When Grief Is Complicated or Prolonged

[Reviewed and updated February 26, 2024]

Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical and spiritual necessity, the price you pay for love. The only cure for grief is to grieve.  ~ Dr. Earl A. Grollman 

You may have heard of the controversy over including Prolonged Grief Disorder in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, Text Revision (DSM-5-TR), which is the most widely used psychiatric reference in the world. For more than a decade, mental health professionals and researchers worked diligently to agree upon specific criteria for identifying and assessing complicated grief ~ in order to obtain payment for treatment and funding for research, to identify those at risk, and to distinguish depression from complicated grief. 

While it is estimated that 10-15% of bereaved people may feel debilitated by their grief for an extended period of time, the concern among many experts and practitioners in the field of grief and bereavement was to what extent this effort to label complicated mourning as a psychiatric disorder “pathologizes” normal grief. Some believed that grief should not be a diagnostic category at all, because that in itself makes it a problem. 

Others argued that persistent and debilitating grief falls outside of normal grief patterns, and acknowledging Prolonged Grief Disorder as a distinct condition would encourage researchers and clinicians to find and offer more effective therapeutic interventions. 

Experience demonstrates that the distinction between uncomplicated grief and complicated grief is not clear, since most signs and symptoms occur along a continuum from less severe to very severe. Even in papers published in the professional literature, the terms used to describe grief kept changing (e.g., complicated mourning, prolonged grief disorder, abnormal grief, pathologic grief, neurotic grief and traumatic grief) ~ and everyone agreed that a lot more research in these areas was needed. The condition is not limited to the loss of a person through death, either. People can experience complicated grief following any significant loss: a home, a career, loss through infertility, or loss of a cherished companion animal, for example.

Several years ago I heard one grief therapist suggest that a better term for complicated grief might be compound grief (as in “compound fracture”). “Temperatures of 99 and 106 are both fevers,” she said, “and the objective is the same: to get the fever down. If we let it run its course, the body will heal itself. The struggle toward rebirth is a necessary part of the process, in order for us to grow. Literally fighting for one’s life is not pathology, not disease ~ it is health.” She made the point that we human beings are designed to heal naturally ~ physically, emotionally and spiritually ~ and grief is a natural process. When it is interfered with, she said, it can become complicated.

So just what is complicated or prolonged grief? It is the usual and expected grief reactions taken to the extreme ~ when normal grief reactions become so severe and last so long as to significantly impair one’s functioning in the world: socially, occupationally, and in activities of daily living. It is grief that becomes chronic or prolonged, is delayed or inhibited in some way, or is distorted by other underlying issues or pre-existing conditions. Danger signals include suicidal thoughts and / or plans to act upon such thoughts; self-destructive behaviors; severe mental disorganization; deep feelings of guilt, regrets and low self-esteem; continued irritability or violent outbursts of rage; radical, sudden, shocking changes in lifestyle; and physical symptoms that imitate those of the deceased. Contributing factors include the nature of the loss or death (sudden, violent, multiple, etc.), the relationship between the bereaved and the deceased, the personality and life experiences of the bereaved, and other social issues.
 
Anyone reading the posts in the online Grief Healing Discussion Groups I moderate will quickly discover that severe symptoms that persist for many months (and even years) do not necessarily indicate complicated, prolonged or pathological grief. Since there is no simple formula for determining when grief becomes complicated or prolonged (that is, how severe is too severe; how long is too long; and how dysfunctional is too dysfunctional), when in doubt it is always wise to seek an assessment by a qualified mental health practitioner who is familiar with complications of grief and psychiatric disorders.

And in a sense, all grief is complicated, because any significant loss turns our entire life upside down, and we are faced with learning to live in a world forever changed. In the words of clinical psychologist and certified grief specialist J. Shep Jeffreys,

I offer yet another impression of ‘normal’ grief and complicated grief. I approach all grief reactions as a complication in the life of the individual who seeks help with this human phenomenon. We travel life’s roadway and suddenly, around the bend, the bridge is out. A death, a life-threatening diagnosis, accident, layoff notice, or other traumatic change has painfully altered the course of our journey and requires a new way of looking at life. The process of grieving represents a disruption, a need for altering our direction, our plans, and how we identify ourselves in the post-loss / changed world. Normal grief presents many complications and deserves the help of a care provider who is an exquisite witness. People who are grieving deserve care at whatever level their situation requires whether we call it complicated or not. At all times, individual differences must be taken into consideration when determining how we as care providers will serve them. – J. Shep Jeffreys, Ed.D., C.T., in Helping Grieving People: When Tears Are Not Enough, 2nd Edition, Brunner-Routledge, © 2011, p. 293.

Your feedback is welcome! Please feel free to leave a comment or a question, or share a tip, a related article or a resource of your own in the Comments section below. If you’d like Grief Healing Blog updates delivered right to your inbox, you’re cordially invited to subscribe to our weekly Grief Healing Newsletter. Sign up here. 

