Complicated Grief and Prolonged Grief Disorder

Overview

Most bereaved individuals, despite the intensity of their suffering, gradually adapt to loss through a natural process of oscillation between grief and restoration. For approximately 7-10% of bereaved adults, however, grief becomes a chronic, debilitating condition that does not follow the expected trajectory of gradual integration. This condition — now formally recognized in the DSM-5-TR as Prolonged Grief Disorder (PGD) and in the ICD-11 as a distinct diagnostic entity — represents a failure of the normal grief adaptation process, not merely intense sadness prolonged beyond an arbitrary timeline.

Complicated grief (CG), the broader clinical term encompassing prolonged grief disorder and related presentations, is characterized by persistent, intense yearning for the deceased, difficulty accepting the death, emotional numbness alternating with acute pangs of grief, bitterness and anger, and a pervasive sense that life without the deceased is meaningless. It differs from both normal grief (in its persistence and functional impairment) and major depression (in its specificity — the distress is focused on the loss rather than being a generalized state of hopelessness).

This article examines the diagnostic criteria, neurobiology, risk factors, and evidence-based treatments for complicated grief, with particular attention to M. Katherine Shear’s Complicated Grief Treatment (CGT), the overlap between PTSD and grief, and the role of attachment patterns in determining who is most vulnerable to this devastating condition.

Diagnostic Criteria and Clinical Presentation

DSM-5-TR: Prolonged Grief Disorder

The inclusion of Prolonged Grief Disorder in the DSM-5-TR (2022) represented the culmination of decades of research and clinical advocacy. The diagnostic criteria require:

Criterion A: The death of someone close to the bereaved at least 12 months prior (6 months for children and adolescents).

Criterion B: Since the death, the persistent presence (nearly every day, for at least the last month) of one or both: (1) intense yearning/longing for the deceased, (2) preoccupation with thoughts or memories of the deceased (in children, preoccupation may focus on circumstances of death).

Criterion C: Since the death, at least three of eight symptoms present nearly every day for at least the last month: identity disruption, marked disbelief about the death, avoidance of reminders, intense emotional pain related to the death, difficulty reintegrating into life, emotional numbness, feeling that life is meaningless, and intense loneliness.

Criterion D: The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

Criterion E: The duration and severity of the bereavement reaction exceeds expected social, cultural, or religious norms.

Distinguishing CG from Depression and PTSD

The differential diagnosis between complicated grief, major depressive disorder, and PTSD is clinically critical because each requires different treatment approaches.

Depression involves pervasive anhedonia, worthlessness, and hopelessness that extends across all domains. In CG, the person can experience moments of pleasure when distracted from grief, and the worthlessness is specifically related to life without the deceased rather than a global self-evaluation. Antidepressant medications are first-line for depression but show limited efficacy for the core yearning and preoccupation of CG.

PTSD involves re-experiencing a traumatic event, avoidance of trauma reminders, hyperarousal, and negative alterations in cognition and mood. While traumatic bereavement can produce PTSD, the core of CG is not the traumatic circumstances of the death but the ongoing absence of the deceased. A person can have CG from a peaceful, expected death — the “trauma” is the loss itself, not the manner of dying.

Comorbidity is common: approximately 50% of individuals with CG also meet criteria for MDD, and in cases of violent or traumatic death, PTSD-CG comorbidity is frequent. Treatment must address all co-occurring conditions.

Neurobiology of Complicated Grief

The Reward System and Craving

Mary-Frances O’Connor’s seminal neuroimaging research revealed that individuals with complicated grief show nucleus accumbens activation when viewing photographs of the deceased — activation not present in those experiencing normal grief. The nucleus accumbens is a core component of the brain’s reward circuitry, primarily associated with craving and reward anticipation.

This finding suggests that in CG, the brain continues to generate approach motivation toward the deceased despite the cognitive knowledge that they are gone. In neurochemical terms, the dopaminergic reward circuits that sustained the attachment bond have not been updated to reflect the reality of the death. Each reminder of the deceased triggers a craving response — a neural “reach” toward the absent person — followed by the devastating recognition that the reaching cannot succeed.

