Prolonged Grief Disorder: Symptoms, Diagnosis, and Evidence-Based Treatment

Prolonged Grief Disorder (PGD) is a mental health condition characterized by an intense, persistent, and disabling grief response that goes beyond what is expected given the person's cultural, religious, or social norms. It was officially added to the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) in 2022 and is also recognized in the ICD-11 (International Classification of Diseases, 11th Revision) under the name "Prolonged Grief Disorder."

It is important to understand that grief itself is not a disorder. Grief is a natural, universal human response to the death of a loved one, and it can be profoundly painful without being pathological. Most people who experience bereavement — even severe bereavement — gradually adapt over time. They do not develop a clinical disorder. However, for a meaningful minority of bereaved individuals, the acute grief reaction does not follow its expected trajectory. Instead, it becomes stuck — intensely preoccupying, deeply disabling, and persistent well beyond the timeframe that cultural context would explain.

PGD is sometimes informally referred to as "complicated grief," though this term is broader and has been used inconsistently in the research literature. The formal recognition of PGD in the DSM-5-TR represented a significant step in clinical psychiatry, giving clinicians a validated diagnostic framework and opening the door to targeted, evidence-based interventions.

According to estimates derived from large epidemiological studies, approximately 7% to 10% of bereaved adults develop prolonged grief disorder, though prevalence rates vary depending on the population studied and the criteria applied. Rates are higher in certain contexts — for example, after the sudden or violent death of a loved one, or following the death of a child.

The central feature of Prolonged Grief Disorder is an intense, persistent longing or yearning for the deceased person, or a pervasive preoccupation with thoughts or memories of the deceased. This must be present nearly every day for at least 12 months following the death (or at least 6 months in children and adolescents).

In addition to this core feature, the DSM-5-TR requires that at least three of the following eight symptoms are present at a clinically significant level nearly every day for at least the last month:

• Identity disruption — Feeling as though a part of oneself has died or been lost along with the deceased.
• Marked sense of disbelief — Difficulty accepting or comprehending the reality that the person is truly gone.
• Avoidance of reminders — Active avoidance of situations, people, places, or objects that serve as reminders that the person has died.
• Intense emotional pain — Profound emotional suffering related to the death, such as sorrow, anger, bitterness, or anguish that feels unrelenting.
• Difficulty reintegrating into life — Struggling to engage in relationships, pursue interests, plan for the future, or carry out everyday activities.
• Emotional numbness — A pronounced sense of emotional detachment, feeling stunned, or an absence of emotion since the death.
• Feeling that life is meaningless — A persistent belief that life has lost its purpose or significance without the deceased.
• Intense loneliness — A profound sense of being alone or detached from others as a result of the death.

These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Importantly, the grief response must also be clearly out of proportion to what would be expected given the person's cultural, religious, or social norms — a distinction that requires cultural sensitivity in assessment.

Warning signs that grief may be becoming prolonged include:

• Grief intensity that does not diminish at all — or worsens — after many months.
• Persistent inability to function at work, school, or in relationships well beyond the initial bereavement period.
• Ongoing avoidance of anything connected to the deceased.
• Recurrent thoughts that life is not worth living without the person who died.
• Social withdrawal that deepens over time rather than gradually improving.

There is no single cause of Prolonged Grief Disorder. Like most psychiatric conditions, it arises from a complex interaction of biological, psychological, social, and situational factors. Research has identified several categories of risk factors that increase the likelihood of a grief response becoming prolonged and impairing.

Factors related to the nature of the death:

• Sudden or unexpected death — Deaths that occur without warning (accidents, heart attacks, suicide, homicide) are associated with higher rates of PGD compared to anticipated deaths.
• Violent or traumatic death — When the circumstances of the death are violent, gruesome, or involve perceived suffering, the risk of prolonged grief increases substantially.
• Death of a child — Parental bereavement carries among the highest risks for developing PGD, regardless of the child's age at death.
• Pandemic or mass casualty events — Deaths occurring in contexts where normal mourning rituals are disrupted (such as during the COVID-19 pandemic) elevate PGD risk.

