When Grief Lingers: Recognizing and Addressing Prolonged Mourning

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Table of Contents

Grief is one of the most profound human experiences, a natural and necessary response to the loss of someone we love. For most people, the intense pain of grief gradually softens over time, allowing them to adapt to life without their loved one while maintaining their memory. However, for a significant minority of bereaved individuals, the grieving process becomes prolonged, intense, and debilitating, interfering with their ability to function in daily life. Understanding prolonged grief disorder, recognizing its signs, and knowing how to address it are essential for both those experiencing it and the people who support them.

What Is Prolonged Grief Disorder?

Prolonged grief disorder is characterized by intense and persistent grief that causes problems and interferes with daily life. Unlike the natural grieving process, which typically follows a trajectory of gradual healing and adaptation, prolonged grief disorder represents a distinct mental health condition that requires professional attention and treatment.

Prolonged grief disorder is the newest disorder to be added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), included in the text revision of DSM-5 (DSM-5-TR), which was released in March 2022. Prolonged grief disorder in the DSM-5-TR is classified as a “trauma and stressor-related disorder”. This formal recognition came after decades of research demonstrating that many people experience persistent difficulties associated with bereavement that substantially exceed culturally expected norms.

Grief is a natural response to the loss of a loved one, and 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. For a small proportion of people, intense and distressing symptoms of grief persist, cause problems in daily functioning, and may even pose challenges to simply getting through the day. Prolonged grief disorder is characterized by intense and persistent grief symptoms which are not only distressing in themselves but also associated with problems in functioning. Thus, those who meet criteria for prolonged grief disorder constitute a group of bereaved persons who are significantly disturbed and disabled by their grief.

The Difference Between Normal Grief and Prolonged Grief Disorder

It’s important to understand that experiencing intense grief after losing a loved one is completely normal and expected. The distinction between normal grief and prolonged grief disorder lies not in the presence of grief itself, but in its intensity, duration, and impact on functioning.

Although normal grief remains with the bereaved person far into the future, its ability to disrupt the survivor’s life is believed to dissipate with time. Normal grief, while painful, allows individuals to gradually re-engage with life, form new relationships, and find meaning again. In contrast, prolonged grief disorder involves grief that remains intensely painful and disruptive long after the loss, preventing the bereaved person from moving forward.

In the case of prolonged grief disorder, the duration of the person’s bereavement exceeds expected social, cultural or religious norms and the symptoms are not better explained by another mental disorder. This cultural sensitivity is crucial, as different societies and religions have varying expectations about appropriate mourning periods and expressions of grief.

Diagnostic Criteria and Timeline

Understanding the formal diagnostic criteria for prolonged grief disorder can help individuals and their loved ones recognize when grief has become complicated and may require professional intervention.

Time Requirements

For a diagnosis of prolonged grief disorder, the loss of a close other person must have occurred at least a year ago for adults and at least 6 months ago for children and adolescents. It can happen when someone close to the bereaved person has died within at least 6 months for children and adolescents, or within at least 12 months for adults. This timeline acknowledges that intense grief in the first months after a loss is normal and expected, and that children and adolescents may show signs of problematic grief earlier than adults.

Core Symptoms

An individual with prolonged grief disorder (PGD) may experience intense longing for the person who has died and/or feelings of being preoccupied by thoughts of the death of that person. In prolonged grief disorder, the bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents, with the circumstances around the death. These grief reactions occur most of the day, nearly every day for at least a month.

According to psychologist Holly Prigerson, an editor on the trauma and stressor-related disorder section of the DSM-5-TR, strong and ongoing longing for the deceased is a key symptom of prolonged grief, but it is not a feature of depression or any other disorder in the DSM. This distinguishing characteristic helps differentiate prolonged grief disorder from other mental health conditions that may occur after bereavement.

Additional Symptoms

In addition, the grieving individual must have experienced at least 3 of the symptoms below nearly every day for at least the last month prior to the diagnosis. The symptoms of prolonged grief disorder 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 without the deceased person

The individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning. This functional impairment is a critical component of the diagnosis, distinguishing prolonged grief disorder from intense but adaptive grief.

Recognizing the Signs of Prolonged Grief

While the formal diagnostic criteria provide a clinical framework, it’s helpful to understand how prolonged grief disorder manifests in everyday life. Recognizing these signs early can lead to timely intervention and support.