This craving-model of CG has direct therapeutic implications: treatments that facilitate the brain’s updating of its reward-prediction model (through exposure to the reality of the loss) are likely to be more effective than treatments that merely address symptoms.

Default Mode Network Hyperconnectivity

Resting-state fMRI studies show that CG is associated with hyperconnectivity within the default mode network (DMN), particularly between the medial prefrontal cortex and posterior cingulate cortex. This hyperconnectivity sustains the rumination that characterizes CG — the repetitive, intrusive replaying of events surrounding the death, counterfactual thinking (“what if I had…”), and the persistent internal focus on the deceased.

In healthy grief, the brain oscillates between DMN activity (processing the loss, maintaining the internal representation of the deceased) and task-positive network activity (engaging with the external world, pursuing goals). In CG, the DMN dominates, trapping the individual in an internal world centered on the lost relationship.

Amygdala and Prefrontal Regulation

Functional neuroimaging reveals reduced connectivity between the amygdala and the ventrolateral and dorsolateral prefrontal cortex in CG. These prefrontal regions normally exert top-down regulation of emotional responses — enabling cognitive reappraisal, emotional distancing, and the flexible shifting of attention. Their reduced connectivity in CG corresponds to the clinical observation that CG patients cannot modulate their grief responses: the waves of emotion feel ungovernable, and attempts at cognitive reappraisal (“it’s been two years, I should be moving on”) fail to translate into emotional change.

Risk Factors for Complicated Grief

Attachment Style

Attachment theory provides the most robust framework for predicting who will develop CG. Anxious attachment — characterized by preoccupation with the availability of attachment figures, hyperactivation of the attachment system, and difficulty self-regulating distress — is the strongest psychological predictor of CG. Anxiously attached individuals respond to separation with intensified proximity-seeking behavior; when the separation is permanent (death), this proximity-seeking becomes the yearning and searching that define CG.

Research by Holly Prigerson and colleagues demonstrates that pre-loss attachment anxiety predicts CG severity even after controlling for relationship quality, circumstances of death, and social support. The attachment system, calibrated in early childhood, shapes the neural response to loss decades later.

Disorganized attachment, rooted in early trauma, produces a particularly complex grief presentation: simultaneous yearning for and fear of connection, oscillation between intrusive grief and emotional numbness, and difficulty establishing therapeutic alliance in treatment.

Relationship Factors

The nature of the lost relationship shapes CG risk. Loss of a child carries the highest risk of CG, followed by loss of a spouse/partner and loss of a parent. Within these categories, specific relationship qualities increase risk: high dependency on the deceased, conflicted relationships with unresolved issues, relationships in which the deceased served as the primary source of self-worth or social identity, and relationships involving caregiving (where the survivor’s entire daily structure was organized around the deceased).

Circumstantial Factors

Sudden, unexpected deaths carry higher CG risk than anticipated deaths, particularly violent deaths (homicide, suicide, accident). The absence of a body (as in disasters, military deaths, or disappearance) dramatically increases risk, likely because the attachment system cannot complete the perceptual processing of death’s reality. Suicide bereavement carries unique CG risk due to the added burden of stigma, guilt, and unanswerable questions about prevention.

Personal Vulnerability Factors

History of prior losses (particularly early childhood losses), pre-existing mental health conditions (depression, anxiety, PTSD), limited social support, and a cognitive style characterized by rumination and counterfactual thinking all increase CG risk. The dose-response relationship is significant: each additional risk factor compounds vulnerability.

Evidence-Based Treatments

Complicated Grief Treatment (CGT)

M. Katherine Shear’s Complicated Grief Treatment is the most extensively studied and empirically supported intervention for CG. CGT is a 16-session manualized treatment that integrates principles from cognitive-behavioral therapy, attachment theory, and the dual process model of grief.

The core components include:

Grief monitoring: Daily tracking of grief intensity, providing both patient and therapist with data on the grief trajectory and reducing the sense that grief is amorphous and ungovernable.

Situational revisiting: Graduated exposure to situations and activities that the patient has been avoiding due to grief-related distress. This addresses the avoidance dimension of CG and facilitates the restoration-oriented processing that has been shut down.

