Prolonged Grief Disorder: Criteria, Risks, and Treatment

Prolonged grief disorder occurs when intense mourning persists for at least 12 months, significantly impairing daily functioning, but evidence-based therapies like cognitive behavioral therapy and complicated grief treatment provide effective healing through specialized therapeutic support.

When grief feels endless and overwhelming, you're not imagining things. Prolonged grief disorder affects millions who struggle to function months after loss - but understanding the signs and therapeutic support available can guide you toward healing.

Understanding Prolonged Grief Disorder: Diagnostic Criteria, Risk Factors, And Therapeutic Approaches

The loss of someone we love represents one of life’s most profound challenges. While grief is a natural human response to bereavement, some individuals experience a particularly intense and persistent form of mourning that significantly disrupts their ability to function in daily life. The mental health field has increasingly recognized this experience through the diagnostic category of prolonged grief disorder (PGD), which was recently added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Understanding the distinction between typical grief responses and prolonged grief disorder can help individuals recognize when they might benefit from professional support. As licensed clinical social workers specializing in grief counseling, we at ReachLink work with many clients navigating the complex terrain of loss and mourning. This article explores what prolonged grief disorder is, how it differs from ordinary bereavement, and what therapeutic approaches may help.

The Natural Process of Grief

Before examining prolonged grief disorder, it’s important to understand that grief itself is not a mental health condition. Mourning a significant loss is a universal human experience that varies widely across individuals, cultures, and circumstances. There is no single “correct” way to grieve, and the intensity and duration of grief responses differ based on numerous factors, including the nature of the relationship, cultural background, personal history, and the circumstances of the loss.

Research indicates that common grief responses include:

• Initial shock, disbelief, or emotional numbness
• Intense emotions such as sadness, anxiety, anger, guilt, or yearning
• Physical manifestations including fatigue, sleep disturbances, changes in appetite, and physical pain
• Cognitive difficulties with concentration, memory, and decision-making
• Behavioral changes such as social withdrawal, crying, or seeking connection with the deceased through photographs, places, or activities
• Vivid dreams or intrusive thoughts about the person who died

Importantly, most bereaved individuals also experience moments of relief, acceptance, gratitude, and even joy alongside their pain. These positive emotions don’t diminish the significance of the loss or indicate a lack of love for the deceased. Rather, they often reflect psychological resilience and the capacity to hold complex, sometimes contradictory feelings simultaneously.

For most people, grief evolves over time. The intensity of distress typically comes in waves rather than remaining constant, with periods of acute pain interspersed with moments of relative calm or even contentment. While significant dates, places, or reminders may trigger intense grief reactions even years after a loss, most bereaved individuals gradually develop the capacity to engage with life again while maintaining connection to their memories of the deceased.

When Grief Becomes Prolonged: Recognizing the Difference

So how do mental health professionals distinguish between the natural, if painful, process of mourning and a condition that might warrant clinical attention? The difference often lies in the persistence, intensity, and functional impact of grief responses rather than their presence alone.

Several indicators may suggest complicated grief responses:

Duration and Intensity: While there’s no universal timeline for grief, symptoms that remain severe and unremitting for many months or years may indicate difficulties in the mourning process.

Pattern of Distress: Grief that remains continuously intense without the typical fluctuation between acute pain and relative stability may be concerning.

Functional Impairment: When grief prevents someone from meeting basic responsibilities, maintaining relationships, or engaging in previously meaningful activities for an extended period, this may signal a need for support.

Avoidance Patterns: While some avoidance is common early in grief, persistent refusal to acknowledge the loss, discuss the deceased, or engage with any reminders may complicate the mourning process.

Identity Disruption: Feeling unable to imagine a meaningful identity or future without the deceased for an extended period may indicate complicated grief.

Extreme Self-Blame or Worthlessness: While guilt is common in grief, persistent feelings of extreme self-blame or worthlessness may suggest overlapping mental health concerns.

Prolonged Grief Disorder: Clinical Definition

According to the American Psychiatric Association, prolonged grief disorder describes a pattern of grief responses that persist nearly every day for at least 12 months following a loss (or six months for children and adolescents). The diagnosis requires the presence of intense yearning for or preoccupation with the deceased, along with at least three of the following experiences:

• Intense emotional pain related to the death, including profound sadness, guilt, anger, or bitterness
• Difficulty accepting the reality of the death
• Feeling that part of oneself has died
• Avoiding reminders of the person who died
• Intense loneliness or feeling detached from others
• Difficulty engaging with life or pursuing interests and activities
• Emotional numbness or reduced emotional experience
• Feeling that life is meaningless or empty without the deceased

Critically, these experiences must be severe enough to cause significant distress or impairment in social, occupational, or other important areas of functioning. They must also be distinguishable from cultural, religious, or age-appropriate norms for bereavement.

