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Complicated Grief

What Is Complicated Grief?

Experiencing the death of a loved one is one of the most painful life events. Grief is a normal reaction and includes a variety of psychological and physiological symptoms that evolve over time. For example, it is natural and expected to experience intense emotions immediately after someone dies. The time and the associated symptomatic response after the loss is referred to as acute grief, and includes strong yearning, longing, and sadness. Thoughts and images of the person who has died are also prominent during acute grief. There is often a sense of disbelief or feelings of shock that a loved one is gone, a lessening of interest in activities unrelated to the person who died, and feeling disconnected from other people.

Most people adapt to even the most difficult loss and, as they make adjustments, grief is integrated into their ongoing life. Thoughts about the deceased person are accessible, but no longer dominate the bereaved person’s mind, and the sadness and yearning are less frequent and eventually less intense. Successful adaptation requires understanding the finality and consequences of the loss, revising future hopes and plans, and redefining the relationship with the deceased. Additionally, adaptation to loss is helped by the experiences of positive emotion, self-compassion, and the presence of social supports. Even with successful adaptation, intensity of grief may wax and wane. For example, it might spike in response to holidays, anniversaries, and milestones or other losses and stressful events. As the grief and loss become integrated into a person’s ongoing life and worldview, surges in grief become shorter and more manageable.

While most people who lose a loved one instinctively adapt to the loss, for a substantial minority of the bereaved the adaptation process is slowed or halted by complications, and the symptoms of acute grief persist indefinitely. We call this condition complicated grief. The complications can include ruminations related to the circumstances or consequences of the death, thoughts about what we might have done differently, behaviors such as excessive avoidance, difficulties regulating emotions, or developing problems, such as addictions, or exacerbating existing conditions, like obsessions or feelings of isolation.

How Common Is Complicated Grief?

Complicated grief affects between 2% to 3% of the population worldwide and 7% to 10% of bereaved people. It amounts to millions of people in the U.S. alone. This condition is characterized by intense grief that lasts longer than would be normally expected and that impairs daily functioning. Complicated grief can follow the loss of any close relationship, especially after the death of a romantic partner and among parents who have lost a child.

How to Recognize Complicated Grief

As in acute grief, the hallmark of complicated grief is persistent, intense yearning, longing, and sadness; these symptoms are usually accompanied by insistent thoughts or images of the deceased and a sense of disbelief or an inability to accept the painful reality of the person’s death. Rumination is common and is often focused on angry or guilty thoughts related to circumstances of the death. Avoidance of situations that serve as reminders of the loss is also common, as is the tendency to constantly reminisce about the deceased person or by trying to keep reminders close by viewing, touching, or smelling their belongings. People with complicated grief often feel shocked, stunned, or emotionally numb, and they may become estranged from others because of the belief that happiness is inextricably tied to the person who died. They may have a diminished sense of self or discomfort with a changed social role and are often confused by their seemingly endless grief. We generally think of complicated grief after at least 6 months after the death and sometimes longer if there are other social, cultural, or religious ties to the person. Other names for this condition include Prolonged Grief Disorder or Persistent Complex Bereavement Disorder.

How Complicated Grief Is Different From Depression

Complicated grief is different from depression and/or posttraumatic stress disorder (PTSD). While they do co-occur in some cases, and all might include symptoms of depressed mood, anxiety, preoccupying thoughts or cognitive distortions, and avoidance, in complicated grief these symptoms center specifically around the circumstances of the loss. Ruminations or avoidance also relate directly to reminders of the deceased. In depression, depressed mood is pervasive across contexts, and preoccupying thoughts are focused on negative thoughts about the self, others, or the world, while avoidance consists of general social withdrawal, not avoidance of circumstances related to the death or the deceased.

How Complicated Grief Is Different From Posttraumatic Stress Disorder

In PTSD, anxiety is focused on the fear of recurrent danger, as opposed to insecurity without the deceased as in complicated grief, and intrusive or distorted thoughts relate to the traumatizing event, as opposed to the deceased individual. Symptoms of anxiety and depression can occur in complicated grief, and targeted treatment of the complicated grief response will also reduce anxiety and depression.

What Are the Known Risk Factors for Developing Complicated Grief?

Risk factors include a history of mood or anxiety disorders, alcohol or drug abuse, and multiple losses. Depression in persons who have been caregivers during a loved one’s terminal illness and those who had depression early in bereavement are more likely to develop complicated grief later in bereavement. Personal factors such as these may interact with characteristics of the relationship to the deceased or with the circumstances, context, or consequences of the death to increase the risk. Losing someone with whom one has had a close relationship can be especially hard if the bereaved person had a difficult upbringing or if there are unusually stressful consequences of the death, inadequate social supports, serious conflicts with friends or relatives, or major financial problems after the death.

Is There an Effective Treatment for Complicated Grief?

There are two approaches: one deals with complicated grief; the other gives us strategies for accepting the loss and for restoring a sense of the possibility of future happiness. A short-term approach called complicated grief treatment (CGT) has been effective with 2 out of 3 people, and is more effective than other treatments for complicated grief, including interpersonal therapy and antidepressant medication, and is therefore the treatment of choice for complicated grief. CGT seeks to identify and resolve complications of grief and to facilitate adaptation to the loss. The treatment includes two key areas: restoring effective functioning by generating enthusiasm and creating plans for the future and helping patients find a new way to think about the death that does not evoke intense feelings of anger, guilt, or anxiety. Research suggests that interventions that include strategies to reduce avoidance of thoughts about the death and avoidance of activities and places that are reminders of the loss are more effective than those that do not. While CGT is the preferred method of treatment because it is most effective, where CGT is not available, a reasonable approach is an intervention that provides information about adaptation to grief and includes both strategies to reduce avoidance of reminders of the loss and strategies for helping with depression.

For additional information and resources, please visit The Center for Complicated Grief at Columbia University:

How should you grieve? loss-CBT

A Grief That Won’t Heal a-grief-that-wont-heal/

What is Cognitive Behavior Therapy?

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