Grief is a natural response to the loss of a loved one. For most people, the symptoms of grief begin to decrease over time. However, for a small group of people, the feeling of intense grief persists, and the symptoms are severe enough to cause problems and stop them from continuing with their lives. Prolonged grief disorder is characterized by this intense and persistent grief that causes problems and interferes with daily life.
Symptoms and Diagnosis
An individual with prolonged grief disorder may experience intense longing for the person who has died or preoccupation with thoughts of that person. In children and adolescents, the preoccupation may focus on the circumstances around the death. Additionally, the individual may experience significant distress or problems performing daily activities at home, work, or other important areas. The persistent grief is disabling and affects everyday functioning in a way that typical grieving does not.
For a diagnosis of prolonged grief disorder, the loss of a loved one had to have occurred at least a year ago for adults, and at least 6 months ago for children and adolescents. In addition, the grieving individual must have experienced at least three of the symptoms below nearly every day for at least the last month prior to the diagnosis.
Symptoms of prolonged grief disorder (APA, 2022) include:
- Identity disruption (such as feeling as though part of oneself has died).
- Marked sense of disbelief about the death.
- Avoidance of reminders that the person is dead.
- Intense emotional pain (such as anger, bitterness, sorrow) related to the death.
- Difficulty with reintegration (such as problems engaging with friends, pursuing interests, planning for the future).
- Emotional numbness (absence or marked reduction of emotional experience).
- Feeling that life is meaningless.
- Intense loneliness (feeling alone or detached from others).
In addition, the person’s bereavement lasts longer than might be expected based on social, cultural, or religious norms.
An estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder (Szuhany et al., 2021). Among children and adolescents who have lost a loved one, approximately 5%-10% will experience depression, posttraumatic stress disorder (PTSD), and/or prolonged grief disorder following bereavement (Melhem et al., 2013).
Some individuals may be at greater risk of developing prolonged grief disorder, including older adults and people with a history of depression or bipolar disorder. Caregivers, especially if they were caring for a partner or had experienced depression before the loss, are also at greater risk. The risk for prolonged grief is also greater when the death of the loved one happens very suddenly or under traumatic circumstances (Szuhany et al., 2021).
Prolonged grief disorder often occurs along with other mental disorders such as PTSD, anxiety or depression. Sleep problems are also common; an estimated 80% of people with prolonged grief disorder experience long-term poor sleep (Szuhany et al., 2021).
The inclusion of the diagnostic criteria for prolonged grief disorder in DSM-5-TR allows clinicians to use a common standard to differentiate between normal grief and this persistent, enduring, and disabling grief.
For most people, grief-related symptoms following the death of a loved one decrease over time and do not impact their everyday functioning. Although feelings and symptoms of grief may sometimes increase at different points in time, they do not usually require mental health treatment. However, for people who develop the more intense, ongoing symptoms of prolonged grief disorder, evidence-based treatments are available. Treatments using elements of cognitive-behavioral therapy (CBT) have been found to be effective in reducing symptoms.
One type of treatment, complicated grief treatment, incorporates components of CBT and other approaches to help adapt to the loss. It focuses on both accepting the reality of the loss and restoration—working toward goals and a sense of satisfaction in a world without the loved one (Szuhany et al., 2021). (More information at the Columbia University Center for Prolonged Grief.)
CBT can also be helpful in addressing symptoms that occur along with prolonged grief disorder, such as sleep problems. Research has shown that CBT for insomnia is effective in improving sleep. Research also suggests that CBT can be effective with children and adolescents experiencing symptoms of prolonged grief (Melham, et al., 2013; Boelen et al., 2021).
Bereavement support groups can also provide a useful source of social connection and support. They can help people feel less alone, thus help avoid the isolation that could increase the risk for prolonged grief disorder. There are currently no medications to treat specific symptoms of grief.
Despite the existence of effective treatments, people experiencing ongoing intense grief may not seek help. One study found that among caregivers with prolonged grief disorder, the majority did not access mental health services (Lichtenthal et al., 2011).
Why was prolonged grief disorder added to the DSM?
In this short video, Katherine Shear, M.D. and Holly Prigerson, Ph.D. answer questions about prolonged grief disorder and the DSM-5-TR.
- American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing. https://www.psychiatry.org/psychiatrists/practice/dsm
- Boelen, P. A., Lenferink, L., & Spuij, M. (2021). CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial. The American journal of psychiatry, 178(4), 294–304. https://doi.org/10.1176/appi.ajp.2020.20050548
- Lichtenthal, W. G., Nilsson, M., Kissane, D. W., Breitbart, W., Kacel, E., Jones, E. C., & Prigerson, H. G. (2011). Underutilization of mental health services among bereaved caregivers with prolonged grief disorder. Psychiatric services (Washington, D.C.), 62(10), 1225–1229. https://doi.org/10.1176/ps.62.10.pss6210_1225
- Melhem, N. M., Porta, G., Walker Payne, M., & Brent, D. A. (2013). Identifying prolonged grief reactions in children: dimensional and diagnostic approaches. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 599–607.e7. https://doi.org/10.1016/j.jaac.2013.02.015
- Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Focus (American Psychiatric Publishing), 19(2), 161–172. https://doi.org/10.1176/appi.focus.20200052
Paul Appelbaum, M.D.
Lamyaa Yousif, M.D., Ph.D., M.Sc.