Grief, bereavement and prolonged grief disorder

• Grief is the natural response to losing someone close and, for most people, the intensity eases over months while everyday life gradually returns.
• Prolonged grief disorder (PGD) is the diagnosis when intense, persistent grief remains beyond the normal period for the culture, causes significant impairment, and is not better explained by another disorder.
• The two accepted criteria sets differ: ICD-11 (WHO) expects an atypically prolonged grief response of more than 6 months at a minimum, with significant impairment, whereas DSM-5-TR (APA) requires at least 12 months since the death, a core separation-distress symptom and at least 3 of 8 accessory symptoms. ^[2]
• PGD is not the same as depression: grief waves, preserved self-worth, and longing for the deceased are typical, whereas pervasive anhedonia, self-loathing and suicidality point to depression.
• The best-supported help is a grief-focused cognitive behavioural therapy that processes the loss and rebuilds life; antidepressants treat comorbid depression or anxiety but do not treat grief itself, and no medication is licensed for PGD.
• Culture sets the clock: some communities expect mourning for much longer than a year, and a grief reaction that fits the culture is normal grief, not PGD.

By the end of this page you should be able to:

1. Describe the normal course of grief and the variations that are still healthy.
2. State the ICD-11 and DSM-5-TR criteria for prolonged grief disorder from memory.
3. Explain the differences between PGD, major depressive disorder, adjustment disorder and post-traumatic stress disorder.
4. Assess a bereaved patient, including risk assessment, and decide when investigation is needed.
5. Outline evidence-based psychological and adjunctive care for PGD.
6. List the risk factors, complications and red flags that alter management.
7. Discuss bereavement and PGD in low-resource settings.

The term "complicated grief" is still widely used in older literature and in the titles of instruments such as the Inventory of Complicated Grief; it refers to the same clinical problem as PGD. Persistent complex bereavement disorder was the place-holder term in DSM-5 (Section III). DSM-5-TR and ICD-11 now call it prolonged grief disorder.

A useful clinical division separates three states.

• Normal or acute grief: a painful but ultimately adaptive response. The person can still experience moments of pleasure, self-worth is usually preserved and the intensity gradually lessens.
• Prolonged grief disorder: grief that has persisted beyond the cultural norm, with intense longing or preoccupation and significant impairment in personal, social, occupational or other important areas of functioning.
• Other disorders that can follow a death: major depressive disorder, post-traumatic stress disorder, an adjustment disorder, or a substance use problem. These may be present on their own, together with PGD, or instead of it.

This page covers normal grief and PGD. Depression, stress-related disorders and substance problems are covered on their own pages and are mentioned here only where they must be distinguished.

Loss is universal and most bereaved people do not develop a disorder. An estimated 4 to 15% of bereaved adults experience the persistent symptoms of prolonged grief disorder.^[1] Where a sample of people who already lost someone is studied, diagnostic rates move with the rule used: one representative German study reported 4.7% using DSM-5-TR criteria and 5.4% using ICD-11 criteria, and another reported 3.3% and 4.2% respectively.^[2]

Normal grief can be intense without being pathological. In a representative bereaved sample, intrusive thoughts or images related to the deceased were reported by 30.7%, intense emotional pain or waves of grief by 20.7% and intense longing or yearning by 23.4%.^[2]

There is no single cause of PGD. Risk is shaped by the relationship to the deceased, the circumstances of the death, the bereaved person's history and their social situation.

Risk factors supported by current evidence include:

• Relationship to the deceased. The death of a child or spouse or partner carries a higher risk than the death of a parent or more distant relative.^[1]
• Circumstances of the death. Sudden, unnatural or violent deaths (accidents, suicide, homicide) and deaths in an intensive care unit as opposed to death at home carry higher risk.^[1]
• Personal history. Past depression, an anxious attachment style, and high levels of pre-loss grief or closeness to the deceased increase risk.^[1]
• Social factors. Low socioeconomic status, lack of social support, older age, and female sex are associated with higher symptom severity.^[1]
• Trauma exposure and insecurity. Trauma history and lack of a secure base reduce the capacity to adapt to the loss.

