Complicated grief disorder
In psychiatry, complicated grief disorder (CGD) is a proposed disorder for those who are significantly and functionally impaired by prolonged grief symptoms for at least twelve months after the bereavement. It is distinguished from non-impairing grief and other disorders (such as major depressive disorder and posttraumatic stress disorder). This disorder has been reviewed by the DSM-5 work groups, who have decided that it be called Persistent complex bereavement disorder and placed it in the chapter on Conditions for Further Study in the new DSM-5.
Complicated grief is considered when an individual’s ability to resume normal activities and responsibilities is continually disrupted beyond six months of bereavement. Six months is considered to be the appropriate point of CGD consideration, since studies show that most people are able to integrate bereavement into their lives by this time.
The symptoms of complicated grief are mentioned in the most-recently proposed diagnostic criteria; they include maladaptive thoughts and behaviors related to the death or the deceased, continuous emotional dysregulation about the death, social isolation and suicidal ideation. Central to complicated grief is the presence of yearning.
Causes and predictors
Although more research is needed to determine the multiple pathways to complicated grief disorder, preexisting conditions (such as major depression, PTSD, and sleep disorders) are thought to exacerbate the interruption of the natural healing process.
There are some known predictive characteristics for CGD. An individual is at increased risk for CGD if they are:
- Female and Age of 61 or older 
- Previously diagnosed with a mood disorder
- Low self-reported social support
- An insecure attachment
- High stress
- A positive caregiving experience and dependency on the deceased
- Have had an early pregnancy loss (miscarriage)
- Monthly income below €1250
Untreated CGD has clinically significant consequences. A high level of impairment can be pervasive, including destructive thoughts and behaviors (such as substance abuse). CGD may worsen the course of preexisting disorders and contribute to the development of new ones.
CGD is an atypical grief response, occurring only in a minority of the bereaved population. It is considered more common in those experiencing disasters, violence, the loss of a child, and the loss of a spouse.
It has also been found in family members (or friends) of:
CGD is relatively unresponsive to antidepressants or interpersonal psychotherapy; however, recent studies support the use of CG-targeted psychotherapy (similar to PTSD-targeted psychotherapy). Other methods of psycho-pharmacological treatment are under investigation.
Complicated grief therapy (CGT)
CGT was developed in 2001 by Shear et al. (2001) and has been researched extensively by its creators and other researchers. CGT identifies the areas of CGD that is impeding the individual to grieve naturally. This is completed through a 16-weekly therapy session. These sessions are based on seven principles that help the individual understand and accept their grief, manage and monitor symptoms, think about the future, reconnect with others, tell the death story, learn to live with reminders, and connect with memories. This treatment has been found to show greater response rates and faster response times compared to interpersonal psychotherapy for CGD.
Although the DSM-5 work groups have suggested using "adjustment disorder, specified as bereavement-related" to diagnose complicated grief, opposing opinions contend that this does not fit the nature of CGD and is an inappropriate diagnosis for those suffering from CGD. The DSM-5 has now included Persistent complex bereavement disorder as a diagnosis under conditions for further study.
Medicalizing (or misdiagnosing) normal grief
Following the DSM-5 work groups’ recommendation to remove the bereavement-exclusionary criteria, there is some concern that the addition of CGD may increase the possibility of medicalizing the grieving process. However, proponents of CGD claim that with proper clinical assessment only those with abnormally incapacitating levels of grief will receive this diagnosis and benefit from treatment. Furthermore, despite the possibility of diagnosis-related stigma the clinical necessity for treatment is a priority for those suffering from CGD.
Cultural norms for grief
An individual’s culture plays a large role in determining an inappropriate pattern of grief, and it is necessary to consider cultural norms before reaching a CGD diagnosis. There are cultural differences in expected emotional levels, their expression and duration; the external symptoms of grief differ in non-Western cultures, presenting increased somatization.
- "Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th edition)2014 102 Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th edition) Washington, DC American Psychiatric Association 2013 xliv+947 pp. 9780890425541(hbck);9780890425558(pbck) £175 $199 (hbck); £45 $69 (pbck)". Reference Reviews. 28 (3): 36–37. 2014-03-11. doi:10.1108/rr-10-2013-0256. ISSN 0950-4125.
- O'Connor MF, Wellisch DK, Stanton AL, Eisenberger NI, Irwin MR, Lieberman MD (August 2008). "Craving love? Enduring grief activates brain's reward center". NeuroImage. 42 (2): 969–72. doi:10.1016/j.neuroimage.2008.04.256. PMC 2553561. PMID 18559294.