Emotional and Psychological Signs

Persistent and Intense Sadness: Unlike normal grief, where sadness comes in waves and gradually becomes less frequent and intense, prolonged grief involves an unrelenting sense of sorrow that doesn’t improve with time. The bereaved person may feel stuck in their grief, unable to experience joy or positive emotions even temporarily.

Constant Yearning and Preoccupation: People with PGD can experience a chronic aching and yearning for the dear departed, feel that they are not the same person anymore (identity disturbance), become emotionally disconnected from others, or lack the desire to “move on” (in some cases feeling that doing so would be betraying the person who is now deceased). This preoccupation can consume much of the person’s mental energy, making it difficult to focus on work, relationships, or daily responsibilities.

Disbelief and Denial: Even months or years after the loss, individuals with prolonged grief disorder may struggle to accept the reality of the death. They may find themselves expecting the person to walk through the door or reach for the phone to call them, experiencing repeated shocks when confronted with the reality of the loss.

Identity Disruption: Many people with prolonged grief disorder describe feeling as though a part of themselves died with their loved one. This sense of a fractured or incomplete self can be particularly pronounced when the deceased played a central role in the bereaved person’s identity, such as a spouse, parent, or child.

Behavioral Signs

Social Withdrawal and Isolation: People experiencing prolonged grief often withdraw from friends, family, and social activities. They may feel that others cannot understand their pain, or they may lack the energy or motivation to engage with others. This isolation can create a vicious cycle, as lack of social support can further intensify grief symptoms.

Avoidance of Reminders: While some avoidance is normal in early grief, prolonged grief disorder involves persistent and excessive avoidance of people, places, or things that remind the person of their loved one. This might include avoiding the deceased’s belongings, refusing to visit places they frequented together, or staying away from mutual friends.

Difficulty Engaging in Life: Individuals with prolonged grief disorder often struggle to re-engage with life activities, pursue interests, or plan for the future. They may feel that moving forward would dishonor their loved one’s memory or that life without the deceased person is meaningless.

Physical Signs

Prolonged grief doesn’t just affect mental and emotional health—it can also manifest in physical symptoms. These may include persistent fatigue, sleep disturbances, changes in appetite, headaches, and other stress-related physical complaints. The chronic stress of unresolved grief can take a significant toll on the body’s systems.

How Common Is Prolonged Grief Disorder?

Understanding the prevalence of prolonged grief disorder helps contextualize this condition and recognize that those experiencing it are not alone.

A meta-analysis published in the Journal of Affective Disorders assessed 14 studies and found that the prevalence of prolonged grief disorder among adults was 9.8 percent. However, prevalence rates vary depending on the population studied and the circumstances of the loss.

The conditional prevalence of developing CG after major bereavement was 6.7%; the prevalence of CG in the general sample was 3.7%. Prevalence within the general population was 4.8%. Current grief was reported by 1089 participants, and of these 277 (25.4%) were diagnosed with complicated grief. These figures suggest that while most bereaved individuals do not develop prolonged grief disorder, a significant minority do experience this debilitating condition.

About 10-20% of bereaved individuals experience a persistent, debilitating, and intense phenomenon referred to as complicated grief (CG) or prolonged grief disorder (PGO). This range reflects variations in study populations, diagnostic criteria used, and the nature of the losses studied.

Risk Factors for Developing Prolonged Grief Disorder

While anyone who experiences bereavement can potentially develop prolonged grief disorder, certain factors increase the risk. Understanding these risk factors can help identify individuals who may need additional support after a loss.

Relationship Factors

Nature of the Relationship: The type of relationship with the deceased significantly impacts grief intensity and duration. Time since bereavement and relationship to deceased, particularly when the source was a spouse or child, were predictive of complicated grief. Losing a spouse, child, or parent often carries a higher risk for prolonged grief disorder due to the central role these relationships play in our lives.

Attachment Style: PGO is principally considered an attachment disorder found across many cultures and age ranges. Anxious and insecure attachment styles (e.g., excessive dependency, compulsive caregiving) are correlated with PGO. Individuals who had particularly close, dependent, or conflicted relationships with the deceased may be at higher risk.

Increased dependency on the deceased prior to the death is listed among the risk factors in the DSM-5-TR. When someone has relied heavily on the deceased for emotional support, practical assistance, or identity definition, their loss can feel particularly devastating and difficult to integrate.