Family history of mental illness, particularly depression, and dependence on the deceased also appear in the literature. These associations describe risk, not destiny: most people with several risk factors still adapt well.

Normal grief has a recognisable shape even though cultures and individuals differ. It usually begins with shock, numbness or disbelief and moves in waves rather than along a smooth line. Pain often intensifies in the first days and weeks, then gradually becomes less continuous, with sudden surges triggered by reminders, anniversaries and new losses. The mourner can usually still feel pleasure in brief moments, still cares about others and does not lose self-esteem. Sleep, appetite and concentration are commonly disturbed for weeks or months.

What matters more than duration alone is the direction and the functional impact. Grief that is gradually shifting to include restored interest, moments of positive affect and re-engagement with life is usually healthy, even if waves of sadness remain for a year or more. A reaction that is unchanged in intensity from the first month, dominates every day and blocks all normal activity is the pattern that warrants assessment for PGD. Cultural and religious practices matter: some communities expect prolonged visible mourning, and a reaction that fits those expectations is normal grief rather than a disorder.

Two classification systems are in current use, and they use the same name but different rules.^[1][2]

Three practical points follow from the comparison.

First, the ICD-11 wording about time ("an atypically long period... more than 6 months at a minimum") refers to the persistence of the grief response, not merely the passage of 6 months since the death. Counting from the loss rather than from persistent symptoms can over-diagnose PGD.^[2]

Second, the ICD-11 threshold is intentionally sensitive and the DSM-5-TR threshold is more specific. A person who meets ICD-11 criteria but not DSM-5-TR criteria is not necessarily healthy; it means the clinician should look closely at function, culture and comorbidity before treating.

Third, culture is part of the diagnosis in both systems. Where prolonged visible mourning is normative, a grief reaction that fits that culture remains normal grief.

The WHO clinical version of ICD-11, the clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders (CDDR), was published in 2024 to support reliable diagnosis in clinical settings worldwide.^[3] NICE has not yet published a guideline on prolonged grief disorder: the topic was prioritised in November 2025 and the guideline is awaiting development, so in the United Kingdom clinicians currently apply WHO ICD-11 or APA DSM-5-TR criteria alongside general depression guidance.^[4]

The key clinical skill is to decide whether the central problem is grief or depression, because the treatment differs. They frequently coexist, and a person with PGD has an elevated risk of major depression, but the two are not the same.

Where a patient has both, treat the depression as depression and the grief with grief-focused therapy. NICE's depression guideline recognises bereavement as a major stressful life event and advises clinicians to ask about suicidal ideation, support and current circumstances in anyone depressed after a death.^[5]

Symptoms of PGD are not confined to sadness. They include:

• Intense longing or yearning for the deceased, or deep preoccupation with thoughts and memories of them.
• Difficulty accepting the reality of the death; feeling stunned, shocked or dazed.
• Avoidance of reminders, or distress on encountering them.
• Intense emotional pain: anger, bitterness, sorrow, regret.
• Feeling that a part of oneself has died with the deceased, with confusion about identity and role.
• Emotional numbness or a marked reduction in emotional experience.
• Feeling that life is meaningless, unfulfilling or empty without the deceased.
• Intense loneliness and detachment from others.
• Difficulty reintegrating: problems engaging with friends, pursuing interests and planning for the future.
• Difficulty experiencing positive mood or positive reminiscence.

PGD commonly co-occurs with insomnia, loss of appetite, somatic complaints, fatigue, anxiety, substance use and suicidal thinking. It is also associated with a higher rate of medical consultations, chronic physical illness and functional impairment.^[7] Risk of PGD varies with kinship (higher after the death of a child or spouse or partner), violent or sudden causes, and place of death.^[1]

A structured assessment covers:

• Current grief intensity, longing and preoccupation, and their change since the death.
• Mood, anhedonia, sleep, appetite, energy and concentration.
• Any thoughts of death or suicide, and any plan or intent. Suicidal ideation must be explored directly; grief can produce a wish to die in order to be reunited with the deceased, which carries real risk.
• Substance and alcohol use.
• Social support, finances, caring responsibilities and housing.
• Functional domains: work, relationships, self-care, parenting, driving.
• The patient's own explanatory model and expectations of mourning.
• Cultural, religious and spiritual context of the loss.

