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Complicated grief

Grief is an unavoidable and normal experience. But it can take intense forms that surprise a bereaved person, including forms that in other circumstances would be called a psychiatric disorder. In some cases, psychiatric treatment may help.

Bereaved persons may suffer not only sadness but anger and suspicions about the motives of people who offer support. They may ruminate obsessionally about the events leading up to the death and blame themselves or others for it. Up to 50% of widows and widowers have symptoms typical of major depression in the first few months. They may also have hallucinatory experiences.

These symptoms are usually normal responses to the loss. They call for comforting and sometimes explanation, but not treatment. But if the symptoms linger and become increasingly debilitating, the condition turns into what is now being called unresolved, protracted, traumatic, or complicated grief. It has features of both depression and post-traumatic stress disorder (PTSD). And there is some evidence that a distinct type of treatment may bring relief.

The most characteristic symptoms are intrusive thoughts and images of the deceased person and a painful yearning for his or her presence. Other complications are denial of the death, imagining that the dead person is alive, desperate loneliness and helplessness, anger and bitterness, and wanting to die..

Risk factors

The risk of developing complicated grief depends on both the immediate circumstances of the death and the background against which it occurs. PTSD is more likely to follow a traumatic experience if the person who undergoes it regards his reactions as a sign of weakness, fears that he will lose his sanity, or ruminates about how he or someone else could have prevented it from happening. These are also risk factors for complicated grief, and the disorder is more likely to occur after a death that is traumatic — premature, sudden, violent, or unexpected.

But even normal bereavement can produce complicated grief. Whether that happens depends on how a person copes, not just with trauma, but with loss. For anyone who could not respond to earlier losses without losing emotional equilibrium, complicated grief becomes a greater danger. So a person with a history of depression, anxiety disorders, or a personality disorder is more likely to suffer complicated grief after bereavement, as well as PTSD after a traumatic experience.


Treatment of complicated grief often relies on the idea that grieving is an experience to be worked through. Some people are thought to be stuck and unable to free themselves because of problems arising from emotional instability, previous losses, or difficulties in their relationship with the person who has died. A promising treatment called traumatic grief therapy uses cognitive behavioral methods for traumatic symptoms and stress relief, along with interpersonal techniques to encourage re-engagement with the world.

Patients tell the story of the death repeatedly and listen to tapes of the recitation — imaginal exposure. They learn to confront thoughts and situations they may have been avoiding — in vivo exposure. They evoke happy memories, and hold imaginary conversations with him or her under a therapist’s guidance, exploring regrets or resentment. They are encouraged to think about how to enjoy other activities rather than dwell on the loss.

In one study, traumatic grief therapy was found to be especially effective for people mourning a violent death; more than half of them improved, compared with 13% in standard interpersonal therapy.

Complicated grief is not one of the disorders in the American Psychiatric Association official diagnostic manual. .Some think a standard diagnosis is needed to improve research on the symptoms of complicated grief. Others regard that as simply another variation on PTSD. What matters is not whether another diagnostic category is introduced, but how to identify and help the minority of bereaved people who need more than the usual comfort and support.

December 2006 Update

Emotional Health: Coping with Grief and Loss
Click to enlarge

Coping with Grief & Loss: A Guide to Healing

Have you recently lost a loved one or know someone who has? Grief often produces a host of emotions, including numbness, despair, anger, sadness, and guilt. Coping with Grief & Loss can help with the wide range of emotions and ease sorrow in a time of loss. Read more

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