Factors related to the relationship with the deceased:

• High dependency on the relationship — When the bereaved person's identity, daily routine, or emotional regulation was deeply intertwined with the deceased.
• Insecure attachment style — Individuals with anxious or disorganized attachment patterns are more vulnerable to prolonged grief responses.
• Conflicted or ambivalent relationships — Unresolved relational conflict can complicate the grief process.

Individual vulnerability factors:

• Pre-existing mental health conditions — A history of depression, anxiety disorders, or prior traumatic experiences increases susceptibility.
• Prior losses — Cumulative bereavement or a history of multiple significant losses can compound grief.
• Limited coping resources — Individuals with fewer adaptive coping strategies or lower distress tolerance are at greater risk.
• Neuroticism and rumination — Personality traits associated with high emotional reactivity and repetitive negative thinking are linked to prolonged grief.

Social and environmental factors:

• Lack of social support — Social isolation or perceived lack of support following the loss is one of the strongest and most consistent predictors of PGD.
• Caregiver burden — Individuals who served as primary caregivers before the death are at elevated risk, particularly if the caregiving period was prolonged or distressing.
• Financial or practical hardship — Secondary losses such as financial instability, loss of housing, or role changes can intensify and prolong grief.

Prolonged Grief Disorder is diagnosed through a comprehensive clinical evaluation conducted by a qualified mental health professional, such as a psychiatrist, psychologist, or licensed clinical social worker. There is no blood test, brain scan, or biomarker for PGD. Diagnosis is based on a thorough clinical interview, symptom assessment, and consideration of the person's cultural context.

The DSM-5-TR diagnostic criteria for PGD require the following:

• A. The death of a person close to the bereaved occurred at least 12 months ago (at least 6 months for children and adolescents).
• B. Since the death, the individual has experienced, on more days than not, an intense longing/yearning for the deceased and/or preoccupation with thoughts or memories of the deceased (in children and adolescents, this preoccupation may focus on the circumstances of the death).
• C. At least three of the eight additional symptoms listed in the previous section have been present at a clinically significant level nearly every day for at least the last month.
• D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• E. The duration and severity of the grief response clearly exceed expected social, cultural, or religious norms for the individual's culture and context.
• F. The symptoms are not better explained by another mental disorder (such as major depressive disorder or PTSD) and are not attributable to the physiological effects of a substance or another medical condition.

Several validated assessment instruments can assist clinicians in evaluating prolonged grief symptoms, including:

• Prolonged Grief Disorder-13 (PG-13) — A 13-item self-report measure developed by Holly Prigerson and colleagues, widely used in research and clinical settings.
• Inventory of Complicated Grief (ICG) — A 19-item questionnaire that assesses grief-related symptoms. Scores above a certain threshold suggest the presence of complicated grief features.
• Brief Grief Questionnaire (BGQ) — A short screening tool useful for identifying individuals who may benefit from a more comprehensive grief assessment.

A critical part of the diagnostic process involves cultural formulation. Grief is one of the most culturally shaped of all human experiences, and mourning practices vary enormously across cultures. What appears to be "prolonged" grief in one cultural context may be entirely normative in another. Clinicians must take care to understand the bereaved individual's cultural, religious, and community norms before applying diagnostic criteria.

Research over the past two decades has established that Prolonged Grief Disorder responds to targeted psychological intervention and, in some cases, pharmacotherapy. General bereavement support — while valuable — is typically insufficient for individuals who meet full diagnostic criteria for PGD. The most effective treatments directly address the specific mechanisms that keep grief from following its natural adaptive course.

Prolonged Grief Disorder Therapy (PGDT)

Formerly known as Complicated Grief Treatment (CGT), this is the most extensively studied and empirically supported intervention for PGD. Developed by M. Katherine Shear and colleagues at Columbia University, PGDT is a 16-session, manualized psychotherapy that integrates elements of cognitive-behavioral therapy, attachment theory, and interpersonal therapy. It includes:

• Psychoeducation about grief, loss, and the distinction between acute and integrated grief.
• Dual process work — Based on the Dual Process Model of bereavement, therapy alternates between loss-oriented activities (processing the pain of the loss) and restoration-oriented activities (rebuilding engagement with life, relationships, and goals).
• Revisiting exercises — Guided, repeated retelling of the story of the death to reduce avoidance and promote emotional processing (analogous to exposure techniques in PTSD treatment).
• Situational revisiting — Gradual, planned engagement with avoided situations, places, or activities connected to the loss.
• Imaginal conversations — Structured exercises in which the bereaved person engages in an imagined dialogue with the deceased to address unfinished business, express feelings, and facilitate adaptation.