There is no blood test, imaging or score that diagnoses PGD. Investigation is directed at the differential diagnosis and at complications.

• Consider basic tests when presentation is atypical or there are physical symptoms: full blood count, thyroid function, inflammatory markers, and review of medication.
• Where a mood or trauma disorder is suspected, use validated instruments and clinical assessment rather than relying on symptom counts.
• Sleep studies or targeted tests are justified by specific symptoms.
• Use caution with brain imaging: it is reserved for focal neurological features or when an organic cause is suspected.
• Instruments such as the PG-13-Revised and the Traumatic Grief Inventory (Self-report Plus) are used in research and clinical services to quantify grief symptoms; they support, but do not replace, clinical judgement.

A full medical and psychiatric assessment is needed before concluding that the criteria are met, because depression, bipolar disorder, substance misuse, traumatic brain injury and neurodegenerative conditions can all mimic aspects of PGD.

Support begins at the time of death, not only when a disorder is diagnosed.

1. Acknowledge the loss and allow the person to tell the story; active listening is the core intervention for most bereaved people.

2. Assess safety: suicide risk, self-neglect, and risk to others, especially children.

3. Provide accurate information about what grief is, what is normal, and what to expect, including that it usually comes in waves.

4. Mobilise the patient's own network: family, friends, faith or community leaders, and trusted professionals.

5. Normalise sleep and routine; advise gradual return to activities and postpone major irreversible decisions where possible.

6. Screen for risk factors and, where present, arrange earlier follow-up.

7. Reassess regularly during the first year, earlier if the person is deteriorating, and refer when impairment is significant or criteria are met.

8. Document the plan and share it with primary care.

Grief-focused cognitive behavioural therapy is the best-supported specific treatment. It combines exposure to the reality of the loss with behavioural activation and restoration of meaningful life activity, and trials show reductions in grief symptoms.^[1][6] Online interventions that let mourners express grief in written messages to the deceased person also show benefit.^[1] Supportive counselling, peer support and bereavement support groups help with isolation and with being heard, and are appropriate when distress is subthreshold or when the person does not want formal therapy; they are less targeted than grief-focused CBT where PGD is present.

Children and adolescents can benefit from adapted cognitive behavioural therapy, including grief-specific work, and family involvement is important.^[1]

There is currently no medication that treats the specific symptoms of grief.^[1] Antidepressants do not resolve grief itself, but they are indicated for comorbid major depression or anxiety, and adherence to the standard principles of depression care applies.^[5] Benzodiazepines and hypnotics may be used briefly for severe insomnia or acute distress but are not a treatment for PGD and should be limited because of dependence and falls risk, particularly in older adults. Complicated pharmacological cases, for example a depressed bereaved patient with suicidality or psychotic symptoms, warrant specialist care.

Red flags that should raise the level of care are:

• Any suicidal intent or plan, or self-neglect.
• Functional collapse: inability to care for children or self.
• Emergence of psychotic or severe mood symptoms.
• Substance misuse escalating after the loss.
• Domestic violence towards or by the patient.
• Comorbidities that worsen under stress (cardiovascular disease, diabetes, chronic pain).

Children and adolescents. The shorter 6-month time frame applies to children and adolescents; preoccupation in young people may centre on the circumstances of the death, and grief should be distinguished from separation anxiety and childhood depression. School and family support is central, and sensitive communication is essential. Older adults. Bereavement is common and is often followed by medical deterioration, falls, cognitive decline and isolation. Depression is under-recognised, so screen actively after a loss.