Circumstances of the Death

Sudden or Unexpected Death: Deaths that occur without warning, such as accidents, sudden medical events, or suicide, often carry a higher risk for prolonged grief disorder. The lack of opportunity to prepare emotionally or say goodbye can complicate the grieving process.

Traumatic or Violent Death: Shorter time since loss, lower education, loss of a partner, and unnatural/violent deaths increased chances of inclusion in the high symptoms class. Deaths involving violence, trauma, or particularly distressing circumstances can lead to complicated grief, especially when combined with symptoms of post-traumatic stress.

Personal and Social Factors

Previous Mental Health History: Individuals with a history of depression, anxiety, or previous unresolved grief may be more vulnerable to developing prolonged grief disorder after a new loss.

Lack of Social Support: They can help people feel less alone; thus, help avoid the isolation that could increase the risk for prolonged grief disorder. Limited social support networks, strained family relationships, or social isolation can significantly increase the risk of complicated grief.

Socioeconomic Factors: Severe grief reactions were relatively overrepresented in individuals with low education and low income, which aligns with findings of previous studies showing associations of complicated grief with low socio-economic status. Financial stress, limited access to healthcare, and other socioeconomic challenges can compound the difficulties of grieving.

Age and Life Stage: People with complicated grief were older, had a lower level of education, and more cognitive impairment. Older adults may face particular challenges, including multiple losses, health issues, and reduced social networks.

Cultural and Religious Context: While grief is universal, cultural and religious backgrounds shape how grief is expressed and processed. Disturbances in caregiver availability and support for bereaved children can also increase risk, highlighting the importance of stable support systems, especially for young people.

The Impact of Prolonged Grief on Health and Well-Being

Prolonged grief disorder doesn’t exist in isolation—it can have far-reaching effects on multiple aspects of a person’s life, including physical health, mental health, and social functioning.

Mental Health Consequences

Depression: It has been observed that complicated grief often co-occurs with other psychiatric diagnoses, especially depression and posttraumatic stress disorder. The persistent sadness, hopelessness, and loss of interest characteristic of prolonged grief can evolve into or coexist with major depressive disorder. However, it’s important to note that prolonged grief disorder and depression are distinct conditions, even though they may occur together.

Anxiety Disorders: The intense emotional pain and uncertainty associated with prolonged grief can manifest as anxiety symptoms. Bereaved individuals may experience panic attacks, generalized anxiety, or specific fears related to loss and death.

Post-Traumatic Stress Disorder: PTSD and PGD, while being separate diagnoses, do have overlap, as both include similar symptoms of intrusive thoughts relating to death, experiencing numbness to emotions, and possible disturbances in sleep. When a death occurs under traumatic circumstances, individuals may develop both PTSD and prolonged grief disorder, creating a complex clinical picture.

This argument also underscored the urgent evidence that PGD has been associated with increased rates of other mental disorders, including PTSD, suicidality, and depression. The risk of suicidal thoughts and behaviors is a serious concern among those with prolonged grief disorder, particularly when combined with depression or feelings of wanting to join the deceased.

Physical Health Effects

Difficulties with coping with grief predicted a broad range of physical health problems. The chronic stress associated with prolonged grief disorder can affect virtually every system in the body.

Cardiovascular Health: Prolonged stress and grief can increase the risk of heart disease, high blood pressure, and other cardiovascular problems. The intense emotional pain of grief creates physiological stress responses that, when sustained over time, can damage the cardiovascular system.

Immune Function: Chronic grief can weaken the immune system, making individuals more susceptible to infections and illnesses. The body’s stress response, when activated continuously, can suppress immune function and slow healing processes.

Sleep Disturbances: Many people with prolonged grief disorder experience significant sleep problems, including insomnia, nightmares, or disrupted sleep patterns. Poor sleep quality further compounds other health issues and makes it more difficult to cope with grief.

Appetite and Weight Changes: Grief can dramatically affect appetite, leading to significant weight loss or gain. Some individuals lose interest in food entirely, while others may turn to food for comfort.

Parents who had lost a child due to cancer and felt that they had not worked through their grief were more likely to experience anxiety, depression, and physical health problems than parents who had worked through their grief. This research underscores the importance of processing grief rather than avoiding or suppressing it.

