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COMPLICATED GRIEF
Published as a public service by
The Hospice Support Fund
a program of New Hope Foundation
P.O. Box 1839
Merrifield, VA 22116-8039
M8245CG
Grief is normal. Grief is a common, natural
response one experiences after a significant and Most people assume the grieving person will
permanent loss. Grief is usually caused by death have feelings of loss and sadness soon after the
of the loved one, but may be caused by the death death or separation, which lessen over time as
of a pet, the end of a relationship (i.e. divorce), or the person moves through the stages of grief.
the loss of property.1 Over time, grief lessens in In fact, most people do not experience grief in
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intensity and the grieving individual returns to a this way. For many people, grief is never really
normal or near normal level of functioning. over. Instead, the grieving person finds herself in
one of four categories: resilience, chronic grief,
Complicated grief, on the other hand, is abnormal. depressed improved, and chronic depression.5
It is a state of intense, unrelenting, and disabling People who grieve in one of these four normal
sorrow. Complicated grief is a distinct psychiatric ways regain a reasonable level of functioning;
syndrome requiring specific treatment. people with complicated grief do not.
What is “normal” grief? Resilience
While everyone agrees grief is normal, few People who experience the resilience grief
people agree on a precise definition of “normal” pattern show very few signs of grief, sadness,
grief. Grief is a complex reaction that includes or loss. Instead, they show a relatively low level
emotional, physical, cognitive, and psychological of chronic distress or simply no outward signs
components. of grief whatsoever. This pattern was previously
considered abnormal. People with this grieving
One of the oldest and well-known models of grief style were encouraged to “let out their emotions”
is the five-stage model proposed by Elizabeth and “stop trying to be strong.”
Kübler-Ross. She said a grieving individual
will normally progress through denial, anger, Careful research of the resilience pattern has
bargaining, and depression and then ultimately revealed it is not abnormal at all. In fact, 46% of
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come to accept the loss. Newer research people experience grief in a resilience pattern.
suggests many people do not experience grief Moreover, people in this category have positive
in a sequential order and may also experience coping styles and healthy adjustment to the loss.
symptoms such as emotional numbness, They have few or no symptoms of depression
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yearning, and despair. at six or 18 months after the loss.6 Not only is
resilience the most common grief pattern, but it
Perhaps because of this multistage progression, appears to cause the least number of functional
grief has been viewed as something from which and psychological problems. Resilient grievers
one “recovers.” Grief is a process, not a state. It experience and express positive emotions and
progresses in fits and starts and may ebb and flow. remember their lost love one fondly. Individuals
It is generally felt in waves of intense sadness, in this group may experience occasional pangs
loss, and separation. One does not simply “get of loss and continued yearning, but still function
over” the loss of a loved one, just as one does at their normal level.8
not get over graduation or a wedding. The loss
of a loved one is a major life event that will be Chronic Grief
remembered and contemplated. It will cause
emotions that may be unpleasant, painful, and A small percentage of people experiencing grief
powerful. One hopes the waves of emotion even will manifest a chronic grief pattern. People in
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2 out into ripples over time. this category will experience significant pangs
of loss and sadness and sustained yearning for four patterns are distinct from complicated grief.
the lost individual. Chronic grief occurs most
commonly in widows/widowers who were quite Complicated Grief: Features and Symptoms
dependent on their deceased spouse. Chronic
grief eventually resolves within four years on Approximately 7% of those who experience grief
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average as the person integrates the loss into will develop complicated grief. The rate is even
normal living.8 higher among those who have suffered the loss
of a life partner or child, especially to a violent
Depressed Improved death. Complicated grief is most common in
women over the age of 60.9
One in ten individuals who have lost a spouse
exhibit a depressed improved pattern grieving.6 Complicated grief is an unusually severe and
This pattern occurs most often when the prolonged form of grief that impairs the sufferer’s
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deceased suffered a long health problem prior to ability to function. In most cases, people with
death or the couple had an unhappy relationship. complicated grief will experience persistent,
The depressed phase of the depressed improved intense yearning and sadness accompanied
pattern occurs before the loss and the improved by frequent thoughts of the deceased and an
phase begins upon death. The grieving inability to accept the person is gone. Sufferers
individual is able to focus on positive memories tend to ruminate on the factors surrounding the
of the deceased, finds meaning in the loss of the death itself. For example, sufferers may be angry
deceased, and visualizes/experiences the benefits with those they deem responsible for the death or
of living without the deceased. The loss of a guilty that they did not do more to prevent death
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loved one is the loss of a chronic stressor. Thus, or prolong the life of the deceased.