Imaginal revisiting: The patient narrates the story of the death in session, with the therapist facilitating emotional processing. This is recorded and listened to between sessions — a procedure that promotes habituation and integration of the loss experience.

Imaginal conversations: The patient conducts an internal dialogue with the deceased, expressing what has been left unsaid and receiving (in imagination) the deceased’s response. This addresses unfinished business and facilitates the transformation of the attachment bond from one of physical proximity to one of continuing, internalized connection.

Personal goals work: The patient identifies and pursues aspirations for their own life — a direct intervention on the “life is meaningless” dimension of CG.

Randomized controlled trials demonstrate that CGT produces remission in approximately 70% of patients, compared to approximately 30% for standard interpersonal psychotherapy. The treatment effect is specific: CGT outperforms IPT for grief symptoms even though IPT shows equivalent effects on depressive symptoms, confirming that CG is a distinct condition requiring targeted treatment.

EMDR for Grief

Eye Movement Desensitization and Reprocessing (EMDR), originally developed for PTSD, has been adapted for complicated grief with promising results. The EMDR grief protocol targets both the traumatic aspects of the death (if present) and the core yearning and separation distress.

EMDR may work by facilitating the transfer of grief memories from amygdala-dominant, sensory-emotional encoding to hippocampal-prefrontal narrative encoding — essentially helping the brain “file” the loss experience rather than continuously re-experiencing it as present-tense reality. Solomon and Rando’s work on EMDR for grief emphasizes that the target is not the elimination of grief but the resolution of the “stuck” processing that prevents natural adaptation.

Pharmacological Approaches

Pharmacotherapy for CG is an adjunct, not a primary treatment. SSRIs may address comorbid depression and reduce anxiety but do not target the core grief symptoms. A notable study by Shear and colleagues found that CGT alone was superior to citalopram alone, but the combination of CGT plus citalopram was superior to CGT plus placebo — suggesting that antidepressants can enhance but not replace grief-specific psychotherapy.

Emerging pharmacological interests include naltrexone (targeting the opioid-mediated craving dimension of CG), ketamine (for rapid relief of acute grief-related suicidality), and psilocybin-assisted therapy (which may promote the neural plasticity needed to update the brain’s internal model).

The PTSD-Grief Interface

Traumatic Bereavement

When death occurs through violence, suicide, accident, or disaster, the survivor may develop both PTSD and CG — conditions that interact in complex ways. PTSD intrusions focus on the traumatic event (how they died), while CG intrusions focus on the relationship (that they are gone). Treatment must address both: trauma processing alone may resolve PTSD symptoms while leaving CG intact, and grief treatment alone may be insufficient when traumatic intrusions prevent engagement with loss-oriented processing.

The concept of “traumatic grief” or “traumatic bereavement” captures this comorbidity. Clinically, it often requires a phased approach: stabilization, trauma processing (using EMDR or prolonged exposure), and then grief-specific work (using CGT principles). The sequencing is important — unprocessed trauma can block grief processing, but premature grief work can destabilize a patient whose PTSD is not yet managed.

Moral Injury and Grief

When death involves perceived moral failure — a parent who feels they did not protect their child, a combat veteran who survived while comrades died, a physician whose patient died under their care — the grief is complicated by moral injury. Guilt, shame, and the violation of deeply held moral beliefs compound the loss itself, creating a grief that is resistant to standard interventions. Brett Litz’s work on moral injury in military contexts is directly applicable to any bereavement complicated by self-blame and perceived culpability.

Clinical and Practical Applications

Screening and Early Identification

Given that CG affects 7-10% of bereaved individuals (and higher proportions after traumatic deaths, child loss, or in high-risk populations), routine screening in primary care and mental health settings is warranted. The Inventory of Complicated Grief (ICG-19), developed by Prigerson and colleagues, provides a brief, validated screening instrument. A score above 25 suggests CG requiring clinical attention.

Early identification is critical because CG, untreated, tends to persist. Unlike normal grief, which generally shows gradual improvement over 12-24 months, CG can remain at acute-phase intensity for years or decades without intervention.

