Developing Prolonged Grief Disorder: When Intense Emotional Pain Doesn’t Resolve

Prolonged grief disorder is a mental disorder that occurs when a person experiences the death of someone close to them and continues to display debilitating symptoms of intense grief for an extended period, with no sign of feeling better or processing the loss. This condition is also known as “complicated grief” and is distinguished from what is considered “normal grief” by the extent, duration, and severity of symptoms. 

Address prolonged or complex grief in therapy

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Diagnosing prolonged grief disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association to provide guidance on mental health diagnoses, classifies prolonged grief disorder as “persistent complex bereavement disorder.” To be diagnosed with the condition, a person must have lost someone with whom they had a close relationship and experience specific symptoms. Symptoms may begin in the first few months after a loved one’s death, but it is possible for them to be delayed for months or years. 

The individual must also exhibit at least six of the below symptoms for more days than not, for at least twelve months (in adults) or six months (in children): 

• Difficulty accepting the death, i.e., continuing to behave as though the person is still alive – In children, this symptom should be assessed based on their developmental capacity to understand the permanence of death
• Disbelief regarding the loss
• Emotional numbness
• Becoming more upset when talking about positive memories of the person who died
• Anger or bitterness related to the loss
• Blaming oneself for the loss or adopting other negative beliefs about oneself 
• Avoiding individuals, places, or situations associated with the person who died – In children, this avoidance can also extend to thoughts and emotions related to the person
• A desire to die to reunite with the deceased
• Difficulty trusting other people
• Intense loneliness or detachment from other people 
• Believing that life is meaningless without the person who died or that one cannot function effectively without the person
• Confusion
• A diminished sense of one’s own identity, believing that a part of oneself died along with the deceased
• Reluctance to engage in previously enjoyed activities
• Withdrawal from relationships
• Difficulty planning for the future

Prolonged grief disorder may be more likely in certain populations of people, including women and parents who have lost a child. Children who experience a less stable caregiving environment after their loss may also be more likely to develop the condition, even if the person they lost was not a primary caregiver. 

Other symptoms associated with prolonged grief reactions

Being diagnosed with prolonged grief disorder does not mean a person will experience only the symptoms included in the DSM-5. Additional symptoms, including the following, can occur but are not required for diagnosis: 

• Auditory or visual hallucinations of the person who died, i.e., hearing their voice or seeing them approach
• Digestive issues
• Pain
• Fatigue
• Somatic complaints that mirror the symptoms experienced by the person who died, particularly if they died of an illness or other medical condition
• Suicide ideation
• Negative impacts on one’s ability to work or to function in social situations
• Increased substance use, particularly with alcohol and tobacco
• Higher risk of developing particular serious medical conditions, like hypertension, cancer, immune system dysfunction, and heart disease
• In young children: developmental regression and separation anxiety

People with prolonged grief disorder may be more likely to experience co-occurring mental illnesses. Common co-morbidities include major depressive disorder, substance use disorders, and post-traumatic stress disorder (PTSD). Developing PTSD may be more likely if a person’s loved one died under traumatic or violent circumstances, like a suicide or homicide. Additional symptoms may occur specifically for people with this experience, like a fixation on the last moments of the person who died and their degree of suffering or injury. 

Therapy for prolonged grief disorder

Symptoms of prolonged grief disorder can often be effectively addressed with cognitive-behavioral therapy (CBT). CBT is based on the premise that a person’s thoughts are directly related to their behaviors and that working to change unhelpful thoughts with the help of a therapist can reduce maladaptive actions that may be negatively affecting a person’s life.

Researchers and practitioners have developed a specific form of CBT, known as complicated grief treatment, to treat prolonged grief disorder. In this therapeutic model, a person experiencing prolonged grief disorder may work with their therapist to:

• Better understand their grieving process
• Learn techniques to adjust to the loss
• Boost their coping skills
• Process feelings of blame, shame, and guilt
• Redefine their life goals in light of the loss
• Roleplay conversations “with” the person who died and develop a narrative around their death, which may reduce immediate distress when reminded of the loss
• Receive a treatment plan for any other mental health conditions that may be co-occurring alongside prolonged grief disorder

Address prolonged or complex grief in therapy

Connect with a grief therapist

Alternative support options 

Someone who is experiencing prolonged grief disorder, especially in the early stages, may not have the energy to attend an in-person therapy appointment. In these situations, online therapy could be a beneficial alternative option. With online therapy through an accredited service like BetterHelp, clients can browse a database of therapists specializing in a wide range of mental health conditions, including those related to grief. They can connect with their therapist from the safe space and comfort of their own home, on their schedule. In addition, they may be able to access support groups to talk to others who have experienced grief. 

Research has found that online therapy may have similar efficacy rates to traditional in-person therapy, including when addressing symptoms of grief and loss. One recent study analyzed data regarding online therapy for grief treatment and found that online therapy can have similar outcomes to in-person therapy.