Complicated Grief

Posted by • January 9th, 2015

Complicated grief is intense grief after the death of a loved one that lasts longer than expected according to social norms and causes functional impairment. Psychotherapy directed at the loss and at restoring activities and effective functioning is recommended.

The condition of complicated grief, which is also called prolonged grief disorder, affects about 2 to 3% of the population worldwide. This condition is characterized by intense grief that lasts longer than would be expected according to social norms and that causes impairment in daily functioning. Complicated grief can follow the loss of any close relationship. Clinical experience suggests that without treatment, symptoms of complicated grief diminish slowly and can persist.

Clinical Pearls

What are the symptoms of complicated grief?

The hallmark of complicated grief is persistent, intense yearning, longing, and sadness; these symptoms are usually accompanied by insistent thoughts or images of the deceased and a sense of disbelief or an inability to accept the painful reality of the person’s death. Rumination is common and is often focused on angry or guilty recrimination related to circumstances of the death. Avoidance of situations that serve as reminders of the loss is also common, as is the urge to hold onto the deceased person by constantly reminiscing or by viewing, touching, or smelling the deceased person’s belongings. People with complicated grief often feel shocked, stunned, or emotionally numb, and they may become estranged from others because of the belief that happiness is inextricably tied to the person who died. They may have a diminished sense of self or discomfort with a changed social role and are often confused by their seemingly endless grief.

What are the risk factors for complicated grief?

Risk factors include a history of mood or anxiety disorders, alcohol or drug abuse, and multiple losses. Depression in persons who have been caregivers during a loved one’s terminal illness and depression early in bereavement are predictors of complicated grief later in bereavement. Personal factors such as these may interact with characteristics of the relationship with the deceased or with the circumstances, context, or consequences of the death to increase the risk. Losing someone with whom one has had a close relationship can be especially hard if the bereaved person had a difficult upbringing or if there are unusually stressful consequences of the death, inadequate social supports, serious conflicts with friends or relatives, or major financial problems after the death.

Morning Report Questions

Q: How can clinicians identify patients with complicated grief?

A: Questions about important losses should be part of a standard diagnostic evaluation, especially in the case of older patients, for whom loss is common. Patients are sometimes ashamed of their persistently intense grief, so it is important for clinicians to ask direct questions in a sensitive and empathic way. A semistructured-interview format to facilitate assessment of complicated grief is a shortened version of a validated instrument. The Brief Grief Questionnaire and the Inventory of Complicated Grief are self-report questionnaires that can be used to screen patients for complicated grief. The clinical evaluation of a bereaved person should also include screening for other psychiatric and medical disorders, since coexisting conditions are common.

Table 1. Provisional Proposed Guidelines for the Diagnosis of Prolonged Grief Disorder in the International Classification of Diseases, 11th Revision.

Table 2. Differential Diagnosis of Complicated Grief, Major Depression, and Post-Traumatic Stress Disorder (PTSD).

Q: What treatments are recommended for complicated grief?

A: Randomized, controlled trials have shown that psychotherapy is efficacious for complicated grief, so it is the first-line treatment. A short-term approach called complicated grief treatment is the treatment that has been most extensively studied to date. Its objectives are to identify and resolve complications of grief and to facilitate adaptation to loss. Trials suggest that interventions that include strategies to reduce avoidance of thoughts about the death and avoidance of activities and places that are reminders of the loss are more effective than those that do not. Although data are lacking from randomized trials to inform the use of pharmacotherapy for complicated grief, antidepressant medication is used commonly in practice. Five open-label trials that involved a total of 50 patients suggested improvement in patients who received antidepressants, but not benzodiazepines.

Table 3. Core Components of Treatment for Complicated Grief.

One Response to “Complicated Grief”

  1. Stephanie says:

    It’s so very awful to see someone going through so much pain. I’m glad you are putting so much thought and research into this.