Randomized controlled trials have demonstrated that PGDT produces significantly greater symptom reduction than standard interpersonal psychotherapy, with approximately 70% of participants showing meaningful improvement.

Cognitive-Behavioral Therapy (CBT) for Grief

CBT-based approaches for prolonged grief focus on identifying and modifying maladaptive cognitions that maintain the grief response — such as catastrophic interpretations of grief symptoms, guilt-laden appraisals, or beliefs that engaging in life again would be a betrayal of the deceased. Behavioral components involve systematic reduction of avoidance behaviors. Research, particularly from Paul Boelen and colleagues in the Netherlands, supports CBT as an effective treatment for PGD symptoms.

Pharmacotherapy

The evidence for medication as a standalone treatment for PGD is more limited than for psychotherapy, but some findings are noteworthy:

• Antidepressants (SSRIs) — Studies suggest that SSRIs such as escitalopram may provide modest benefit for grief-related symptoms, particularly when depression co-occurs. However, SSRIs alone do not appear to be as effective as targeted grief psychotherapy.
• Combined treatment — Research by Shear and colleagues found that PGDT combined with the antidepressant citalopram produced somewhat better outcomes than PGDT alone, particularly for bereaved individuals with concurrent depressive symptoms.
• Naltrexone — Emerging research has explored whether naltrexone, an opioid receptor antagonist, might help address the intense yearning component of PGD by modulating the brain's reward and attachment systems. This remains an area of active investigation and is not yet standard practice.

Other Therapeutic Approaches

• Group therapy — Grief-specific group therapy can provide social support, reduce isolation, and normalize the grief experience. It is often used as an adjunct to individual treatment.
• Internet-based interventions — Structured, therapist-guided online grief programs have shown promising results in clinical trials, offering a more accessible option for individuals who face barriers to in-person treatment.
• Mindfulness-based interventions — While less studied specifically for PGD, mindfulness approaches may help with emotional regulation and acceptance components of the grief process.

The prognosis for Prolonged Grief Disorder is generally favorable when appropriate treatment is provided. Clinical trials consistently show that the majority of individuals who engage in evidence-based grief therapy experience meaningful symptom relief. In the landmark randomized controlled trial of Complicated Grief Treatment (now PGDT), approximately 70% of participants in the treatment group showed clinically significant improvement, compared to about 32% in the comparison condition.

However, several important points about recovery deserve emphasis:

• Recovery does not mean forgetting. The goal of treatment is not to erase grief or eliminate attachment to the deceased. Rather, the aim is to help the bereaved person move from a state of acute grief — where the loss dominates nearly every moment — to integrated grief, in which the loss is woven into the person's life story. In integrated grief, the bereaved person can hold the pain of the loss alongside the capacity to find meaning, experience pleasure, and engage with the future.
• Without treatment, PGD tends to follow a chronic course. Research suggests that prolonged grief symptoms do not simply resolve on their own with the passage of time. Longitudinal studies indicate that individuals who meet criteria for PGD at 12 months post-loss are likely to still meet criteria years later if no intervention is provided.
• Comorbid conditions influence prognosis. The presence of co-occurring major depression, PTSD, or substance use disorder can complicate recovery and may require integrated treatment approaches.
• Functional recovery often precedes full emotional recovery. Many individuals begin to re-engage with work, social relationships, and daily activities before they experience a full resolution of grief-related distress. This is a normal and expected pattern.
• Grief can be revisited. Even after successful treatment, anniversaries, holidays, and life milestones may temporarily reactivate grief responses. These "grief surges" are normal and do not indicate relapse. They typically become less intense and less frequent over time.