Current research suggests that approximately 10% of bereaved individuals meet criteria for prolonged grief disorder, though this percentage may increase substantially following sudden, violent, or traumatic deaths.

The Spectrum of Grief-Related Difficulties

Prolonged grief disorder represents one way that bereavement can intersect with mental health challenges, but it’s not the only pattern. Some individuals experience what clinicians call complicated or complex grief, where typical grief responses become intertwined with symptoms of other conditions such as depression, anxiety, or trauma.

The relationship between loss and these other mental health concerns can be complex. Research indicates that the circumstances of death and individual characteristics may influence which types of difficulties emerge. For example, individuals who lose loved ones to violence may experience trauma symptoms including flashbacks, hypervigilance, or panic attacks alongside their grief. Those with a history of depression may find that bereavement triggers a depressive episode that extends beyond typical grief responses.

Personal attachment patterns may also play a role. Individuals with avoidant attachment styles—characterized by discomfort with emotional closeness and difficulty relying on others—may be more vulnerable to depressive symptoms following loss, perhaps because they struggle to seek or accept support during bereavement.

Understanding these patterns helps licensed clinical social workers tailor therapeutic approaches to address the specific constellation of difficulties each client faces.

Factors That May Increase Vulnerability

While anyone can experience prolonged grief disorder, certain factors may increase vulnerability:

Circumstances of the Loss:

• Sudden or unexpected death
• Violent or traumatic death
• Loss of a child, parent, or spouse
• Multiple losses within a short timeframe

Individual Characteristics:

• History of depression, anxiety, or other mental health conditions
• Childhood experiences of trauma, abuse, or significant adversity
• Certain cognitive patterns, such as excessive self-blame or rumination
• Difficulty regulating emotions
• Avoidant coping strategies

Social and Environmental Factors:

• Limited social support or isolation
• Strained family relationships
• Financial stress or instability
• Having been a primary caregiver for the deceased before their death

Early Grief Experience:

• Severe depressive symptoms in the initial weeks after loss
• Difficulty accepting the reality of the death
• Persistent avoidance of grief-related emotions or reminders

It’s important to note that having these risk factors doesn’t mean someone will inevitably develop prolonged grief disorder. Rather, awareness of these vulnerabilities can help individuals and their support systems recognize when additional help might be beneficial.

Therapeutic Approaches to Prolonged Grief

When grief becomes prolonged and debilitating, professional support from a licensed clinical social worker or other qualified mental health provider can make a significant difference. While medication may sometimes be used to address co-occurring conditions like depression or anxiety, psychotherapy represents the primary evidence-based treatment for prolonged grief disorder itself.

Cognitive Behavioral Approaches

Cognitive behavioral therapy (CBT) and related approaches have demonstrated effectiveness in helping individuals work through complicated grief. These therapeutic methods typically focus on:

Examining Thought Patterns: Identifying and gently challenging beliefs that may be prolonging suffering, such as “I should have been able to prevent this” or “I can never be happy again.”

Addressing Avoidance: Gradually reducing avoidance behaviors that, while providing short-term relief, may prevent the natural processing of grief. This might include talking about the deceased, visiting meaningful places, or engaging with memories.

Restoring Meaning and Connection: Exploring how to maintain connection to the deceased while also re-engaging with life, relationships, and activities that provide meaning and purpose.

Processing the Loss: Creating space to acknowledge and work through the reality of the death and its implications.

Complicated Grief Treatment

Complicated Grief Treatment (CGT) represents a specialized approach that integrates elements from cognitive behavioral therapy, interpersonal therapy, and motivational interviewing. This structured treatment specifically addresses the unique features of prolonged grief, helping clients:

• Accept the reality and finality of the loss
• Manage painful emotions without becoming overwhelmed
• Imagine a meaningful future while maintaining connection to the past
• Rebuild relationships and reengage with life
• Address any guilt, regret, or unfinished business related to the deceased

The Therapeutic Relationship

Regardless of the specific approach, the relationship between client and therapist forms the foundation of effective grief therapy. Licensed clinical social workers bring training in building supportive, non-judgmental therapeutic relationships that provide a safe space for clients to express complex, sometimes contradictory emotions without fear of being rushed or judged.

This relationship offers what many bereaved individuals need most: consistent, compassionate presence and the permission to grieve at their own pace while also gently encouraging movement toward healing when the time is right.

Accessing Support Through Telehealth

For many individuals struggling with grief, accessing traditional in-person therapy can present challenges. Grief itself often brings fatigue, difficulty concentrating, and reduced motivation—all of which can make traveling to appointments feel overwhelming. Additionally, some people live in areas with limited access to grief specialists or have mobility limitations that complicate in-person visits.

Telehealth mental health services offer an alternative that addresses many of these barriers. Through secure video sessions with licensed clinical social workers, individuals can access specialized grief support from the comfort and privacy of their own homes. The flexibility of scheduling and elimination of travel time can make it easier to maintain consistent engagement with therapy during a period when energy and motivation may be limited.

