• Thanatology Today

What Is and Is Not Complicated Grief?

Updated: Mar 4

Grief, brought on by loss, is our adaptive response to the internal and external changes we are experiencing. Given that a range of grief reactions and expressions are healthy and normal, and they are idiosyncratic, it is sometimes difficult to distinguish between normal and complicated grief responses.


Complicated grief affects between 10% and 20% of all grievers, and over the years, it has been referred to as pathological grief, unresolved grief, chronic grief, delayed grief, or exaggerated grief. Today, the accepted term used for the diagnosis of complicated grief is prolonged grief disorder (PGD). The American Psychiatric Association (APA) recently announced that prolonged grief disorder (PGD) will be added to the newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

What is Complicated Grief?


Complicated grief is the intensification of grief to the extent in which a person becomes overwhelmed and is unable to move into and progress through the mourning process towards adaptation. Similarly, those grievers that adequately move into mourning, but get stuck, may struggle with complicated mourning. Pathology is primarily related to the intensity and duration of a reaction rather than to the presence or absence of symptoms or behaviors.


There are four types of complicated grief:


Chronic grief reactions are prolonged in duration and do not lead to a comfortable outcome.


Delayed grief reactions involve the suppression or postponement of grief until appearing as an exaggerated reaction to a subsequent loss or triggering event.


Exaggerated grief reactions are excessive or disabling reactions that may lead to an irrational fear or phobia, physical or psychological symptoms, or deviant or maladaptive behavior.


Masked grief reactions are symptoms or behaviors that cause a person difficulty but aren’t readily attributed to the loss.


man climbing a mountain
Complicated Grief Feels Overwhelming and Insurmountable Source: Wix Media

Predisposing Factors


Complicated grief reactions often develop because of a difficult relationship with the lost person (i.e., ambivalent, dependent, or narcissistic) relationships. There are several other predisposing factors in the bereaved that may lead to complicated grief including:


· Circumstances surrounding the loss

· Multiple/traumatic losses

· Personal history/personality

· Social factors


Signs of Complicated Grief


Medically speaking, complicated grief will occur in a relatively small number of people who experience or display the following signs:


1. Chronic and disruptive yearning for the lost person

2. At least four of the following eight symptoms appear often, for a period of more than six months to a year, and are disruptive:


· trouble accepting the reality of the loss

· feeling life is empty or meaningless without the lost person

· uneasiness about moving on

· bitterness or anger related to the loss

· inability to trust others

· chronic anxiety

· numbness/detachment

· envisioning a bleak future


A dissonant or maladaptive response to grief represents the grievers inability to express their inner experience of grief. Often this involves suppressing and avoiding deep feelings of loss. The negative consequences include feelings of low self-esteem, heightened stress levels, substance abuse and addiction, and shame. Especially if this dissonant response includes the denial of the reality and finality of the loss as a form of penitence or for other reasons, mourning can become complicated.


Adapting to Loss


While we never truly overcome a loss, we can accept and adapt, internally and externally, to it. Initially, we accommodate for the immediate and short-term demands of grief in the way we experience and express it. In the long term, adaptation requires us to rethink who we are, what we have lost, and reevaluate our assumptive world.


A series of readjustments must be made to cope with, compensate for, and adapt to what has been lost physically and psychosocially. This adaptation to loss generally involves the following:


· Neither obsession nor avoidance of memories

· Adjustment to a new reality and newly emerging assumptive world

· Perception of the lost person is open to change

· Memories of the lost person are not threatening and may even evoke a sense of well-being

· The griever can think of the lost person without immense pain.

· The griever regains an interest in life, feels more hopeful, experiences gratification again, and adjusts to new social roles.



grieving woman
Source: Wix Media

Symptoms Misread as Complicated Mourning


Again, most reactions and expressions of grief are healthy and normal, so it may be difficult to recognize complicated grief and mourning. Several symptoms are occasionally misread as complicated mourning:


· Having emotions other than sadness

· Feeling part of oneself has died too

· Feeling sorry for oneself to a degree

· Having a continuing relationship with the deceased

· Experiencing aspects of mourning that continue for years

· Feeling resentment that others continue to live or that others are not mourning

· Resurrection of feelings about unresolved conflicts from past losses

· Temporary periods of acute grief long after the death


Grief and Depression


Routine referral to a medical provider is neither necessary nor advisable for those experiencing the natural process of grief and mourning. However, failure to make appropriate adaptions and reorientations leaves grievers to relate inappropriately to the lost person and their new reality. If complicated mourning persists, it is reasonable to expect complications with our physical and mental health leading to one or more of the following outcomes:


· Mental disorder including developmental disorders, eating disorders, sleep disorders, depression, anxiety, substance abuse, paranoid disorders, and sexual disorders

· Physical ailments such as cancer, high blood pressure, heart conditions, and disability

· Death by suicide, car accident, cirrhosis of the liver, and more


The expression of feelings may cause momentary pain and long-term relief, while the suppression of feelings may cause momentary relief and a lifetime of pain. ~ Variation on a Chinese Proverb



Doka, K.J., & Martin, T.L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. Routledge.


Kecmanovic, J. (2021, October 22). Prolonged grief disorder recognized as official diagnosis: Here’s what to know about chronic mourning. The Washington Post. https://www.washingtonpost.com/lifestyle/2021/10/21/prolonged-grief-disorder-diagnosis-dsm-5/


Krull, E. (2021, August 17). Grief by the numbers: Facts and statistics. The Recovery Village Drug and Alcohol Rehab. https://www.therecoveryvillage.com/mental-health/grief/related/grief-statistics/


Worden, J.W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). Springer Publishing Company.

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