What Is Complicated Grief?

Kirsten Schuder
Young woman looking numb with grief

Unresolved grief and complicated grief are often used interchangeably. Unresolved grief is difficult to differentiate from the grieving process. However, there are certain symptoms that differentiate it from the normal process. Watching out for these can help determine if you or your loved one has unresolved grief.

Definition of Unresolved or Complicated Grief

Unresolved grief is another term for complicated grief. It's also known medically as persistent complex bereavement disorder, and can occur in approximately 7% of bereaved people. They describe a person who has prolonged periods of intense mourning with no progression in the healing process or a worsening in symptoms over time. The term may also describe a person who simply doesn't mourn, but instead is in denial over the loss.

It should be noted that this type of grief frequently in paired with co-occurring disorders such as "adjustment disorders, major depression, substance abuse, and post-traumatic stress disorder."

Complicated Grief and Normal Grief

With unresolved or complicated grief, a person is grieving for a prolonged period, with intense symptoms such as suicidal ideation or suicide attempts. This type of grief can interfere with the person's ability to function in daily life. However, it may not look any different than the grieving process on the outset, but it is differentiated by:

  • Its severity
  • Its duration - it can continue for years
  • Its interference with normal, daily functioning
  • Its intensity, and the fact that the grief does not decrease over time (the proposed guideline for when to diagnose PCBD is one year after the loss for adults)

Causes and Risk Factors for Complicated Grief

It is not known what causes complicated grief. However, there are certain risk factors that are believed to contribute to the development of complicated grief.

  • Violent death
  • Suicide
  • No social support for the bereaved
  • Childhood trauma
  • Attachment and anxiety issues in childhood
  • Codependent on the deceased
  • The death is sudden
  • Inability to adapt

Behaviors of Unresolved Grief

People with unresolved grief display different types of behaviors. The type of behavior a person displays is dependent upon different factors, including age.


Adults with unresolved grief may have extreme reactions to their loss. They may:

  • Not want to speak about the loss or acknowledge the loss in any way
  • Obsess over the person to the point where they are unable to think about other things
  • Spend all their time immersed in a hobby or work thus avoiding dealing with the grief
  • Become more anxious about their health
  • Avoid other people
  • Become depressed
  • Engage in destructive behaviors, such as drugs and alcohol, or take up smoking


Teenagers with unresolved grief may display some of the same symptoms as adults. In addition, teens may be more likely to engage in risky behavior, such as increasing different sexual partners, stealing a car, or using illicit drugs.


Children typically display different symptoms than adults and teens due to their maturity level. Children with unresolved grief may:

  • Become hostile
  • Withdraw from friends and family or be very quiet in school
  • Stop caring about appearance (not brush their hair, or wear ripped clothing)
  • Have problems with sleeping
  • Feel anxious

Diagnosis of Complicated Grief

A "differential diagnosis" needs to be conducted because other issues, such as PTSD, can be confused with complicated grief or can co-occur with complicated grief. Consequently

In the past, this proposed a challenge because there was not an official diagnosis for treatment of complicated grief. With the inclusion of PCBD in the DSM-5, there are some guidelines available for clinicians to follow to tease out PCBD from depression and PTSD.

Separation Distress

A person with PCBD must meet at least one of these criteria:

  • Aches for, or thinks about, the passed loved one to the point that it interferes with the daily functioning
  • Feels lonely or empty without the person
  • Wants to die to be with their loved one in death, not wanting to participate in life

Thoughts, Feelings, and Behaviors

The person with PCBD will have at least two of these symptoms:

  • Obsesses over how her loved one died
  • Has a feeling that she can't accept, believe, or accept the death
  • Experiences shock or numbness that won't go away
  • Will not trust others since the death
  • Feels pain or symptoms the deceased person had
  • Hears or sees the person who has passed
  • Visibly upset when memories are mentioned
  • Obsesses or avoids people, places, and objects associated with the person who has passed

Treatment for Complicated Grief

According to Harvard University, "traumatic grief therapy" has a demonstrated positive effect for people experiencing complicated grief.

The components of traumatic grief therapy are:

  • Cognitive behavioral techniques to address symptoms of possible trauma and coping with stress.
  • "Imaginal exposure," where the client listens to recordings of themselves explaining how their loved one died.
  • "In vivo exposure," which helps clients who are using avoidance to think about the deceased.
  • Role play guided conversations with the deceased to explore feelings of guilt.
  • Bring up happy memories about the deceased.
  • Reshift the client's focus when she is obsessing over thoughts and feelings about the deceased.

Prevention of Complicated Grief

There isn't a known prevention of complicated grief. The University of York conveyed a study that compared intervention with preventative techniques in the treatment of complicated grief. Therapy was shown to be effective for the treatment of complicated grief while preventative measures were not effective to prevent complicated grief.

The Mayo Clinic suggests that early intervention is the best way to improve grieving outcomes.

When to Seek Professional Help

According to the Academy for Psychosomatic Medicine, people with unresolved grief tend to be younger and have a higher likelihood of experiencing severe depression. Also, once a person has unresolved grief, it lingers and is harder to overcome. This is why getting help as soon as possible is recommended. It is important to resolve these issues before they complicate your life further.

Helping children who have unresolved grief is especially important. Counseling is recommended to help children process and understand confusing and difficult events and feelings.

You need to see a licensed mental health counselor if you feel you are experiencing sleep problems, depression symptoms, or drug dependency issues.

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What Is Complicated Grief?