘somewhat,’ ‘a lot’) which has been used to screen for CG (6).

1. How much of the time are you having trouble accepting the death of a loved one?
2. How much does your grief interfere with your life?
3. How much are you having images or thoughts of your loved one when he or she died or other thoughts about the death that really bother you?
4. Are there things that you used to do when your loved one was alive that you don’t feel comfortable doing more, that you avoid? How much are you avoiding these things?
5. How much are you feeling cut off or distant from other people since your loved one died, even people you used to be close to, like family or friends?

Expert recommendation is that individuals with scores of ≥5 should undergo a diagnostic evaluation by a mental health professional (7).

Treatment     A recent meta-analysis on the treatment of CG showed efficacy of interventions including cognitive-behavioral and group therapy in alleviating symptoms with a duration of benefit from 3-6 months. Limitations of the meta-analysis include under-representation of men (average 71% female), small number of studies included (n=5), and small number of participants (n=485, 109 lost to follow up) (8). There have been no randomized controlled trials evaluating the pharmacologic treatment of CG and there is currently no defined role for drug therapy. A randomized trial is currently underway to evaluate the effect of a selective serotonin reuptake inhibitor on CG. Many hospice agencies provide bereavement services, even if the bereaved’s loved one was not a patient of the hospice agency.

Bottom Line     Most bereaved individuals experience normal grief. A minority will experience long-term, persistent, disruptive symptoms that impair functioning and increase the risk for negative mental and physical health states. Individuals suffering from CG benefit from referral to a trained mental health provider who can administer therapy specific to CG.

References

1. Zhang B, et al. Update on bereavement research: evidence-based guidelines for the diagnosis and treatment of complicated bereavement. J Pall Med. 2006; 9:1188-1203.
2. Lichtenthal WG, et al. A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clin Psych Rev. 2004; 24:637-662.
3. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Arlington, VA, APA Press.
4. Van Doorn C, et al. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis. 1998; 186:566-573.
5. Shear KM, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety.  2001; 28:103-117.
6. Shear KM, et al. Screening for complicated grief among project liberty service recipients 18 months after September 11, 2001. Psychiatric Services. 2006; 57:1291-7.
7. Reynolds C, et al. Healing Emotions After Loss (HEAL): Diagnosis and Treatment of Complicated Grief. UPMC Synergies. Spring 2011. Available at: http://healstudy.org/wp-content/uploads/2010/10/S270-Synergies_GR_Spring_2011.pdf. Accessed March 22, 2012.
8. Wittouck C, et al. The prevention and treatment of complicated grief: a meta-analysis. Clin Psych Rev. 2011; 31:69-78.

Authors’ Affiliation:   University of Pittsburgh Medical Center, Pittsburgh, PA.

Version History:  First published June 2012. Updated December 2012 with the addition of Reference #6. Updated again in August 2015 with reference # 3 added and incorporated into the text.