Social and Functional Impairment

Prolonged grief disorder can severely impact a person’s ability to function in daily life. Work performance may suffer due to difficulty concentrating, lack of motivation, or frequent absences. Relationships with family and friends may become strained as the bereaved person withdraws or struggles to engage meaningfully with others.

Financial difficulties may arise from reduced work capacity, medical expenses, or poor decision-making during the acute phase of grief. The cumulative effect of these impairments can create a downward spiral, where functional difficulties exacerbate grief symptoms, which in turn further impair functioning.

Substance Use and Unhealthy Coping Mechanisms

Some individuals with prolonged grief disorder may turn to alcohol, drugs, or other unhealthy coping mechanisms in an attempt to numb their pain or escape from their grief. Additional signs include difficulty coping without the deceased, problems recalling positive memories, social withdrawal, and increased substance use or suicidal thoughts. Substance use can provide temporary relief but ultimately complicates grief and creates additional problems.

Distinguishing Prolonged Grief from Other Conditions

One of the challenges in recognizing prolonged grief disorder is distinguishing it from other mental health conditions that can occur after bereavement, particularly depression and post-traumatic stress disorder.

Prolonged Grief Disorder vs. Depression

While prolonged grief disorder and major depressive disorder share some symptoms, such as sadness, sleep disturbances, and loss of interest in activities, they are distinct conditions with different core features.

The hallmark of prolonged grief disorder is intense yearning and preoccupation with the deceased, which is not a feature of depression. In depression, the sadness is more generalized and pervasive, whereas in prolonged grief disorder, the emotional pain is specifically tied to the loss and the deceased person.

People with depression often experience feelings of worthlessness and guilt that are not specifically related to the deceased, whereas in prolonged grief disorder, any guilt typically relates to the death or the relationship with the deceased. Additionally, individuals with prolonged grief disorder may still be able to experience moments of joy or connection when not confronted with reminders of their loss, whereas depression involves a more persistent inability to experience pleasure.

Prolonged Grief Disorder vs. PTSD

When a death occurs under traumatic circumstances, it can be challenging to distinguish between prolonged grief disorder and PTSD, as both conditions can involve intrusive thoughts, avoidance behaviors, and emotional numbness.

The key distinction lies in the focus of the symptoms. In PTSD, the intrusive thoughts and distress center on the traumatic event itself—the circumstances of the death, the violence or horror witnessed, or the threat experienced. In prolonged grief disorder, while the person may think about the circumstances of the death, the primary focus is on the loss of the person and the yearning for their presence.

PTSD involves hypervigilance and exaggerated startle responses related to perceived threats, whereas prolonged grief disorder does not typically include these features. However, it’s important to note that an individual can experience both conditions simultaneously, particularly after a traumatic loss.

The Importance of Accurate Diagnosis

Findings show that PGD per DSM-5-TR is a distinct condition and underscore that reducing avoidance behaviors is important in the treatment of post-loss psychopathology. Since the 1990s, studies have demonstrated the validity of distinguishing PGD from mental disorders with similar symptom clusters, specifically major depressive disorder and post-traumatic stress disorder. Validity has also been demonstrated for the DSM-5-TR criteria.

Accurate diagnosis is crucial because different conditions respond to different treatments. While there is overlap in some therapeutic approaches, specialized treatments for prolonged grief disorder have been developed and shown to be effective, and these may differ from standard treatments for depression or PTSD.

Treatment and Intervention Strategies

The good news is that prolonged grief disorder is treatable. With appropriate intervention, individuals can learn to integrate their loss, reduce their symptoms, and re-engage with life while maintaining a meaningful connection to their loved one’s memory.

Professional Therapeutic Approaches

Complicated Grief Treatment (CGT): One form of therapy shown to help the bereaved is called complicated grief treatment. This approach uses elements of cognitive-behavioral therapy and attachment theory. It helps patients understand the nature of grief, process their emotions, accept the reality of their loss, develop coping skills, establish new goals, shore up relationships, and build a fulfilling life while honoring their loved one’s memory.

Research shows that complicated grief treatment can effectively reduce symptoms among those with prolonged grief disorder. This specialized treatment was developed specifically for prolonged grief and has been validated through rigorous research studies.

Prolonged Grief Disorder Therapy: Most experts recommend a type of psychotherapy provided by mental health professionals called “prolonged grief disorder therapy” as first line treatment based on best published data. This therapy typically involves helping the bereaved person confront avoided reminders of the loss, process the reality of the death, and gradually re-engage with life.