Grief-Informed Clinical Practice

All clinicians should be able to distinguish CG from normal grief and from depression. The key discriminating features are the specificity of distress (centered on the deceased rather than generalized), the prominence of yearning (the most characteristic symptom of CG), the identity disruption (feeling that a part of oneself has died), and the severity-duration profile (severe functional impairment persisting beyond 12 months).

Four Directions Integration

• Serpent (Physical/Body): CG has measurable somatic correlates — elevated inflammatory markers, immune suppression, cardiovascular stress, and sleep disruption that persist far longer than in normal grief. Body-based interventions (yoga, somatic experiencing, vagal toning, aerobic exercise) address the autonomic dysregulation that sustains the physiological dimension of CG.

• Jaguar (Emotional/Heart): The emotional core of CG is yearning — the relentless ache for the physical presence of the deceased. Treatment requires neither suppressing this yearning nor being consumed by it, but gradually transforming it from a demand for physical proximity to an internalized, continuing bond. This is the heart’s most difficult task.

• Hummingbird (Soul/Mind): CG involves a crisis of meaning — the world has been shattered and the narrative self cannot reorganize around the absence. Meaning reconstruction, identity work, and the restoration of personal goals and aspirations address this dimension. The soul must build a new story that includes the loss rather than being defined by it.

• Eagle (Spirit): From the transcendent perspective, CG may represent an attachment that has not yet found its spiritual resolution — the deceased being held too tightly at the personality level rather than being released to their larger journey. Spiritual practices that support letting go while maintaining love — prayer, meditation, ritual — can address this dimension without diminishing the significance of the bond.

Cross-Disciplinary Connections

CG connects to neuroscience through the reward-system and DMN-hyperconnectivity models. It connects to attachment theory through the robust predictive relationship between attachment style and CG risk. Functional medicine approaches to CG would address the neuroimmune disruption, cortisol dysregulation, and chronic inflammation that CG sustains. Somatic therapy modalities (SE, Sensorimotor Psychotherapy) can address the body-level “freeze” that CG often involves — the grief that is stuck not only psychologically but physiologically. TCM views prolonged, unresolved grief as Lung qi stagnation progressing to yin deficiency, providing a framework for acupuncture and herbal support that complements psychological treatment.

Key Takeaways

• Prolonged Grief Disorder is now a recognized diagnosis in the DSM-5-TR, validating decades of clinical observation that some grief becomes pathologically persistent and impairing.
• CG is neurobiologically distinct from both depression and PTSD, involving reward-system craving, DMN hyperconnectivity, and reduced prefrontal emotional regulation.
• Anxious attachment style is the strongest psychological predictor of CG, because the attachment system’s hyperactivation prevents the updating of the internal working model after loss.
• Complicated Grief Treatment (CGT) is the gold-standard intervention, achieving remission in approximately 70% of patients through a combination of exposure, imaginal techniques, and restoration-oriented goal work.
• CG and PTSD frequently co-occur in traumatic bereavement and require integrated treatment addressing both traumatic and grief dimensions.
• Pharmacotherapy is adjunctive, not primary — SSRIs may help comorbid depression but do not address core grief symptoms. CGT plus medication outperforms either alone.
• Untreated CG does not spontaneously resolve and can persist at acute-phase intensity for years, making early identification and treatment essential.

References and Further Reading

• Shear, M. K. (2015). Complicated Grief. New England Journal of Medicine, 372(2), 153-160.
• Prigerson, H. G., et al. (2009). Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.
• O’Connor, M.-F., et al. (2008). Craving love? Enduring grief activates brain’s reward center. NeuroImage, 42(2), 969-972.
• Shear, M. K., et al. (2005). Treatment of complicated grief: A randomized controlled trial. JAMA, 293(21), 2601-2608.
• Boelen, P. A., & Prigerson, H. G. (2007). The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life. Psychological Medicine, 37(10), 1359-1369.
• Solomon, R. M., & Rando, T. A. (2012). Treatment of grief and mourning through EMDR: Conceptual considerations and clinical guidelines. European Review of Applied Psychology, 62(4), 231-239.
• Litz, B. T., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706.
• Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement. Death Studies, 23(3), 197-224.
• Bowlby, J. (1980). Attachment and Loss, Vol. 3: Loss, Sadness, and Depression. Basic Books.
• American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). American Psychiatric Publishing.