Background for Fast Fact #254     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, and intense phenomenon referred to as complicated grief (CG) or prolonged grief disorder (PGO) (1,2).  The most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM V-TR) and the ICD-11 both relabeled CG as prolonged grief disorder (PGO) (3). Throughout this Fast Fact therefore we will utilize the term PGO.

Risk factors     PGO is principally considered an attachment disorder found across many cultures and age ranges (1). Anxious and insecure attachment styles (e.g., excessive dependency, compulsive caregiving) are correlated with PGO. Additionally, supportive marital relationships (characterized as security-enhancing, confiding, and emotionally supportive) are correlated with PGO suggesting that the loss of a spouse who provides emotional stability and security can illicit an exacerbated grief reaction (4).  Other risk factors include age older than 61, lower socioeconomic status, history of mental illness, death of a young person, death by violent means, caregiver burden, overly aggressive medical interventions prior to death, perception of an uncaring medical staff, uncertainty about the cause of death, childhood abuse and neglect, female gender, low perceived social support, and low preparation for the loss (1,5-7).

Impact on health     PGO is associated with mental and physical health problems including depression, hypertension, work and social impairment, increased use of alcohol, difficulty trusting others, impaired concentration, early mortality, and reduced quality of life (7,8). Additionally, PGO increases an individual’s risk of suicidal ideation (present in approximately 40%), suicide, and suicidal behavior (7).

Diagnosis     PGO 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 PGO are debated (5). Symptoms must cause marked dysfunction in important domains. Commonly agreed upon characteristics include (9):   

• Intense grief that lasts at least 6 months after the loss.
• Separation distress – yearning for the deceased.
• Traumatic distress – disbelief, trouble accepting the death, intrusive thoughts/images of the death.
• Inhibited willingness to explore the world – feeling disconnected from others, loss of interest in ongoing life or other relationships.
• Excessive avoidance of reminders of the loss.
• Difficulty regulating emotions.
• Ruminating thoughts around caregiver self-blame, anger, or alternative scenarios to the death.

In one study, the 5 most frequent PGO symptoms were yearning for the deceased (88%); feeling upset by memories of the deceased (82%); loneliness (81%); feeling life is empty 80%; and disbelief (76%) (9).

Screening   The Brief Grief Questionnaire is a 5-item screening tool for PGO scored on a 0-2 Likert scale (‘not at all,’ ‘somewhat,’ ‘a lot’) (6). Individuals with scores of ≥4 should undergo diagnostic evaluation (5). 

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?
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?
5. How much are you feeling cut off or distant from other people since your loved one died?

Treatment     The goal of PGO treatment is to facilitate integration of the loss, it is not to eliminate all grief-related symptoms.  Most experts recommend a type of psychotherapy provided by mental health professionals called “prolonged grief disorder therapy” as first line treatment based on best published data (10-12).  If this does not work, mental health professionals may utilize cognitive-behavioral therapy techniques, exposure therapy, or mindfulness-based cognitive therapy (8,11,13). 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 PGO will benefit from referral to a trained mental health provider who can administer therapy specific to PGO.

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.  Diagnostic and statistical manual of mental disorders. 2022; 5th ed., text rev.
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. Fujisawa D, Miyashita M, Nakjima S, et al.  Prevalence and determinants of complicated grief in general population.  J Affect Disord 2010;127(1-3):352.
6. Hudson P, Hall C, Boughey A, et al.  Bereavement support standards and bereavement care pathway for quality palliative care.  Palliat Support Care 2018; 16(4):375.
7. Nielson MK, Neergaard MA, Jensen AB, et al.  Predictors of complicated grief and depression in bereaved caregivers: a nationwide prospective cohort study. J Pain Symptom Manage 2017; 53(3):540.
8. Boelen PA, Smid GE. Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder. BMJ 2017; 357:j2016.
9. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 2009; 6(8):e1000121.
10. Doering BK, Eisma MC. Treatment for complicated grief: a state of the science and ways forward. Curr Opin Psychiatry 2016; 29(5):286.
11. Wittouck C, et al. The prevention and treatment of complicated grief: a meta-analysis. Clin Psych Rev. 2011; 31:69-78.
12. Shear MK, Reynolds CFIII, Simon NM, et al.  Optimizing treatment of complicated grief: a randomized controlled trial. JAMA Psychiatry 2016; 73(7):685-694.
13. Bryant RA, Kenny L, Joscelyne A, et al.  Treating prolonged grief disorder: a 2-year follow-up on a randomized controlled trial. J Clin Psychiatry 2017; 78(9):1363.

Authors’ Affiliation:   University of Pittsburgh Medical Center, Pittsburgh, PA.
Version History:  First published June 2012. Reviewed and updated in 2015; reviewed and updated again in September 2025.
Conflicts of Interest: none to report.