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Complicated grief
By Mayo Clinic Staff
Sep 28, 2007

Losing a loved one is one of the most distressing and emotional experiences people face. But because death is such a common life experience, virtually everyone deals with grief at some point. Despite the emotional difficulty, most people experiencing normal grief and bereavement endure a period of sorrow, numbness, and even guilt and anger, followed by a gradual fading of these feelings as they accept the loss and move forward.

For some people, though, this normal grief reaction becomes much more complicated, painful and debilitating, or what's known as complicated grief. In complicated grief, painful emotions are so long lasting and severe that you have trouble accepting the death and resuming your own life.

Researchers are beginning to pay more attention to complicated grief because of the serious toll it can exact — possibly leading to depression and thoughts of suicide. Researchers have even developed a new treatment that may help people with complicated grief come to terms with their loss and reclaim a sense of joy and peace.

Signs and symptoms
Mental health experts are still analyzing how complicated grief symptoms differ from those of normal grief or other bereavement reactions. During the first few months after a loss, many signs and symptoms of normal grief are the same as those of complicated grief. However, while normal grief symptoms gradually start to fade within six months or so, those of complicated grief get worse or linger for months or even years. Complicated grief is like being in a chronic, heightened state of mourning.

Signs and symptoms of complicated grief can include:

  • Extreme focus on the loss and reminders of the loved one
  • Intense longing or pining for the deceased
  • Problems accepting the death
  • Numbness or detachment
  • Preoccupation with your sorrow
  • Bitterness about your loss
  • Inability to enjoy life
  • Depression or deep sadness
  • Difficulty moving on with life
  • Trouble carrying out normal routines
  • Withdrawing from social activities
  • Feeling that life holds no meaning or purpose
  • Irritability or agitation
  • Lack of trust in others

Causes

It's not known what causes complicated grief. As with many mental health disorders, it may involve a complex interaction between your genes, environment, your body's natural chemical makeup and your personality.

Some researchers believe in the five stages of grief theory, attributed to the late psychiatrist Elizabeth Kubler-Ross, M.D. Although she intended this process for people at the end of their lives, some researchers said that bereaved survivors also went through these stages in an orderly fashion:

  1. Denial, shock or isolation
  2. Anger
  3. Bargaining
  4. Depression or sadness
  5. Acceptance of the loss

People who didn't follow the steps in order or who became stuck at one of these stages were thought to be in an unhealthy grieving pattern. Today, though, most grief experts don't embrace this theory, instead believing that while grief is an evolution, most people don't go through organized stages.

Risk factors
Complicated grief is considered relatively uncommon. Because research about complicated grief is evolving, it's difficult to know how many people are affected. Some estimates suggest that as few as 6 percent or as many as 20 percent of bereaved people develop complicated grief.

While it's not known specifically what causes complicated grief, researchers continue to learn more about the factors that may increase the risk of developing it. These risk factors may include:

  • An unexpected or violent death
  • Suicide of a loved one
  • Lack of a support system or friendships
  • Traumatic childhood experiences, such as abuse or neglect
  • Childhood separation anxiety
  • Close or dependent relationship to the deceased person
  • Being unprepared for the death
  • In the case of a child's death, the number of remaining children
  • Lack of resilience or adaptability to life changes

When to seek medical advice

It's normal to experience grief after a significant loss. Most people who experience normal or uncomplicated grief can move forward eventually with support from family and friends. But if it's been several months or more since your loss and your emotions remain so intense or debilitating that you have trouble going about your normal routine, consider talking to your health care provider.

Specifically, you may benefit from professional help if you:

  • Can focus on little else but your loved one's death
  • Have persistent pining or longing for the deceased person
  • Have thoughts of guilt or self-blame
  • Believe that you did something wrong or could have prevented the death
  • Feel as if life isn't worth living
  • Have lost your sense of purpose in life
  • Wish you had died along with your loved one

At times, people with complicated grief may consider suicide. If you're considering suicide, reach out to someone as soon as possible. The best choice is to call 911 or your local emergency services number.

Screening and diagnosis
Complicated grief isn't yet recognized by mental health providers as an actual disorder. However, there's growing consensus that it should be. And even though it's not an official disorder, you may still be diagnosed with complicated grief.

To help diagnose complicated grief, mental health providers perform a thorough psychological evaluation. They ask many questions about the events surrounding the loss of your loved one, your mood, thoughts and behavior, your lifestyle and social situation, and sleeping and eating patterns, for example. You may also fill out psychological questionnaires. And you may have a physical exam to check for any other health problems that may be causing or contributing to your symptoms.

Because bereavement also can lead to other disorders, such as depression or post-traumatic stress disorder, you may be evaluated for those conditions.