- Silverman GK, Jacobs SC, Kasl SV, Shear MK, Maciejewski PK, Noaghiul FS, Prigerson HG (July 2000). "Quality of life impairments associated with diagnostic criteria for traumatic grief". Psychological Medicine. 30 (4): 857–62. doi:10.1017/s0033291799002524. PMID 11037094.
- Simon NM, Shear KM, Thompson EH, Zalta AK, Perlman C, Reynolds CF, Frank E, Melhem NM, Silowash R (2007). "The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief". Comprehensive Psychiatry. 48 (5): 395–9. doi:10.1016/j.comppsych.2007.05.002. PMID 17707245.
- Neria Y, Gross R, Litz B, Maguen S, Insel B, Seirmarco G, Rosenfeld H, Suh EJ, Kishon R, Cook J, Marshall RD (June 2007). "Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks". Journal of Traumatic Stress. 20 (3): 251–62. doi:10.1002/jts.20223. PMID 17597124.
- Melhem NM, Rosales C, Karageorge J, Reynolds CF, Frank E, Shear MK (November 2001). "Comorbidity of axis I disorders in patients with traumatic grief". The Journal of Clinical Psychiatry. 62 (11): 884–7. doi:10.4088/jcp.v62n1108. PMID 11775048.
- Kersting A, Kroker K, Horstmann J, Baune BT, Hohoff C, Mortensen LS, Neumann LC, Arolt V, Domschke K (2007). "Association of MAO-A variant with complicated grief in major depression". Neuropsychobiology. 56 (4): 191–6. doi:10.1159/000120624. PMID 18337637. S2CID 9857681.
- Viederman M (January 1995). "Grief: normal and pathological variants". The American Journal of Psychiatry. 152 (1): 1–4. doi:10.1176/ajp.152.1.1. PMID 7802098.
- Melhem NM, Moritz G, Walker M, Shear MK, Brent D (April 2007). "Phenomenology and correlates of complicated grief in children and adolescents". Journal of the American Academy of Child and Adolescent Psychiatry. 46 (4): 493–499. doi:10.1097/chi.0b013e31803062a9. PMID 17420684.
- Bonanno GA, Neria Y, Mancini A, Coifman KG, Litz B, Insel B (May 2007). "Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity". Journal of Abnormal Psychology. 116 (2): 342–51. doi:10.1037/0021-843X.116.2.342. PMID 17516766.
- Conditions Proposed by Outside Sources | APA DSM-5
- Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J, Carr D, Nesse RM (November 2002). "Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss". Journal of Personality and Social Psychology. 83 (5): 1150–64. doi:10.1037//0022-35126.96.36.1990. PMID 12416919.
- DeVaul RA, Zisook S (May 1976). "Psychiatry: unresolved grief. Clinical considerations". Postgraduate Medicine. 59 (5): 267–71. doi:10.1080/00325481.1976.11714374. PMID 1264920.
- DeVaul RA, Zisook S, Faschingbauer TR (June 1979). "Clinical aspects of grief and bereavement". Primary Care. 6 (2): 391–402. PMID 258819.
- Zisook S, Shuchter S, Schuckit M (June 1985). "Factors in the persistence of unresolved grief among psychiatric outpatients". Psychosomatics. 26 (6): 497–9, 503. doi:10.1016/S0033-3182(85)72830-7. PMID 4011815.
- Dopson CC, Harper MB (January 1983). "Unresolved grief in the family". American Family Physician. 27 (1): 207–11. PMID 6823793.
- Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, et al. (February 2011). "Complicated grief and related bereavement issues for DSM-5". Depression and Anxiety. 28 (2): 103–17. doi:10.1002/da.20780. PMC 3075805. PMID 21284063.
- Shear MK, Jackson CT, Essock SM, et al. Screening for complicated grief among project liberty service recipients 18 months after september 11, 2001. Psychiatr Serv 2006;57: 1291–1297.
- Kersting A, Brähler E, Glaesmer H, Wagner B (June 2011). "Prevalence of complicated grief in a representative population-based sample". Journal of Affective Disorders. 131 (1–3): 339–43. doi:10.1016/j.jad.2010.11.032. PMID 21216470.
- Piper WE, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk JS (October 2001). "Patient personality and time-limited group psychotherapy for complicated grief". International Journal of Group Psychotherapy. 51 (4): 525–52. doi:10.1521/ijgp.51.4.525.51307. PMID 11582899. S2CID 27390606.