death releases the grieving person from a difficult Like those with post-traumatic stress disorder,
relationship or from caregiving duties associated people with complicated grief tend to avoid
with caring for a chronically ill loved one. situations that may evoke feelings of grief or
reminders of loss. On the other hand, this same
Chronic Depression person may spend inordinate amounts of time
viewing photos, mementos, or belongings of the
People who experience the chronic depression deceased.
pathway of grief share an important feature
with the depressed improved individual, namely In some cases, the person with complicated
experience depression before the loved one dies. grief has a diminished sense of self, meaning the
Unlike people in the third group, the depression sufferer cannot imagine a life without the lost
of chronically depressed grievers does not begin loved one, causing the sufferer to withdraw from
to resolve with the loved one’s death. Instead, work, family, and social ties. As a result, the
the depression remains or worsens. The ongoing sufferer’s support system is strained, frustrating
depression may last for four years or more after family members and friends, causing them to
the loss and may reflect a long-standing mood further distance themselves from the grieving
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disorder rather than simple grief. person. Thus, the sufferer’s sense of isolation is
perpetuated.
In summary, resilience, chronic grief, depressed
improved, and chronic depression are considered The most common features of complicated grief
normal pathways or patterns of grief. Those who are yearning for the deceased and feeling upset by
experience one of these four patterns of grief memories of the deceased. In a survey of nearly
may experience mild functional difficulty, yet all 300 patients with complicated grief, researchers
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identified the most common symptoms, in order Diagnostic and Statistical Manual (DSM) to
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of decreasing frequency: diagnose mental health conditions, diseases,
• Yearning for the deceased (88% of those and syndromes. Currently, there is no entry for
surveyed) complicated grief in the latest edition of the
• Feeling upset by memories of the DSM, the DSM-5.
deceased (82%)
• Loneliness (81%) Complicated grief is called Persistent Complex
• Feeling life is empty (80%) Bereavement Disorder in the DSM-5 and is
• Disbelief (76%) discussed in appendix of the manual entitled
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• Inability to accept the death (70%) “Conditions for Further Study.” It is quite
possible the next edition of the DSM will include
Complicated Grief: Diagnosis full diagnostic criteria for this disorder, but the
next update is not anticipated until at least 2025.
Ordinarily, psychiatrists and psychologists in the Here is the description of Persistent Complex
United States use diagnostic criteria laid out in Bereavement Disorder in the appendix of the
the American Psychiatric Association’s DSM.
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Provisional DSM-5 Criteria for Persistent Complex Bereavement Disorder
The individual experienced the death of someone with whom he or she had a close relationship.
Since the death, at least 1 of the following symptoms is experienced on more days than not and to a
clinically significant degree has persisted for at least 12 months after the death in the case of bereaved
adults and 6 months for bereaved children:
• Persistent yearning or longing for the deceased. In young children, yearning may
expressed in play and behavior, including behaviors that reflect being separated from,
and also reuniting with, a care-giver or other attachment figure.
• Intense sorrow and emotional pain in response to the death.
• Preoccupation with the deceased.
• Preoccupation with the circumstances of the death. In children this preoccupation with
the deceased may be expressed through the themes of play and behavior and may extend
to preoccupation with possible death of others close to them.
Since the death, at least 6 of the following symptoms are experienced on more days than not and to a
clinically significant degree, and they have persisted for at least 12 months after the death in the case
of bereaved adults and 6 months for bereaved children:
• Reactive distress to death:
• Marked difficulty accepting the death. In children, this is dependent on the
child’s capacity to comprehend the meaning and permanence of death.
• Experiencing disbelief or emotional numbness over the loss.
• Difficulty with positive reminiscing about the deceased.
• Bitterness or anger related to the loss.
• Maladaptive appraisals about oneself in relation to the deceased or the death
(eg, self-blame).
• Excessive avoidance of reminders of the loss (eg, avoidance of individuals,
places, or situations associated with the deceased; in children, this may include
avoidance of thoughts and feelings regarding the deceased.
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