Generally, to be diagnosed with a certain mental health disorder, someone must meet specific criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Because complicated grief isn't yet considered an actual disorder, it's not listed in the current DSM and has no official diagnostic criteria. However, some researchers have proposed adding complicated grief as a specific disorder in the next version of the DSM, scheduled for publication in 2011. Different diagnostic criteria have been proposed. One proposal that has gotten support includes these criteria:

  • Intense pining or longing for the deceased that occurs daily or is distressing or disruptive
  • Trouble accepting the death
  • Inability to trust others after the death
  • Difficulty moving forward with life
  • Excessive bitterness or anger related to the death
  • Feeling emotionally numb or detached from others
  • A feeling that life is now meaningless
  • A belief that the future won't be fulfilling
  • Increased agitation or jumpiness

For diagnosis of complicated grief, these symptoms must last at least six months and cause impairment or disruption in your ability to function in daily life, such as at work or in social engagements.

Complications
Complicated grief can affect you physically, mentally and socially. Without appropriate treatment, these complications can include:

  • Depression
  • Suicidal thoughts or behaviors
  • Increased risk of heart disease, cancer and high blood pressure
  • Anxiety
  • Long-term impairment in daily living
  • Post-traumatic stress disorder
  • Substance abuse
  • Smoking or nicotine use

Treatment

Complicated grief treatment hasn't been standardized because mental health providers are still learning about the condition. Research studies testing various types of treatment have had mixed results. That isn't to say that treatment isn't helpful, though. More study is needed to help determine which treatment options may be best for complicated grief.

Psychotherapy
Some studies have shown big benefits from treating complicated grief with a newly developed type of psychotherapy called complicated grief treatment, also called complicated grief therapy. This form of psychotherapy, which borrows from cognitive behavior therapy and trauma therapy, is comprehensive and sometimes intense. You may learn about such topics as grief reactions, complicated grief symptoms, adjusting to your loss and redefining your life's goals.

This therapy also includes holding imagined conversations with your loved one and retelling the circumstances of the death, perhaps several times to help you become less distressed by images and thoughts of your loved one. Although some people find this therapy painful, others find it ultimately rewarding and freeing after what may have been years of chronic mourning.

Other forms of therapy, such as interpersonal therapy or psychodynamic psychotherapy, also may be effective. Therapy can help you explore and process emotions, improve coping skills and reduce feelings of blame and guilt.

Medications
There's little solid research on the use of psychiatric medications to treat complicated grief. However, some research has shown benefits from using antidepressants in the class of selective serotonin reuptake inhibitors (SSRIs) to reduce complicated grief symptoms.

Prevention
It's not clear how to prevent complicated grief with any certainty. Some studies suggest that participating in a brief course of counseling or psychotherapy soon after a loss may help, especially for those at increased risk of developing complicated grief. In addition, caregivers providing end-of-life care for a loved one may benefit from counseling and support to help prepare for death and its emotional aftermath.

Through early counseling, you can explore emotions surrounding your loss and learn healthy coping skills. This may help prevent negative beliefs about your loss from gaining such a strong hold that they're difficult to overcome. People who themselves may be at risk of suicide following a loved one's suicide may especially benefit from grief counseling or other treatment.

Finding support from family, friendships, group therapy or social support groups after a loss can promote healthy grieving. You can also take steps to improve your resilience skills to help cope with hardships and loss.

Coping skills
Although it's important to get professional treatment for complicated grief, you can take steps on your own to cope, including:

  • Stick to your treatment plan. Take medications as directed and attend therapy appointments as scheduled.
  • Exercise regularly. Physical exercise helps relieve depression, stress and anxiety and can redirect your mind to the activity at hand.
  • Take care of yourself. Get enough rest, eat a balanced diet and take time to relax. Don't turn to alcohol or unprescribed drugs for relief.
  • Reach out to your faith community. If you follow religious practices or traditions, you may gain comfort from rituals or guidance from a spiritual leader.
  • Practice stress management. Learn how to better manage stress. Unmanaged stress can lead to depression, overeating, or other unhealthy thoughts and behaviors.
  • Socialize. Stay connected with people you enjoy being around. They can offer support, a shoulder to cry on or a joke to give you a little boost.
  • Plan ahead for special dates or anniversaries. Holidays, anniversaries and special occasions can trigger painful reminders of your loved one. Find new ways to celebrate or acknowledge your loved one that provide you comfort and hope.
  • Learn new skills. If you were highly dependent on your loved one, perhaps to handle the cooking or finances, for example, try to master these tasks yourself. Ask family, friends or professionals for guidance, if necessary. Seek out community classes and resources, too.
  • Join a support group. You may not be ready to join a support group immediately after your loss, but over time you may find shared experiences comforting and you may form meaningful new relationships.
 

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