Cognitive-Behavioral Therapy (CBT): If this does not work, mental health professionals may utilize cognitive-behavioral therapy techniques, exposure therapy, or mindfulness-based cognitive therapy. CBT can help individuals identify and change unhelpful thought patterns related to their loss, such as beliefs that moving forward means betraying the deceased or that they cannot survive without their loved one.

Other Therapeutic Modalities: Compared with the waiting list, behavioral therapy, third-wave cognitive behavior therapy, family therapy, psychodynamic therapy and cognitive therapy were statistically effective in reducing grief symptom. Different therapeutic approaches may work better for different individuals, and therapists may integrate multiple modalities to address the unique needs of each person.

Medication Considerations

There are currently no medications to treat specific symptoms of grief, but research is underway to explore medications that might prove helpful in mitigating prolonged grief disorder. While no medications are specifically approved for prolonged grief disorder, medications may be prescribed to address co-occurring conditions such as depression or anxiety.

When medication is used, it’s typically as an adjunct to psychotherapy rather than as a standalone treatment. Antidepressants may help with symptoms of depression that accompany prolonged grief, and anti-anxiety medications may provide short-term relief from acute anxiety symptoms. However, medication alone is generally not sufficient to address the core features of prolonged grief disorder.

Support Groups and Peer Support

Bereavement support groups and peer support can also provide a useful source of social connection and support. Connecting with others who have experienced similar losses can be incredibly valuable. Support groups provide a space where bereaved individuals can share their experiences, feel understood, and learn from others who are further along in their grief journey.

Many communities offer grief support groups through hospice organizations, religious institutions, mental health centers, or community organizations. Some groups are general bereavement support groups, while others focus on specific types of loss, such as loss of a spouse, child, or loss to suicide.

Many hospice agencies provide bereavement services, even if the bereaved’s loved one was not a patient of the hospice agency. These services can be an excellent resource for those seeking support after a loss.

Self-Care and Coping Strategies

While professional help is often necessary for prolonged grief disorder, self-care practices can support the healing process and complement professional treatment.

Physical Self-Care: Maintaining basic physical health through regular sleep, nutritious eating, and physical activity can help support emotional resilience. Exercise, in particular, has been shown to reduce symptoms of depression and anxiety and can provide a healthy outlet for grief-related stress.

Mindfulness and Meditation: Mindfulness practices can help individuals stay present with their grief without becoming overwhelmed by it. Meditation, deep breathing exercises, and other relaxation techniques can help manage the intense emotions associated with grief.

Journaling and Expressive Writing: Writing about one’s grief, memories of the deceased, and feelings about the loss can be a powerful tool for processing emotions and gaining insight. Some people find it helpful to write letters to their deceased loved one as a way of maintaining connection and expressing unspoken thoughts and feelings.

Creative Expression: Art, music, poetry, and other creative outlets can provide alternative ways to express and process grief. Creative activities can help individuals access and express emotions that may be difficult to put into words.

Maintaining Routines: While grief can disrupt normal routines, maintaining some structure and predictability in daily life can provide a sense of stability and normalcy. Setting small, achievable goals for each day can help individuals gradually re-engage with life.

Honoring the Deceased

Finding meaningful ways to honor and remember the deceased can be an important part of healing from prolonged grief. This might include:

  • Creating a memorial or tribute
  • Establishing a scholarship or charitable fund in the deceased’s name
  • Participating in activities the deceased enjoyed
  • Sharing stories and memories with others who knew the deceased
  • Celebrating the deceased’s birthday or other significant dates in meaningful ways
  • Keeping meaningful objects or creating memory boxes

The goal is not to “get over” the loss or forget the deceased, but rather to find ways to maintain a continuing bond with them while also moving forward with life. The goal of PGO treatment is to facilitate integration of the loss, it is not to eliminate all grief-related symptoms.

Screening and Assessment Tools

For healthcare providers and mental health professionals, having reliable tools to screen for and assess prolonged grief disorder is essential for early identification and intervention.

The Brief Grief Questionnaire is a 5-item screening tool for PGO scored on a 0-2 Likert scale (‘not at all,’ ‘somewhat,’ ‘a lot’). This brief screening tool asks questions such as:

  • How much does your grief interfere with your life?
  • How much are you having images or thoughts of your loved one when he or she died?
  • Are there things that you used to do when your loved one was alive that you don’t feel comfortable doing more, that you avoid?
  • How much are you feeling cut off or distant from other people since your loved one died?

