People who experience extreme and disturbing grief can be described as experiencing complicated grief.  Other terms that have been used in the literature include complex grief, traumatic grief, prolonged grief or chronic grief. This extreme grief is characterised by a yearning and longing for the deceased which impacts negatively on a person’s relationships, employment and life. 
What is Known
The following circumstances can potentially increase the risk of complicated grief:
- The death 
- traumatic death
- sudden death
- perception of the death (witnessing extreme distress)
- death of a child is often associated with lasting and intense grief.
- Factors about the bereaved person:
- past history of depression 
- coexisting stressors such as financial difficulties can intensify grief
- pre-bereavement depression may be associated with escalation of depression in bereavement 
- widowers and mothers tend to express more intense grief 
- having experienced multiple losses
- childhood loss of parent can lead to complex grief later in life (however, quality of remaining parental care and child’s personality contribute as predictors of outcome) [3,4]
- insecure attachment, childhood abuse and serious neglect, childhood separation anxiety. 
Active research areas / controversies
Diagnostic criteria for complicated bereavement have been proposed for listing in the forthcoming DSM V:
- Event: Bereavement
- Separation distress: Yearning daily
- Cognitive, emotional and behavioural symptoms: Five or more of the following
- Confusion about life's role and diminished sense of self
- Trouble accepting the death
- Avoidance of reminders
- Inability to trust others
- Bitterness or anger about the death
- Difficulty with moving on
- Numbness since loss
- Feeling life is empty or meaningless
- Stunned, dazed and shocked by loss.
- Timing: At least six months have elapsed since loss
- Impairment: Dysfunction in social or occupational domains
- Relation to other disorders: Not accounted for by other major disorders (eg, major depression, post -traumatic stress disorder or generalised anxiety).
Source: Prigerson, Horowitz, Jacobs et al 2009
Tools which measure grief responses have reported good reliability and validity – however screening or predictive functions have yet to be established in the Australian palliative care setting. [5,6]
There is no evidence yet to clarify the issues for specific populations such as parents  or situational factors such as place of death  or the effects of palliative care service provision on the health outcomes of bereaved. 
Furthermore, research is needed into the personal profile of those at risk of complicated grief, such as certain personality traits and interpersonal factors (such as perception of social and community supports) at play. [3,5] Issues of referral and matching intervention to individual require further research.
Research into the efficacy of interventions also needs attention. While in general counselling appears to assist those people experiencing complicated grief, more detail is needed. Apart from the pharmacological treatment of depression currently no evidence exists which clarifies which type of counselling or therapy approach is effective for the different people affected by complex grief. [8,9]
Finding Out More
- Kristjanson L. Lobb L. Aoun S. Monterosso L. A Systematic Review of the Literature on Complicated Grief. 2006 Perth: Commonwealth of Australia Department of Health and Ageing.
- Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Raphael B, Marwit SJ, Wortman C, Neimeyer RA, Bonanno G, Block SD, Kissane D, Boelen P, Maercker A, Litz BT, Johnson JG, First MB, Maciejewski PK. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009 Aug;6(8):e1000121. Epub 2009 Aug 4.
Related CareSearch pages
Bereavement and Grief
When to Refer (Bereaved) (GP hub)
- Prigerson HG, Jacobs SC. Traumatic grief as a distinct disorder: a rationale, consensus criteria, and a preliminary empirical test. In: Stroebe MS, Hansson RO, Stroebe W, Schut H, editors. Handbook of bereavement:consequences, coping, and care. Washington, DC: American Psychological Association; 2001.
- Zhang B, El-Jawahri A, Prigerson HG. Update on bereavement research: evidence-based guidelines for diagnosis and treatment of complicated bereavement. J Palliat Med. 2006 Oct;9(5):1188-203.
- Stroebe M. Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007 Dec 8;370(9603):1960-73.
- Hart MB. Best practices for treating unresolved grief In children: A qualitative meta-analysis [Dissertation]. Minneapolis (MN): Capella University; 2006.
- Kristjanson L, Lobb L, Aoun S, Monterosso L. A systematic review of the literature on complicated grief. Perth: Commonwealth of Australia Department of Health and Ageing; 2006.
- Agnew A, Manktelow R, Taylor B, Jones L. Bereavement needs assessment In specialist palliative care: a review of the literature. Palliat Med. 2010 Jan;24(1):46-59. Epub 2009 Sep 17.
- Hendrickson KC. Morbidity, mortality and parental grief: a review of the literature on the relationship between the death of a child and the subsequent health of parents. Palliat Support Care. 2009 Mar;7(1):109-19.
- Currier JM, Neimeyer RA, Berman JS. Effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive qualitative review. Psychol Bull. 2008 Sept;134(5):648-61.
- Forte A, Hill M, Pazder R, Feudtner C. Bereavement Care Interventions: a systematic review. BMC Palliat Care. 2004 Jul 26;3:3.
Last updated 19 November 2013*