- Robinson T, Marwit SJ (September 2006). "An investigation of the relationship of personality, coping, and grief intensity among bereaved mothers". Death Studies. 30 (7): 677–96. doi:10.1080/07481180600776093. PMID 16869060. S2CID 35066443.
- Ott CH (April 2003). "The impact of complicated grief on mental and physical health at various points in the bereavement process". Death Studies. 27 (3): 249–72. doi:10.1080/07481180302887. PMID 12703505. S2CID 22920006.
- Johnson JG, Zhang B, Greer JA, Prigerson HG (January 2007). "Parental control, partner dependency, and complicated grief among widowed adults in the community". The Journal of Nervous and Mental Disease. 195 (1): 26–30. doi:10.1097/01.nmd.0000252009.45915.b2. PMID 17220736. S2CID 45358849.
- Vanderwerker LC, Jacobs SC, Parkes CM, Prigerson HG (February 2006). "An exploration of associations between separation anxiety in childhood and complicated grief in later life". The Journal of Nervous and Mental Disease. 194 (2): 121–3. doi:10.1097/01.nmd.0000198146.28182.d5. PMID 16477190. S2CID 8995920.
- Prigerson HG, Shear MK, Bierhals AJ, Pilkonis PA, Wolfson L, Hall M, Zonarich DL, Reynolds III CF (1997). "Case histories of traumatic grief". Omega: Journal of Death and Dying. 35 (1): 9–24. doi:10.2190/TDYG-MRB4-H5H8-HHR7. S2CID 144991438.
- Prigerson HG, Shear MK, Frank E, Beery LC, Silberman R, Prigerson J, Reynolds CF (July 1997). "Traumatic grief: a case of loss-induced trauma". The American Journal of Psychiatry. 154 (7): 1003–9. doi:10.1176/ajp.154.7.1003. PMID 9210753.
- van Doorn C, Kasl SV, Beery LC, Jacobs SC, Prigerson HG (September 1998). "The influence of marital quality and attachment styles on traumatic grief and depressive symptoms". The Journal of Nervous and Mental Disease. 186 (9): 566–73. doi:10.1097/00005053-199809000-00008. PMID 9741563.
- Chiu YW, Huang CT, Yin SM, Huang YC, Chien CH, Chuang HY (October 2010). "Determinants of complicated grief in caregivers who cared for terminal cancer patients". Supportive Care in Cancer. 18 (10): 1321–7. doi:10.1007/s00520-009-0756-6. PMID 19816716. S2CID 25628986.
- Schulz R, Boerner K, Shear K, Zhang S, Gitlin LN (August 2006). "Predictors of complicated grief among dementia caregivers: a prospective study of bereavement". The American Journal of Geriatric Psychiatry. 14 (8): 650–8. doi:10.1097/01.JGP.0000203178.44894.db. PMID 16861369.
- Boerner K, Schulz R, Horowitz A (December 2004). "Positive aspects of caregiving and adaptation to bereavement". Psychology and Aging. 19 (4): 668–75. doi:10.1037/0882-79188.8.131.528. PMID 15584791.
- Kersting A, Wagner B (June 2012). "Complicated grief after perinatal loss". Dialogues in Clinical Neuroscience. 14 (2): 187–94. doi:10.31887/DCNS.2012.14.2/akersting. PMC 3384447. PMID 22754291.
- "Miscarriage and loss". American Psychological Association. 2017. Retrieved 2017-09-23.
- Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF, Shear MK, Day N, Beery LC, Newsom JT, Jacobs S (May 1997). "Traumatic grief as a risk factor for mental and physical morbidity". The American Journal of Psychiatry. 154 (5): 616–23. doi:10.1176/ajp.154.5.616. PMID 9137115.
- Chen JH, Bierhals AJ, Prigerson HG, Kasl SV, Mazure CM, Jacobs S (March 1999). "Gender differences in the effects of bereavement-related psychological distress in health outcomes". Psychological Medicine. 29 (2): 367–80. doi:10.1017/s0033291798008137. PMID 10218927.
- Boelen PA, Prigerson HG (December 2007). "The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study". European Archives of Psychiatry and Clinical Neuroscience. 257 (8): 444–52. doi:10.1007/s00406-007-0744-0. PMID 17629728. S2CID 9410388.
- Ott CH, Lueger RJ, Kelber ST, Prigerson HG (April 2007). "Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics". The Journal of Nervous and Mental Disease. 195 (4): 332–41. doi:10.1097/01.nmd.0000243890.93992.1e. PMID 17435484. S2CID 23836831.