More comprehensive assessment tools have also been developed and validated for use in clinical and research settings. These tools help clinicians determine whether an individual meets diagnostic criteria for prolonged grief disorder and assess the severity of symptoms.

Cultural Considerations in Grief and Mourning

Grief is a universal human experience, but the ways in which grief is expressed, processed, and understood vary significantly across cultures. When assessing and treating prolonged grief disorder, it’s essential to consider cultural context.

Notably, the duration of grief expression varies by culture. Researchers have therefore tailored PGD measurement tools to improve cross-cultural validity. What might be considered prolonged grief in one culture may be within normal expectations in another culture with different mourning traditions.

We provided a global perspective on bereavement, grief reactions, and PGD, and we suggested that grief reactions seem to be consistent across different cultures, although differences and variations in the expression of symptoms may exist across cultures. While the core experience of grief appears to be universal, cultural factors influence how grief is expressed, how long mourning periods last, what rituals are performed, and what support systems are available.

Some cultures encourage open expression of grief, while others value stoicism and emotional restraint. Some cultures have elaborate mourning rituals that last for extended periods, while others have shorter, more private mourning practices. Religious beliefs about death, the afterlife, and the relationship between the living and the dead also shape the grief experience.

Healthcare providers must be sensitive to these cultural differences and avoid pathologizing grief expressions that are culturally appropriate. At the same time, they must recognize when grief is causing significant distress and impairment that exceeds cultural norms and warrants intervention.

Supporting Someone with Prolonged Grief

If you have a friend, family member, or colleague who is experiencing prolonged grief, your support can make a significant difference in their healing journey. Here are some ways to provide meaningful support:

What to Do

Be Present and Listen: Sometimes the most valuable thing you can offer is simply your presence and willingness to listen without judgment. Allow the grieving person to talk about their loved one and their feelings without trying to fix their pain or rush them through their grief.

Acknowledge the Loss: Don’t avoid mentioning the deceased or the loss out of fear of causing pain. Bereaved individuals often appreciate when others remember and acknowledge their loved one. Saying the deceased person’s name and sharing memories can be comforting.

Offer Practical Help: Grief can make it difficult to manage daily tasks. Offer specific, practical help such as preparing meals, running errands, helping with household chores, or providing childcare. Specific offers are more helpful than general statements like “let me know if you need anything.”

Encourage Professional Help: If you’re concerned that someone’s grief has become prolonged or complicated, gently encourage them to seek professional help. Offer to help them find a therapist, support group, or other resources. You might offer to accompany them to their first appointment if they’re hesitant.

Be Patient: Healing from grief takes time, and there’s no set timeline. Continue to check in and offer support even months or years after the loss. Many bereaved people feel forgotten as time passes and others move on with their lives.

Remember Significant Dates: Anniversaries, birthdays, holidays, and other significant dates can be particularly difficult for bereaved individuals. Reaching out on these days to acknowledge the loss and offer support can be deeply meaningful.

What to Avoid

Avoid Platitudes and Clichés: Well-meaning phrases like “they’re in a better place,” “everything happens for a reason,” or “time heals all wounds” can feel dismissive and hurtful. These statements minimize the bereaved person’s pain and don’t provide genuine comfort.

Don’t Compare Losses: Avoid comparing the person’s loss to other losses or sharing your own grief experiences in a way that shifts focus away from their pain. While sharing can sometimes be helpful, it should be done carefully and only if it truly serves the grieving person.

Don’t Rush the Process: Avoid suggesting that the person should be “over it” by now or encouraging them to move on before they’re ready. Grief doesn’t follow a predictable timeline, and pressure to “get better” can be counterproductive.

Don’t Avoid the Person: Many people avoid bereaved individuals because they don’t know what to say or fear saying the wrong thing. This avoidance can increase the bereaved person’s sense of isolation. It’s better to reach out, even if you feel awkward, than to stay away.

Prevention and Early Intervention

While it’s not always possible to prevent prolonged grief disorder, early intervention and support after a loss can reduce the risk of complicated grief developing.

Anticipatory Grief Support

When a death is expected, such as with terminal illness, providing support during the anticipatory grief period can help prepare individuals for the loss. This might include encouraging open communication about the impending death, facilitating opportunities to say goodbye, and connecting families with hospice and palliative care services.