Pregnancy and perinatal loss. Grief after miscarriage, stillbirth or neonatal death can be severe, disenfranchised and long-lasting. Validate the loss, offer memory-making where desired and ensure follow-up; risk of PGD is raised after perinatal loss.

PGD is not only a psychiatric problem. It is associated with impaired functioning, chronic physical illness and an increased use of medical services; in a systematic review, 13 of 18 eligible studies found a significant association between ICD-11 PGD and physical or somatic illness.^[7] Somatic symptoms, insomnia, hypertension and immune or endocrine dysregulation have all been reported. Recognising PGD can avoid repeated investigations for medically unexplained symptoms. Distress after bereavement can also worsen pre-existing conditions, so review chronic disease control in the months after a loss. ^[2]

Without treatment, PGD tends to run a chronic course, although some people improve over a longer period. With grief-focused therapy, a substantial proportion respond and regain function. Timeliness matters: longstanding impairment, social isolation, avoidant coping and a traumatic death are associated with poorer outcomes. Even where symptoms do not fully resolve, structured support improves quality of life. Suicidal risk can persist well beyond the first year, so risk assessment should be repeated at intervals.

Universal prevention of normal grief is not appropriate, and pathologising healthy grief helps no one. Targeted measures include:

• Identifying high-risk bereaved people (traumatic death, child loss, insecure attachment, poor support, previous mental illness).
• Proactive follow-up by primary care or community health workers soon after the death and again a few months later.- Informing families about expectable grief and about services.
• Training non-specialist workers to listen, recognise risk and refer.
• Addressing modifiable risks: sleep, substance use, social isolation, fear of dying and financial stress.
• Encouraging advance planning and family communication before anticipated deaths where possible.

Much of the evidence base is from well-resourced settings, and grief interventions in more diverse regions still show benefit: a 2026 meta-analysis of 14 randomised trials (1,122 participants) found psychosocial grief interventions more effective than control conditions (standardised mean difference -0.74).^[6] Where specialist care is scarce:

• Train community health workers, nurses and primary care clinicians in basic bereavement support and in recognising impairment.
• Use locally meaningful practices: family meetings, traditional or religious rituals, and community or peer groups, which are natural supports rather than second-best.
• Adapt materials to language and culture rather than importing Western models unchanged.
• Use telephone or group contact where individual therapy is unavailable.
• Keep treatment focused on safety, sleep, a simple daily routine, practical problem solving and gradual return to activity.
• Refer the minority with suicidality, severe depression, psychosis or functional collapse.
• Monitor physical health: blood pressure, chronic disease control and weight.

• Grief is a normal and adaptive response to loss; only a minority develop prolonged grief disorder, with estimates between 4 and 15% of bereaved adults.^[1]
• PGD is diagnosed when grief persists beyond the cultural norm and causes significant impairment; ICD-11 expects more than 6 months at a minimum of an atypically prolonged response, DSM-5-TR requires at least 12 months in adults and at least 3 of 8 accessory symptoms.
• The time criterion in ICD-11 refers to persistence of symptoms, not simply months since the death, and over-diagnosis is a risk if the difference is ignored.
• Culture is part of the definition in both systems: a reaction that fits social expectations is normal grief.
• PGD is distinct from major depression; low mood is not always present and self-worth is usually preserved, though comorbidity is common.
• Suicide risk must be assessed directly and repeatedly, including wishes for reunion with the deceased.
• Grief-focused cognitive behavioural therapy is the best-supported specific treatment; unsupported therapy still helps and isolation worsens outcomes.
• There is no medication that treats grief itself; antidepressants are appropriate for comorbid depression or anxiety.
• PGD is associated with physical illness, insomnia and functional impairment, so medical review and simple supports matter.
• Low-resource care should be built on local community and family supports, with referral reserved for high risk.

Depression; post-traumatic stress disorder; adjustment disorder; suicide prevention; insomnia; chronic pain; perinatal loss; supporting carers after a death; dementia and complicated bereavement; substance use disorders.