Bereavement is a period of time spent adjusting to a profound loss. During this time, a bereaved person may experience varying levels of grief manifesting in feelings of numbness, shock, sadness, and yearning for the person or pet who has passed.
For most people, it’s normal to have a variety of emotions, as well as fatigue, disturbed dreams, distress, agitation and guilt during the bereavement process, before reaching acceptance. For people suffering from a more complicated time of grief, the final stage of adjustment can take significantly longer to set in. When this happens, a person is thought to have complicated grief.
Prolonged Grief Disorder
Complicated grief is a term that has been around for decades. Although therapists still use it, the newer terms for this type of grief problem is prolonged grief disorder (PGD) and persistent complex bereavement disorder (PCBD).
Recently, PGD, a diagnosis characterized by severe, persistent and disabling grief, was formally included in the 11th revision of the International Classification of Diseases (ICD-11).
To meet PGD, a person needs to experience persistent and pervasive longing for the deceased and/or persistent and pervasive cognitive preoccupation with the deceased, combined with another grief reactions indicative of intense emotional pain for at least six months after bereavement.
Intense emotional pain is described as disturbing feelings, such as those of sadness, guilt, anger, denial, blame; difficulty accepting the death; feeling one has lost a part of one’s self; an inability to experience positive mood; emotional numbness; difficulty in engaging with social or other activities. The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Persistent Complex Bereavement Disorder
By comparison, persistent complex bereavement disorder (PCBD) is a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis assigned to someone who experiences an unusually disabling or prolonged response to bereavement.
Formerly known as complicated grief disorder, (PCBD) causes sufferers to feel extreme yearning for a deceased loved one, typically over a prolonged period. Feelings of longing are often accompanied by destructive thoughts and behaviors brought on by things like anger and sadness, as well as general impairment in resuming normal life.
PCBD is marked by an unshakeable grief that doesn’t follow the typical pattern of improvement over time. Instead, the person continues to experience persistent and intense emotions and moods. They also tend to have unusual, severe symptoms that impair major areas of functioning and cause extreme distress.
A person suffering with PCBD will display symptoms that include:
- Continual yearning for the deceased
- Preoccupation surrounding the circumstances of the deceased’s death
- Intense sorrow that doesn’t improve with time.
- Inability to trust others
- Depression and/or anxiety
- Sudden and unexpected outbursts of anger and hostility
- Detachment and a need for isolation
- Persistent feelings of loneliness
- Impaired social and occupational behaviors
What is considered a normal grief?
Normal (or uncomplicated) grief has no timeline and encompasses a range of feelings and behaviors common after loss such as bodily distress, guilt, hostility, preoccupation with the image of the deceased, and the inability to function as one had before the loss.
Worden’s Four Tasks of Mourning
According to therapist and author James Worden, there are specific tasks that should occur during bereavement that enable a person to successfully emerge on the other side of loss. He proposes these four tasks:
- To accept the reality of the loss
- To process the pain of grief
- To adjust to a world without the deceased
- To find an enduring connection with the deceased in the midst of embarking on a new life
Instead of focusing on bodily discomforts, feelings, and common behaviors, Worden’s model helps a person to better see where they are stuck in the adaptive process. Worden also has a list of indicators that a person is stalled in the process.
Complicated grief like normal grief is different for everyone. If, at any time after a death, you feel your grief symptoms worsening, consider seeking a referral from your family physician for professional grief counseling or therapy.
Randi Fredricks, Ph.D.
References
Worden, James. (2009). Grief Counseling & Grief Therapy: A Handbook for the Mental Health Practitioner. New York, Springer.
Wakefield, J. C. DSM-5 grief scorecard: Assessment and outcomes of proposals to pathologize grief World Psychiatry. 2013 Jun; 12(2): 171–173.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Boelen PA, Lenferink L., IM Comparison of six proposed diagnostic criteria sets for disturbed grief. Psychiatry Res (2020) 285:112786.
Walsh, Katherine (2012). Grief and Loss: Theories and Skills for the Helping Professions. London, England: Pearson.
Boelen PA, Lenferink L, IM, Smid GE. Further evaluation of the factor structure, prevalence, and concurrent validity of DSM-5 criteria for persistent complex bereavement disorder and ICD-11 criteria for prolonged grief disorder. Psychiatry Res (2019. a) 3:206–10.
World Health Organization ICD-10: international statistical classification of diseases and related health problems: tenth revision. 2nd ed. Geneva, Switzerland: World Health Organization; (2004).
Maccallum F, Bryant RA. A network approach to understanding quality of life impairments in prolonged grief disorder. J Trauma Stress (2020) 31:106–15. 10.