Immediate Post-Loss Support

In the immediate aftermath of a loss, ensuring that bereaved individuals have adequate social support, practical assistance, and information about normal grief can help set the stage for healthy grieving. This is particularly important for individuals at higher risk for prolonged grief, such as those who have lost a child or spouse, or those who have experienced a traumatic or sudden loss.

Monitoring and Follow-Up

Healthcare providers, clergy, and others who work with bereaved individuals should monitor for signs of complicated grief and provide referrals to mental health services when needed. Regular check-ins at key time points after a loss (such as 3 months, 6 months, and 1 year) can help identify individuals who are struggling and connect them with appropriate resources.

The Controversy and Debate Around Prolonged Grief Disorder

The inclusion of prolonged grief disorder in diagnostic manuals has not been without controversy. Understanding these debates provides important context for how we think about and respond to prolonged grief.

Concerns About Pathologizing Normal Grief

However, inclusion of PGD in the DSM-5 and ICD-11 was thought at risk of being misunderstood as medicalization of grief, as some thought that introducing PGD would result in over-prescriptions of psychotropic medication and abnormalize normal grief reactions. Critics worry that creating a diagnosis for prolonged grief might lead to the pathologization of normal, albeit intense, grief reactions.

There are concerns that pharmaceutical companies might develop and aggressively market medications for grief, potentially leading to overmedication of normal grief. Some worry that the diagnosis might be applied too broadly, labeling people as disordered when they are simply experiencing intense but normal grief.

The Case for Recognition

Recognizing prolonged grief as a disorder was argued to allow it to be better understood, detected, studied and treated. Proponents argue that formal recognition of prolonged grief disorder benefits those who are truly suffering from debilitating grief by:

  • Legitimizing their experience and reducing stigma
  • Facilitating access to appropriate treatment and insurance coverage
  • Promoting research into effective interventions
  • Educating healthcare providers about this condition
  • Providing a common language for clinicians, researchers, and patients

Proponents of the new diagnosis argue that adding prolonged grief disorder as a diagnosis benefits patients by leading to more knowledge about grief, more informed clinicians, greater access to services, more public awareness and recognition, and greater consistency in the grief literature.

In spite of this concern, studies have shown good accuracy for the ICD-11 and DSM-5-TR definitions, and that nearly all bereaved individuals who met the criteria for PGD were receptive to treatment and their families relieved to know they had a recognizable syndrome. This suggests that the diagnosis is being applied appropriately to those who are truly suffering and in need of help.

Balancing Recognition and Caution

The key is to strike a balance between recognizing and treating prolonged grief disorder while respecting the natural diversity of grief experiences and avoiding unnecessary pathologization. The diagnostic criteria include important safeguards, such as the requirement that symptoms must cause significant distress or impairment and must exceed cultural expectations for grief duration and intensity.

Healthcare providers must use clinical judgment and cultural sensitivity when applying the diagnosis, ensuring that it is reserved for those who are truly experiencing debilitating, persistent grief that interferes with their functioning and well-being.

Research and Future Directions

The field of grief research continues to evolve, with ongoing studies exploring various aspects of prolonged grief disorder and its treatment.

Prevalence Studies

Establishing the prevalence of PGD is an important scientific goal as it may help clarify how many people experience this condition in the general population, and whether, and to what extent, specific groups of bereaved people may be at risk for PGD, which can help guide mental healthcare policy and practice. Researchers continue to study prevalence rates across different populations and cultures to better understand the scope of this condition.

This shows that PGD is of relevance around the world, but seems to be more common in less vulnerable countries with good access to daily necessities and healthcare services. Understanding these patterns can help inform resource allocation and intervention strategies.

Treatment Research

Ongoing research continues to refine and improve treatments for prolonged grief disorder. Studies are examining which therapeutic approaches work best for which individuals, optimal treatment duration and intensity, and how to adapt treatments for different populations and cultural contexts.

Research into potential pharmacological treatments continues, though currently no medications are specifically approved for prolonged grief disorder. Future studies may identify medications that can effectively target specific symptoms of prolonged grief.

Neurobiological Research

Emerging research is exploring the neurobiological underpinnings of prolonged grief disorder, using brain imaging and other techniques to understand how the brain processes grief and what distinguishes prolonged grief from normal grief at a neural level. This research may eventually lead to new treatment approaches.