- Lannen PK, Wolfe J, Prigerson HG, Onelov E, Kreicbergs UC (December 2008). "Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later". Journal of Clinical Oncology. 26 (36): 5870–6. doi:10.1200/JCO.2007.14.6738. PMC 2645112. PMID 19029425.
- Shear K, Monk T, Houck P, Melhem N, Frank E, Reynolds C, Sillowash R (December 2007). "An attachment-based model of complicated grief including the role of avoidance". European Archives of Psychiatry and Clinical Neuroscience. 257 (8): 453–61. doi:10.1007/s00406-007-0745-z. PMC 2806638. PMID 17629727.
- Cruz M, Scott J, Houck P, Reynolds CF, Frank E, Shear MK (May 2007). "Clinical presentation and treatment outcome of African Americans with complicated grief". Psychiatric Services (Washington, D.C.). 58 (5): 700–2. doi:10.1176/ps.2007.58.5.700. PMC 3579573. PMID 17463353.
- Zuckoff A, Shear K, Frank E, Daley DC, Seligman K, Silowash R (April 2006). "Treating complicated grief and substance use disorders: a pilot study". Journal of Substance Abuse Treatment. 30 (3): 205–11. doi:10.1016/j.jsat.2005.12.001. PMID 16616164.
- Hardison HG, Neimeyer RA, Lichstein KL (2005). "Insomnia and complicated grief symptoms in bereaved college students". Behavioral Sleep Medicine. 3 (2): 99–111. doi:10.1207/s15402010bsm0302_4. PMID 15802260. S2CID 23826266.
- Simon NM, Pollack MH, Fischmann D, Perlman CA, Muriel AC, Moore CW, Nierenberg AA, Shear MK (September 2005). "Complicated grief and its correlates in patients with bipolar disorder". The Journal of Clinical Psychiatry. 66 (9): 1105–10. doi:10.4088/jcp.v66n0903. PMID 16187766.
- Maytal G, Zalta AK, Thompson E, Chow CW, Perlman C, Ostacher MJ, Pollack MH, Shear K, Simon NM (December 2007). "Complicated grief and impaired sleep in patients with bipolar disorder". Bipolar Disorders. 9 (8): 913–7. doi:10.1111/j.1399-5618.2007.00446.x. PMID 18076543.
- Ghaffari-Nejad A, Ahmadi-Mousavi M, Gandomkar M, Reihani-Kermani H. The prevalence of complicated grief among bam earthquake survivors in iran. Arch Iran Med 2007;10:525–528.
- Shear, M. K., McLaughlin, K. A., Ghesquiere, A., Gruber, M. J., Sampson, N. A., & Kessler, R. C. (2011). COMPLICATED GRIEF ASSOCIATED WITH HURRICANE KATRINA. Depression and Anxiety, 28(8), 648-657. doi:10.1002/da.20865
- Mancini A, Prati G, Black S. Self-worth mediates the effects of violent loss on ptsd symptoms. J Trauma Stress 2010, in press.
- Mitchell AM, Kim Y, Prigerson HG, Mortimer-Stephens M. Complicated grief in survivors of suicide. Crisis 2004;25:12–18.
- Vessier-Batchen M, Douglas D. Coping and complicated grief in survivors of homicide and suicide decedents. J Forensic Nurs 2006;2:25–32.
- Melhem NM, Day N, Shear MK, et al. Traumatic grief among adolescents exposed to a peer’s suicide. Am J Psychiatry 2004; 161:1411–1416.
- Keesee NJ, Currier JM, Neimeyer RA. Predictors of grief following the death of one’s child: the contribution of finding meaning. J Clin Psychol 2008;64:1145–1163.
- Meert KL, Thurston CS, Thomas R. Parental coping and bereavement outcome after the death of a child in the pediatric intensive care unit. Pediatric Critical Care Medicine 2001;2:324–328.
- Murphy SA. The loss of a child: sudden death and extended illness perspectives. In: Stroebe M, Hansson RO, Schut H, Stroebe W, editors. Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association; 2008.
- Fujisawa D, Miyashita M, Nakajima S, Ito M, Kato M, Kim Y (December 2010). "Prevalence and determinants of complicated grief in general population". Journal of Affective Disorders. 127 (1–3): 352–8. doi:10.1016/j.jad.2010.06.008. PMID 20580096.
- Tomarken A, Holland J, Schachter S, et al. Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology 2008;17:105–111.
- Anderson WG, Arnold RM, Angus DC, Bryce CL. Posttraumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med 2008;23: 1871–1876.
