What Is Prolonged Grief Disorder? DSM-5 Definition, Risk Factors, And Potential Treatments

The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM-5, made many changes to the ways certain mental illnesses are diagnosed and categorized. One potentially controversial update was the addition of prolonged grief disorder (PGD), a diagnosis indicating that a person is experiencing an unusually persistent and severe grief reaction. What exactly are the criteria for this disorder, and what separates it from a common and healthy expression of mourning? 

A prolonged grief disorder diagnosis usually requires intense, debilitating grief reactions lasting for a year or more. While it can be common to have painful feelings about a meaningful loss for a long time afterward, PGD usually indicates that a person is experiencing such severe distress that it’s threatening their mental health and making it hard to function in daily life. We’ll review some of the ways clinicians can distinguish between ordinary grief, prolonged grief, and other types of mental health difficulties related to bereavement and mourning. If you’re struggling to cope with a loss, consider turning to a licensed mental health professional for support.

Why ordinary grief is not considered a mental health disorder

The addition of prolonged grief disorder to the DSM-5 left many researchers and mental health professionals concerned that this could stigmatize the normal and healthy process of mourning a departed loved one. Not everyone experiences grief in the same way, and some people’s emotional pain and distress may be more severe than others. Certain individuals may also need more time before they sense they can move forward in life despite their loss. 

However, simply experiencing particularly strong feelings of grief or continuing to have grief pangs for a long time is not enough to indicate a diagnosis of PGD. Experiencing reactions like the following for some time after bereavement or another significant loss is considered common and non-pathological:

• Shock or disbelief
• Emotional numbness
• Strong negative feelings like sadness, anxiety, anger, and guilt
• Signs of distress like crying, sighing, and experiencing vivid recollections or dreams of the deceased
• Seeking connection with the deceased through actions like looking through photographs, doing activities they once enjoyed, and visiting their grave or significant places from their life
• Fatigue
• Difficulty sleeping
• Lack of interest, motivation, or enjoyment
• Challenges with attention and organization
• Loss of appetite, sometimes leading to weight loss

In addition to these distressing signs, many bereaved individuals also experience occasional positive feelings, such as relief, acceptance, and fond recollections of the departed person. Some may find it confusing and distressing to have positive emotions in a time of sorrow, even experiencing guilt as a result. However, although updated evidence may be beneficial, research suggests that these feelings tend to be common and can be indicators of resilience and mental health. 

Possible signs of pathological grief

How can you distinguish common manifestations of grief from the symptoms of a grief disorder? In some cases, the main difference may be the length of time they persist. Although it can be normal to experience some depressive symptoms, such as numbness and lack of pleasure, when you’re grieving, these symptoms may be concerning if they continue for months or years. 

Another possible warning sign is when negative grief-related thoughts and feelings are continuous rather than fluctuating. For the majority of bereaved people, the most severe distress comes in waves, rising and falling in strength. This distress is usually periodically interrupted by positive mental states, such as peace and acceptance. A sense of worthlessness or extreme self-blame can be indicators of mental health difficulties rather than ordinary grief.

DSM-5 definition of prolonged grief disorder

To be considered indicators of PGD, these symptoms must be severe enough to cause significant distress or disrupt your ability to navigate day-to-day life. Research indicates that meeting these diagnostic criteria tends to be associated with a significantly higher risk for negative outcomes, such as poor quality of life, suicidal ideation, functional impairment, and symptoms of other mental health disorders.

Current estimates suggest that around 10% of bereaved individuals experience prolonged grief disorder. This risk may increase dramatically in cases of sudden or violent death. 

Prolonged grief vs. persistent complex bereavement disorder

When prolonged grief disorder was added to the DSM-5, it replaced an older diagnostic category known as persistent complex bereavement disorder (PCBD). The criteria for these two mental disorders are very similar. Both involve symptoms like numbness, a disrupted sense of identity, a sense of meaninglessness, and difficulty adjusting to life following bereavement. 

Researchers comparing these diagnostic categories found that they appear to identify the same population of individuals experiencing disturbed grief that’s abnormally persistent and severe. For most practical purposes, PGD and PCBD may be considered the same condition. 

Prolonged grief, complicated grief, and traumatic grief

The DSM-5 category of prolonged grief disorder generally describes individuals experiencing an unusually long-lasting, intense, and debilitating version of typical grief responses. However, some people may experience additional psychological complications not found in the usual grieving process, such as indicators of major depressive disorder (MDD), generalized anxiety disorder (GAD), or post-traumatic stress disorder (PTSD). 

This experience is often referred to as complex or complicated grief, and it may represent a distinct type of mental health challenge. Research suggests that personal characteristics and the circumstances surrounding bereavement may influence the types of grief complications that can result. 

For example, people who lose loved ones to violence may be more likely to experience traumatic grief symptoms, such as intrusive memories or panic attacks. 

Meanwhile, those with strongly avoidant attachment styles — meaning a tendency to avoid emotional closeness out of the fear of intimacy — might have a higher risk of depressive symptoms. 

Risk factors for prolonged grief disorder

While a wide variety of cognitive differences and life circumstances can influence a person’s likelihood of developing prolonged grief disorder, the following risk factors may be particularly significant:

• Maladaptive thoughts and beliefs, such as excessive blame toward yourself or others
• Avoidance behaviors, such as refusing to discuss your loss or attempting to avoid reminders of a person’s death
• Female sex
• Older age
• Lower levels of social support
• Lower socioeconomic status
• Sudden, unexpected, or violent loss
• Loss of someone very close, such as a parent, spouse, or child
• History of mood disorders like depression or bipolar disorder
• History of severe adversity in childhood, such as emotional abuse 
• Having been a caregiver for the deceased before their death
• Experience of depressive symptoms early in the grieving process
• Negative rumination (dwelling excessively on negative aspects of bereavement)

How is complicated or prolonged grief treated?

A variety of psychological and pharmacological treatments may be used to assist with prolonged grief disorder. Currently, there’s little evidence for the effectiveness of medication in resolving the primary symptoms of PGD, though treatments like antidepressants might decrease grief-related depression symptoms. 

Psychotherapy appears to have more robust research support as a treatment for PGD. A recent meta-analysis suggests that the evidence is currently strongest for approaches based on cognitive behavioral therapy (CBT). Grief-focused approaches that help patients challenge unhelpful patterns of thought, let go of avoidance behaviors, and find meaning in life following their loss may be particularly helpful.

Complicated grief treatment (CGT) can be seen as a targeted treatment for grief-related mental illness that typically incorporates elements of CBT, interpersonal therapy, and motivational interviewing. Some research suggests it may be especially effective at helping people overcome maladaptive thoughts and behaviors and reintegrate into life following a painful loss. 

Finding therapy for prolonged grief disorder

If you think you may be experiencing symptoms of PGD, it may be a good idea to talk with your primary care doctor about getting a referral for mental health services. You might also be able to find qualified providers through your health insurance company or by searching online databases for licensed psychologists, psychiatrists, counselors, or social workers trained in grief-related CBT methods. 

Trying to incorporate therapy into your routine on top of the many other complications that accompany bereavement may sound overwhelming. Online therapy could be a more convenient and approachable option than face-to-face therapy. Flexible scheduling and the ability to attend sessions from the comfort of home can make internet-based psychotherapy considerably easier to fit into your life. 

In addition, researchers are accumulating a growing body of evidence that this type of treatment can be very effective for grief-related complications. One randomized, controlled trial from 2023 reported that online cognitive behavioral therapy usually strongly reduced symptoms of prolonged grief disorder, post-traumatic stress, and depression in patients who had experienced a significant personal loss.