Cultural Research

More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems. As prolonged grief disorder is recognized globally, more research is needed to understand how it manifests across different cultural contexts and how treatments can be adapted to be culturally appropriate and effective.

Living with and Beyond Prolonged Grief

Recovery from prolonged grief disorder is possible, though it’s important to understand what recovery means in this context. Recovery doesn’t mean forgetting the deceased or no longer feeling sad about the loss. Rather, it means integrating the loss into one’s life story, reducing the intensity and frequency of debilitating symptoms, and re-engaging with life while maintaining a meaningful connection to the deceased.

What Recovery Looks Like

People who have successfully worked through prolonged grief often describe being able to:

  • Think about the deceased without being overwhelmed by intense pain
  • Experience positive emotions and find joy in life again
  • Form and maintain meaningful relationships
  • Pursue goals and interests
  • Accept the reality of the loss
  • Find meaning and purpose in life
  • Remember the deceased with a mixture of sadness and positive feelings
  • Function effectively in work, social, and family roles

Recovery is not linear—there will be setbacks and difficult days, particularly around anniversaries and holidays. However, over time, the difficult days become less frequent and less intense, and individuals develop better coping skills for managing them.

Post-Traumatic Growth

Some individuals who have experienced profound loss and worked through their grief report experiencing post-traumatic growth—positive changes that result from struggling with difficult life circumstances. This might include:

  • Deeper appreciation for life and relationships
  • Greater personal strength and resilience
  • Closer relationships with others
  • New possibilities or life directions
  • Spiritual or existential growth
  • Increased compassion and empathy for others who are suffering

Acknowledging the possibility of growth doesn’t minimize the pain of loss or suggest that the loss was somehow “worth it.” Rather, it recognizes that humans have a remarkable capacity to find meaning and growth even in the midst of profound suffering.

Resources and Where to Find Help

If you or someone you know is struggling with prolonged grief, numerous resources are available:

Professional Resources

  • Mental Health Professionals: Psychologists, psychiatrists, licensed clinical social workers, and counselors who specialize in grief and bereavement can provide assessment and treatment. Look for professionals with specific training in complicated grief treatment or prolonged grief disorder therapy.
  • Primary Care Physicians: Your doctor can provide initial assessment, rule out medical causes of symptoms, and provide referrals to mental health specialists.
  • Hospice Bereavement Services: Many hospice organizations offer bereavement support services to the community, not just to families of their patients.

Support Organizations

Online Resources

Many organizations offer online support groups, forums, and educational resources for bereaved individuals. These can be particularly helpful for those in rural areas or those who prefer the anonymity of online support.

Crisis Resources

If you or someone you know is experiencing suicidal thoughts:

  • National Suicide Prevention Lifeline: 988 (call or text)
  • Crisis Text Line: Text HOME to 741741
  • International Association for Suicide Prevention: Resources for countries worldwide

Conclusion: Hope and Healing

Prolonged grief disorder is a serious condition that can profoundly impact every aspect of a person’s life. However, it’s important to remember that it is treatable, and recovery is possible. The formal recognition of prolonged grief disorder in diagnostic manuals represents an important step forward in ensuring that those who are suffering receive appropriate care and support.

If you’re experiencing prolonged grief, know that your pain is real and valid, and that help is available. Seeking professional support is not a sign of weakness but rather a courageous step toward healing. With appropriate treatment, support from others, and time, it is possible to integrate your loss, honor your loved one’s memory, and re-engage with life in meaningful ways.

For those supporting someone with prolonged grief, your patience, presence, and compassion can make a significant difference. Encourage your loved one to seek professional help, offer practical support, and remember that healing from profound loss takes time.

Grief, even prolonged grief, is ultimately a testament to love. The depth of grief reflects the depth of connection and love that was shared. While the pain of loss may never completely disappear, it can be transformed over time into something more bearable—a bittersweet remembrance that honors both the love that was shared and the life that continues.

Understanding prolonged grief disorder, recognizing its signs, and knowing how to address it are essential steps in supporting those who are struggling with complicated bereavement. By increasing awareness, reducing stigma, and ensuring access to effective treatments, we can help those experiencing prolonged grief find their way back to a life that, while forever changed by loss, can still hold meaning, connection, and even joy.