- Siegel MD, Hayes E, Vanderwerker LC, et al. Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008;36:1722–1728.
- Currier JM, Holland JM, Neimeyer RA. Sense-making, grief, and the experience of violent loss: toward a mediational model. Death Stud 2006;30:403–428.
- Forstmeier S, Maercker A. Comparison of two diagnostic systems for complicated grief. J Affect Disord 2007;99:203–211.
- Kersting A, Kroker K, Horstmann J, et al. Complicated grief in patients with unipolar depression. J Affect Disord 2009;118:201–204.
- Kersting A, Kroker K, Steinhard J, et al. Complicated grief after traumatic loss: a 14-month follow up study. Eur Arch Psychiatry Clin Neurosci 2007;257:437–443.
- Langner R, Maercker A. Complicated grief as a stress response disorder: evaluating diagnostic criteria in a german sample. J Psychosom Res 2005;58:235–242.
- Parkes CM. Symposium on complicated grief. OMEGA 2005–2006;52:1–7.
- Stroebe M, Schut H. Complicated grief: a conceptual analysis of the field. OMEGA 2005–2006;52:53–70.
- Morina N, Rudari V, Bleichhardt G, Prigerson HG. Prolonged grief disorder, depression, and posttraumatic stress disorder among bereaved kosovar civilian war survivors: a preliminary investigation. International Journal of Social Psychiatry 2010;56:288–297.
- Prigerson H, Ahmed I, Silverman GK, et al. Rates and risks of complicated grief among psychiatric clinic patients in karachi, pakistan. Death Stud 2002;26:781–792.
- Schaal S, Elbert T, Neuner F. Prolonged grief disorder and depression in widows due to the rwandan genocide. Omega (Westport) 2009;59:203–219.
- Laor N, Wolmer L, Kora M, et al. Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes. J Nerv Ment Dis 2002;190:824–832.
- Bonanno GA, Papa A, Lalande K, et al. Grief processing and deliberate grief avoidance: a prospective comparison of bereaved spouses and parents in the united states and the People’s Republic of China. J Consult Clin Psychol 2005;73:86–98.
- Ito M. Complicated grief among general Japanese population: validity and reliability of Brief Grief Questionnaire. Presentation World Congress of Behavioral and Cognitive Therapies, Boston, MA; 2010.
- Nakajima S, Shirai A, Maki S, et al. Mental health of the families of crime victims and factors related to their recovery. Seishin Shinkeigaku Zasshi 2009;111:423–429.
- Fujisawa D, Miyashita M, Nakajima S, Ito M, Kato M, Kim Y. Prevalence and determinants of complicated grief in general population. J Affect Disord 2010;127:352–358.
- Pasternak RE, Reynolds III CF, Schlernitzauer M, et al. Acute open-trial nortriptyline therapy of bereavement-related depression in late life. J Clin Psychiatry 1991;52:307–310.
- Reynolds 3rd CF, Miller MD, Pasternak RE, et al. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry 1999;156:202–208.
- Shear MK, Frank E, Foa E, et al. Traumatic grief treatment: a pilot study. Am J Psychiatry 2001;158:1506–1508.
- Shear K, Frank E, Houck PR, Reynolds 3rd CF. Treatment of complicated grief: a randomized controlled trial. J Am Med Assoc 2005;293:2601–2608.
- Shear MK, Frank E, Foa E, Cherry C, Reynolds CF, Vander Bilt J, Masters S (September 2001). "Traumatic grief treatment: a pilot study". The American Journal of Psychiatry. 158 (9): 1506–8. doi:10.1176/appi.ajp.158.9.1506. PMID 11532739.
- Iglewicz A, Shear MK, Reynolds CF, Simon N, Lebowitz B, Zisook S (January 2020). "Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice". Depression and Anxiety. 37 (1): 90–98. doi:10.1002/da.22965. PMID 31622522. S2CID 204774193.
- Shear K, Frank E, Houck PR, Reynolds CF (June 2005). "Treatment of complicated grief: a randomized controlled trial". JAMA. 293 (21): 2601–8. doi:10.1001/jama.293.21.2601. PMC 5953417. PMID 15928281.
- Shear, M. K. (2011). BEREAVEMENT AND THE DSM5. Omega-Journal of Death and Dying, 64(2), 101-118. doi:10.2190
- Wakefield and First, 2012 Wakefield JC, First MB. Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?. World Psychiatry 2012; 11: 3-10.
- Horwitz, A. V., & Wakefield, J. C. (2007). The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. Oxford University Press.