NOTE: The terms complicated grief, traumatic grief, and prolonged grief are essentially synonymous. They are used interchangeably here based on the sources being cited and terminology used in those sources, eventually settling on prolonged grief as it appears in the DSM-5-TR and the ICD-11.
The concept of complicated grief was first developed by Prigerson et al. (1995a). The Inventory of Complicated Grief they developed measured maladaptive symptoms of loss that had “been shown (a) to be distinct from bereavement-related depression and anxiety, and (b) to predict long-term functional impairments” (p. 65). The concept was recognized in the DSM-5 for further study (American Psychiatric Association, 2013) and added to the DSM-5-TR as prolonged grief (American Psychiatric Association, 2022). Google Scholar returns 146,000 results for complicated grief between the introduction by Prigerson et al. (1995a) and publication of the DSM-5-TR in 2022. Clearly, the concept was recognized as an important addition to diagnostic tools. That is not to say the addition of prolonged grief to the DSM was without controversy. Eisma (2023) cited issues with distinguishing prolonged grief from normal grief, pathologizing grief, and problems of validity with assessments.
Prigerson et al. (1995b) defined complicated grief as “the failure to return to preloss [sic] levels of performance or states of emotional wellbeing” (p. 23). Suhany et al. (2021) describe acute grief as most common, followed by integrated grief as individuals adapt to their loss and return to pre-loss functioning. They further highlight that 7-10% of individuals will experience long-term functional impairment of complicated (prolonged) grief. Moore and Freeman (1995) quickly recognized the applicability of complicated grief for counseling survivors of suicide. Ruocco et al. (2022), decrying the lack of attention to the impact of suicide on survivors, found that survivors had increased risk for anxiety, PTSD, depression, complicated grief, and suicide. Shear (2015) pointed out a greater risk of complicated grief after a violent death, such as suicide.
Prolonged grief disorder in adults, as described by the DSM-5-TR (American Psychiatric Association, 2022), “represents a prolonged maladaptive grief reaction that can be diagnosed only after at least 12 months…have elapsed since the death of someone with whom the bereaved had a close relationship” (p. 323). The DSM also specifies the duration and intensity of bereavement must be outside social, cultural, and religious norms.
A great addition to the DSM-5-TR (American Psychiatric Association, 2022) is the “association with suicidal thoughts or behaviors” section for each diagnosis in the DSM. For prolonged grief disorder, the DSM states, “Individuals with symptoms of prolonged grief disorder are at a heightened risk for suicidal ideation, even after adjustment for the effect of major depression and PTSD” (p. 326). We also know that suicide survivors are at increased for suicidal behaviors (Jordan & McMenamy, 2004).
Jordan (2001) argued that suicide bereavement was fundamentally different from mourning other deaths. Citing numerous sources, Jordan claimed a consensus of clinicians that “the mourning process after suicide is different and more difficult than mourning other types of deaths” (p.91). In other words, the more difficult bereavement for a death by suicide can easily lead to prolonged grief, which greatly increases the risk of suicide for suicide survivors that are already at higher risk.
In the DSM-IV -TR (American Psychiatric Association, 2000), the only mention of bereavement is a paragraph under Other Conditions that may be a Focus of Clinical Attention. Prior to the recognition of complicated or prolonged grief, it was suggested here that the focus of clinical attention should be on a diagnosis of major depressive disorder, but the diagnosis is “generally not given unless the symptoms are still present 2 months after the loss” (p. 741) this is a much shorter time period than what was eventually chosen for diagnosis of prolonged grief (12 months). When the World Health Organization added prolonged grief disorder to the ICD-11, they used a timeline of six months (Weir, 2018). Prigerson et al. (1999), again making the case for a distinct diagnosis for traumatic grief (having chosen traumatic grief over complicated grief as used in 1995 articles), argued that simply treating for depression ignored the growing evidence that “the symptoms of traumatic grief form a factor that is separate from symptoms of depression and anxiety” (p. 67). As for clinical implications, they claimed: “precise definition of traumatic grief will lead to the development of more specific treatments” (p. 72).