Prolonged Grief Disorder shares features with several other psychiatric conditions, and co-occurrence is common. Careful differential diagnosis is essential because the most effective treatment depends on accurate identification of the primary condition.

Major Depressive Disorder (MDD)

Depression and prolonged grief frequently co-occur, and they share symptoms such as sadness, sleep disruption, loss of interest, and difficulty concentrating. However, PGD is distinguished by its focus on the loss itself — the yearning, preoccupation with the deceased, and identity disruption are specific to grief. In depression, the low mood tends to be more pervasive and less specifically tied to the loss. Research estimates that approximately 50% to 60% of individuals with PGD also meet criteria for MDD.

Posttraumatic Stress Disorder (PTSD)

When the death was sudden, violent, or traumatic, PTSD and PGD may co-occur. PTSD involves intrusive memories of the traumatic event, hyperarousal, and avoidance of trauma-related stimuli, while PGD centers on separation distress and yearning for the deceased. The two conditions have overlapping avoidance symptoms but differ in their core emotional experiences — fear and horror in PTSD versus longing and sorrow in PGD.

Adjustment Disorders

Adjustment disorders involve emotional or behavioral symptoms in response to a stressor, but they are generally less severe and shorter in duration than PGD. A bereavement-related adjustment disorder might be diagnosed when grief causes significant distress but does not meet the full criteria for PGD.

Separation Anxiety Disorder

PGD can be conceptualized, in part, as a disorder of the attachment system. The intense yearning and preoccupation with the deceased bear resemblance to separation anxiety. Some researchers view PGD as a form of separation distress that has become chronically activated due to the permanent nature of death.

Persistent Complex Bereavement Disorder (PCBD)

This was a condition listed in the "Conditions for Further Study" section of the DSM-5 (2013). PGD in the DSM-5-TR effectively replaced and refined this earlier conceptualization, with a more streamlined set of criteria and a clearer time requirement.

Substance Use Disorders

Bereaved individuals sometimes turn to alcohol, prescription medications, or other substances to cope with the pain of loss. Substance misuse can develop alongside or in the wake of prolonged grief, creating a cycle in which substance use interferes with the natural grief process and grief drives continued substance use.

Grief, even very intense grief, is not inherently a disorder. In the first weeks and months following the death of a loved one, it is entirely normal to feel overwhelmed, to struggle with daily functioning, and to experience waves of intense emotional pain. Most people will gradually adapt to the loss, even if the process is slow and nonlinear.

However, you should consider seeking professional help if you or someone you care about experiences the following patterns:

• Grief intensity remains as severe — or worsens — a year or more after the death, with no sign of gradual adaptation.
• The ability to function at work, school, or in daily life remains significantly impaired long after the initial bereavement period.
• Pervasive yearning or preoccupation with the deceased dominates nearly every waking moment, to the exclusion of other thoughts and activities.
• Active avoidance of reminders of the death is restricting life in meaningful ways — for example, avoiding mutual friends, giving up activities, or refusing to enter certain places.
• Thoughts of suicide or self-harm — including feelings that life is not worth living without the deceased, wishes to die to be reunited with them, or any active suicidal ideation. If you or someone you know is in crisis, contact the 988 Suicide and Crisis Lifeline by calling or texting 988 (in the United States) immediately.
• Increased use of alcohol, drugs, or medications to numb grief-related pain.
• Significant physical health decline — research links prolonged grief to elevated cardiovascular risk, immune dysfunction, and overall health deterioration.

A qualified mental health professional — such as a psychiatrist, psychologist, licensed clinical social worker, or licensed professional counselor — can conduct a thorough evaluation and help determine whether your grief patterns are consistent with Prolonged Grief Disorder or another condition. Importantly, seeking help is not a sign of weakness or an indication that your grief is "wrong." It is a recognition that the pain you are carrying deserves expert support.

When choosing a clinician, consider seeking someone with specific training or experience in bereavement and grief-focused therapies. General therapists may not be familiar with the specialized approaches (such as PGDT) that have the strongest evidence base for this condition.