Understanding Complex Or Complicated Grief

Grief can be described as a human response to loss whose process can manifest differently for each person. Most people experience a period of distress, numbness, and other emotions following the death of a loved one. Sometimes, though, intense grief does not diminish over time, which can significantly impair a person’s quality of life and ability to function. Complex grief can be defined as intense sorrow that persists beyond the normal grief period of most individuals, often involving a painful and persistent yearning for the deceased. 

While complex or complicated grief, also referred to as prolonged grief disorder, can be seen as a distinct condition, many of its symptoms overlap with those of other mental health conditions, such as post-traumatic stress disorder. 

For example, those who experience complex grief may grapple with intrusive memories, experience emotional numbing, and avoid reminders of the loss. Persistent bereavement difficulties can also contribute to an increased risk of depression, anxiety, and suicidality, especially in the absence of adequate support from a mental health professional. If you’re having trouble processing grief, attending therapy can be beneficial.

Complex grief is included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Revised (DSM-5-TR) as prolonged grief disorder (PGD), previously called persistent complex bereavement disorder or PCBD. In the original DSM-5, the condition was listed as persistent complex bereavement as a condition for further study.

Complex grief is included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as prolonged grief disorder (PGD), previously called persistent complex bereavement disorder or PCBD. 

As noted by some researchers, the inclusion of this disorder in the DSM-5-TR may offer the recognition that grief can, in some cases, develop into a mental health condition. 

The APA also notes that for this experience to be considered complicated grief, the condition needs to fall outside what is considered typical in one's cultural, social, and religious context. Other researchers add that complicated grief may have other distinct features, such as episodes of grief that are "frequent, prolonged and more intense," as well as presenting the following:

• Intense, persistent yearning for the deceased person 
• Rumination about the deceased and the circumstances surrounding their death
• Preoccupation with details of the death
• Social withdrawal
• Resentment about the death
• Being stunned by the death
• Functional impairment

Risk factors for developing complicated grief

Findings suggest that complex grief may occur more frequently in connection with the sudden, traumatic, or early death of a loved one. 

Researchers also indicate that a range of factors may raise the risk of a person developing complex grief, including those listed below:

• Lower perceived social support 
• Having had a conflicted relationship with the deceased
• Not having had a chance to say goodbye
• A previous history of depression or anxiety
• Major financial difficulties after the death
• Poorer physical health
• Family members having difficulty accepting the death
• Family conflict during the time of death
• Having experienced separation anxiety during childhood 
• Substance misuse
  

Addressing complicated grief

Findings suggest that this type of grief may co-occur with PTSD, depression, and anxiety, as well as sleep disturbances. 

However, prolonged grief disorder is viewed as distinct and "marked by a pervasive yearning for the deceased," which usually does not respond to antidepressants as well as depression. Below are a few approaches to address prolonged grief disorder or complicated grief:

• Cognitive behavioral therapy approaches adapted to address grief, such as CBT for complicated grief reactions - Complicated grief reactions generally refer to co-occurring conditions, such as PTSD and depression. CBT for complicated grief reactions usually consists of 12, 60-minute weekly sessions involving cognitive restructuring, behavioral activation, and exposure. 
• Complicated grief treatment (CGT) –This typically draws from interpersonal therapy and involves 16 sessions structured around topics like managing painful emotions, strengthening relationships, and learning to cope with reminders. CGT usually incorporates elements of cognitive behavioral therapy (CBT) and other approaches. 
• Narrative therapy - This form of therapy normally seeks to integrate intrusive memories with other memories to create a cohesive narrative of the self. Through writing, a person may reconstruct the loss and elaborate on its significance with the help of a therapist. This approach is thought to aid in emotion control and offer a more balanced perspective for disturbing thoughts.

Self-care to navigate complex grief

Self-care may not come easily when one is experiencing grief. However, making an effort to see friends and family, exercising regularly, eating nourishing meals, and establishing a healthy sleep routine can facilitate the healing process. Here are several other ways to practice self-care:

• Accepting help from others
• Practicing breathing exercises
• Avoiding alcohol and substances
• Aiming to restore old routines
• Being kind to yourself 
• Doing something that gives you pleasure each day, such as taking a bath with essential oils or sitting on the porch to watch the sunset
• Practicing self-compassion
• Postponing major life changes if possible 
• Seeking immediate help if needed, such as contacting local emergency services

Therapy for managing complex grief symptoms

Many people can benefit from help navigating grief. Speaking to a therapist can be beneficial for learning to navigate painful memories and emotions in healthy ways. If in-person therapy isn’t accessible or comfortable for you, consider online therapy. A platform like BetterHelp can empower you to attend sessions with a licensed therapist by phone, video, or online chat. 

A 2021 systematic review and meta-analysis sought to examine the effectiveness of internet- and mobile-based interventions for individuals experiencing complex grief symptoms. The study noted that participants generally rated their user satisfaction and the quality of the intervention highly, and researchers concluded that these interventions "might constitute an effective treatment approach against symptoms of grief in bereaved adults."