Related Articles and Resources:

• A New Treatment Program for the Grief That Won't End
• Anybody Have A Map? Navigating Grief During A Global Pandemic 
• Awash in Grief by Ally J. Levine
• Bearing The Unbearable: Love, Loss and the Heartbreaking Path of Grief by Joanne Cacciatore
• Catch-22 for Victims of Trauma by Debra Wesselmann
• Complicated and Consuming Grief of A Friend by Robert Neimeyer
• Complicated Grief "Disorder?" Really? by Joanne Cacciatore
• Complicated Grief Video Interview with physician and bereaved mom
• Complicated Grief and Prolonged Grief Disorder by Zawn Villines
• Complicated Grief: A NJ Mom Shares Her Grief After Losing A Child (Video)
• Complicated Grief Can Be Complicated by Kenneth Doka
• Complicated Grief: Does It Belong in DSM-5? by Lindsey Getz
• Complicated Grief: "Maybe I Am Nuts" by Marty Tousley
• Complicated Grief: Mourning An Abusive Mother by Marty Tousley
• Complicated Grief: Resources
• Complicated Grief: What Is It? How to Recognize and Treat It
• Complicated Grief: When the Pain of Grief Won't Subside by Chris Lewis
• COVID-19 and Complicated Grief Video Interview with Dr. Katherine Shear
• Explaining 'Complicated Grief': When Grief Doesn't Go Away by Mary Kane
• Getting Through Grief Without Anti-Depressants? by Robert Neimeyer
• Grief and Substnace Abuse via The Recovery Village
• Grief is Not a Disorder by Alan Wolfelt
• Grief, It's Complicated - 10% of The Time TEDx UCD with Susan Delaney
• Grieving Isn't Wallowing by Tim Lawrence
• Have I Grieved Too Long? by Loren Olson
• How Should You Grieve? by Andrea Volpe
• Interview: What Is Complicated Grief? Seven Ponds Blog Interview with Dr. Katherine Shear, Part One
• Interview: What Is The Treatment for Complicated Grief? Seven Ponds Blog Interview with Dr. Katherine Shear, Part Two
• Interview: What Makes People Grieve Differently? via Open to Hope
• Inventory of Complicated Grief via Psychology Today
• Is Grief A Disorder? New Research Challenges The Psychiatrization of Mourning by José Giovanni Luiggi-Hernández, PhD
• Is Grieving Too Long a Disorder? by Mary Elizabeth Williams
• Is My Grief Complicated? Open to Hope Interview with Bereaved Parents
• It's Complicated by Marie Lundorff
• Letting Go of a Relationship: Is Grief  a Disorder? by Mary C. Lamia
• Medicalizing Grief May Threaten Our Ability to Mourn by Zenobia Morrill
• Prolonged Grief Disorder Is Now an Officially Recognized Mental Illness by Ed Cara
• Prolonged Grief Disorder Is Now in the DSM
• Prolonged Grief Disorder Rates Higher Than Before Pandemic by Elizabeth Pratt
• Prolonged Grief Disorder: The Tug-of-War Over Medicalizing Mourning by Royal Examiner
• Prolonged Grief Receives New Recognition by Rachel Jones
• Symptoms of Major Depression and Complicated Grief from American Cancer Society
• The Center for Prolomged Grief
• The Complicated Notion of Complicated Grief by Jane Gross
• The Growing Threat of Complicated Grief by Tracy Lee
• The Nature of Complicated Grief by John Wilson
• The Other Side of Complicated Grief by Rhonda O'Neill
• The Pain of Prolonged Grief Disorder by Alison McCook
• The Paradoxes of Prolonged Grief Disorder by H. Steven Moffic, MD
• The People Who Can't Stop Grieving by Andrea Volpe
• The Shock of Learning New Information After a Death by Kenneth Doka
• Toxic Theology As A Contributing Factor in Complicated Mourning by Terri Daniel
• Transforming Traumatic Grief: Six Steps to Move from Grief to Peace After the Sudden or Violent Death of a Loved One by Courtney Armstrong
• Upon This, I Do Insist by Alison Miller
• What Is Complicated Grief and When to Get Help 
• What Is Complicated Grief? Open to Hope Video Interview with Dr. Katherine Shear
• What Makes Sudden Death So Different? by Michelle Jarvie
• When A Relationship Is Complicated, So Is The Grief Process by Randi Mazzella
• When Good Grief Goes Bad by Allen Frances
• When Mourning Does Not End: Identifying and Treating Complicated Grief by Batya Swift Yasgur, MA, LSW

Image by Luisella Planeta LOVE PEACE 💛💙 from Pixabay

© by Marty Tousley, RN, MS, FT, BC-TMH