Research supports the effectiveness of online grief therapy. Recent studies have found that telehealth-delivered cognitive behavioral therapy can significantly reduce symptoms of prolonged grief disorder, as well as associated depression and trauma symptoms, with outcomes comparable to in-person treatment.

At ReachLink, our licensed clinical social workers specialize in providing compassionate, evidence-based grief counseling through our secure telehealth platform. We understand that each person’s grief journey is unique, and we tailor our therapeutic approaches to meet individual needs, cultural backgrounds, and personal circumstances.

Finding the Right Support

If you’re experiencing intense, persistent grief that’s affecting your ability to function or find meaning in life, reaching out for professional support is a sign of strength, not weakness. Here are some steps you might consider:

Talk with Your Primary Care Provider: Your doctor can assess whether your symptoms might benefit from professional mental health support and can provide referrals to qualified therapists.

Contact Your Insurance Company: Many insurance plans cover mental health services, including grief counseling. Your insurer can provide a list of in-network providers.

Explore Telehealth Options: If convenience, accessibility, or comfort are concerns, consider telehealth mental health services. ReachLink offers secure, confidential video sessions with licensed clinical social workers who specialize in grief and loss.

Seek Specialized Grief Support: Look for therapists with specific training and experience in grief counseling, complicated grief treatment, or trauma-informed approaches to loss.

Consider Your Preferences: Think about what type of therapeutic relationship might feel most comfortable for you. Some people prefer a structured, goal-oriented approach, while others benefit from a more exploratory, relationship-focused style.

Moving Forward While Holding On

The concept of prolonged grief disorder has sparked important conversations about the boundaries between normal suffering and clinical concern. While the diagnostic category serves a purpose in identifying individuals who might benefit from specialized support, it’s equally important to resist the notion that grief should follow a prescribed timeline or that mourning itself requires fixing.

Grief is not a problem to be solved but a process to be navigated—sometimes with support, always with compassion. The goal of grief therapy is not to eliminate sadness or erase the significance of loss, but rather to help individuals find ways to carry their grief while also reconnecting with life, meaning, and possibility.

For some, this means learning to hold both sorrow and joy, absence and presence, loss and continued growth. It means discovering that healing doesn’t require forgetting or “moving on,” but rather finding ways to move forward while maintaining meaningful connection to those we’ve lost.

If you’re struggling with grief, whether it meets criteria for prolonged grief disorder or simply feels overwhelming and isolating, please know that support is available. You don’t have to navigate this journey alone.

FAQ

• How is prolonged grief disorder different from normal grief?

  Prolonged grief disorder is distinguished by the intensity and duration of grief symptoms that persist beyond 12 months and significantly impair daily functioning. While normal grief naturally decreases over time, prolonged grief remains intense and interferes with work, relationships, and self-care. Key signs include persistent yearning for the deceased, difficulty accepting the death, and inability to engage in meaningful activities or relationships.

• What therapeutic approaches are most effective for prolonged grief disorder?

  Evidence-based therapies for prolonged grief include Complicated Grief Therapy (CGT), which focuses on processing the loss and rebuilding life meaning. Cognitive Behavioral Therapy (CBT) helps identify and change unhelpful thought patterns about the loss. Narrative therapy allows individuals to construct new meaning around their loss, while EMDR can process traumatic aspects of grief. These approaches help individuals gradually re-engage with life while maintaining a healthy connection to their loved one's memory.

• When should someone consider seeking therapy for unresolved grief?

  Consider therapy if grief symptoms persist intensely beyond 12 months and interfere with daily functioning. Warning signs include avoiding reminders of the deceased, persistent anger or guilt, inability to trust others, difficulty accepting the death, or feeling life is meaningless. If grief prevents you from working, maintaining relationships, caring for yourself, or engaging in previously enjoyed activities, professional support can provide effective tools for healing.

• What can someone expect during therapy for prolonged grief disorder?

  Therapy for prolonged grief typically involves gradual exposure to grief-related memories and situations in a safe environment. Your therapist will help you process difficult emotions, challenge unhelpful beliefs about the loss, and develop coping strategies. Sessions often include memory work to maintain healthy connections with the deceased while building new life meaning. Progress involves learning to carry grief while re-engaging with relationships, activities, and personal goals.

• How does online therapy work for grief counseling?

  Online grief therapy provides the same evidence-based treatments as in-person sessions through secure video platforms. Many people find the comfort of their own space beneficial when processing intense emotions. Digital therapy offers consistent access to specialized grief counselors regardless of location, and scheduling flexibility helps maintain treatment continuity during difficult periods. Licensed therapists use the same therapeutic techniques virtually, including guided imagery, memory processing, and homework assignments between sessions.