Indeed, by 2024, Rosner et al. (2024) were comparing prolonged grief-specific cognitive behavioral therapy (PG-CBT) to present-centered therapy (PCT). They found that PG-CBT was superior to PCT both after treatment and at follow-up. They described PG-CBT as “focused on the exposure to the worst moment of the loss and cognitive restructuring of grief-related cognitions in combination with solution-focused and experiential methods” (p. E1). For an example of an experiential method, they cited walking to the grave. These methods suggest exposure methods as used for treating PTSD, which is listed as a differential diagnosis for prolonged grief but which is also frequently comorbid. Bryant et al. (2024) found grief-focused CBT to show better results than mindfulness-based cognitive therapy. Bryant set out to show mindfulness-based therapy could be a viable alternative to PG-CBT but found PG-CBT showed better results, both post-treatment and at follow-up, for depression and grief-related cognition.
Thus, evidence is accumulating for best practices addressing prolonged grief. We are also seeing evidence of neuropsychological abnormalities in complicated grief. Functional MRIs have detected alterations in the reward system. Those experiencing prolonged grief show more activity in the reward center than those experiencing depression. It appears the yearning for the deceased is maintaining a connection that is still rewarding (Weir, 2018). Disturbances are also noted in emotional regulation and neurocognitive functioning. There also appears to be a greater likelihood for other health problems such as sleep disturbances, substance use, cardiovascular disease, immune system issues, and more. (Shear, 2015).
Despite the continuing controversy over its inclusion in the DSM, we must at least consider the possibility, if not likelihood, of the existence of prolonged grief and its meaning for suicide survivors. Once we accept that, we will have a good idea of what issues to watch for, and we will have proven therapy for treatment. It has been shown it is more than just depression, and treatments for depression do not work.
Thomas Grinley, MS, MBA, CMQ/OE, LSSGB, CCISM, is Health Services Evaluation Planning and Review Specialist of Bureau of Program Quality – Health Services Assessment Unit at NH Department of Health and Human Services.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.)
Bryant, R. A., Azevedo, S., Yadav, S., Cahill, C., Kenny, L., Maccallum, F., … & Dawson, K. S. (2024). Cognitive Behavior Therapy vs Mindfulness in Treatment of Prolonged Grief Disorder: A Randomized Clinical Trial. JAMA psychiatry.
Eisma, M. C. (2023). Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Australian & New Zealand Journal of Psychiatry, 57(7), 944-951.
Jordan, J. R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and life-threatening behavior, 31(1), 91-102.
Jordan, J. R., & McMenamy, J. (2004). Interventions for suicide survivors: A review of the literature. Suicide and life-threatening behavior, 34(4), 337-349.
Moore, M. M., & Freeman, S. J. (1995). Counseling survivors of suicide: Implications for group postvention. Journal for Specialists in Group Work, 20(1), 40-47.
Prigerson, H. G., Maciejewski, P. K., Reynolds III, C. F., Bierhals, A. J., Newsom, J. T., Fasiczka, A., … & Miller, M. (1995). Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry research, 59(1-2), 65-79.
Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., Anderson, B., Zubenko, G. S., … & Kupfer, D. J. (1995). Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. American journal of Psychiatry, 152(1), 22-30.
Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F., Maciejewski, P. K., Davidson, J. R., … & Zisook, S. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. The British journal of psychiatry, 174(1), 67-73.
Rosner, R., Rau, J., Kersting, A., Rief, W., Steil, R., Rummel, A. M., … & Comtesse, H. (2024). Grief-Specific Cognitive Behavioral Therapy vs Present-Centered Therapy: A Randomized Clinical Trial. JAMA psychiatry.
Ruocco, K.A., Stumpf Patton, C., Burditt, K., Carroll, B., & Mabe, M. (2022) TAPS Suicide Postvention Model [TM]: A comprehensive framework of healing and growth, Death Studies, 46:8, 1897-1908, DOI: 10.1080/07481187.2020.1866241
Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372(2), 153-160.
Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged grief disorder: Course, diagnosis, assessment, and treatment. Focus, 19(2), 161-172.
Weir, K. (2018, November 1). New paths for people with prolonged grief disorder. Monitor on Psychology, 49(10). https://www.apa.org/monitor/2018/11/ce-corner
Zagorski, N. (2020). Nature, Nurture Both Contribute to Suicide Risk. Psychiatric News, 55(19). https://doi.org/10.1176/appi.pn.2020.10a5
