Thursday, April 23, 2015

Cases: Complicated Grief: How Long is Too Long?

by Lisa Podgurski, MD

Ms. K is an 75 year-old woman with peripheral vascular disorder who presented with acute onset of a cold, painful, blue lower extremity and was diagnosed with an arterial clot. In discussion with vascular surgery, she was offered amputation and after consideration she declined surgical intervention and chose to focus on comfort only. Palliative Care was consulted for assistance with comfort measures, given a likely prognosis of a small number of days. The patient’s daughter had been present for Ms. K’s conversation with the surgeon and understood that foregoing amputation would mean her mom would die soon. Ms. K’s daughter supported her mom’s decision and felt it was consistent with her overall values; the daughter expressed distress because this was happening in addition to the loss of her own husband, which continued to occupy her thoughts a great deal. The daughter relayed the story of their close relationship, his terminal decline, and his ultimate death, in vivid detail. In further exploration, it surfaced that his death had actually occurred several years ago, and that Ms. K’s daughter had struggled a great deal with functioning since then.


Normal Grief
“Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical and spiritual necessity, the price you pay for love. The only cure for grief is to grieve.” – Rabbi Earl Grollman
Different people respond to the death of someone close to them differently, and a wide range of responses can be referred to as “normal.” Significant distress is common, and can be emotional, spiritual, cognitive, physical, and/or behavioral in nature. Some commonly-described reactions include: experiencing waves of strong feelings; disbelief that the person has died; somatic symptoms such as insomnia, palpitations, or changes in appetite; and perceptual disturbances such as visual or auditory hallucinations, or constant preoccupation with the deceased (Strada 2013). Labeling these experiences “normal” does not in any way imply that it will feel normal or comfortable for the person who is grieving. Nonetheless, for most people (90% or greater), this process will evolve over time into what is referred to as integrated grief, in which “the reality and meaning of the death are assimilated with a return to ongoing life” (Simon 2013). Sadness and longing may still be present, though less intensely, and the bereaved is able to have other activities at “center stage” for much of the time. In integrated grief, symptoms may feel amplified at certain times, such as anniversaries or holidays. For most people, a transition to integrated grief occurs within 6-12 months of the death (there is still some disagreement in the literature about exact timeframe).

Complicated Grief

Diagnosis: For some people, grief lasts much longer and is more problematic. In the literature, this is most often referred to as prolonged grief, complicated grief, or traumatic grief. The DSM-5 has included the diagnosis “persistent complex bereavement disorder”
as a subtype of other specified trauma and stressor-related disorders, warranting further study. There are reports that the ICD-11 will include the diagnosis “prolonged grief disorder.” Along with the debate about what to call pathologic grief, there is some controversy about the exact diagnostic criteria for the condition. The DSM-5 includes three categories of proposed criteria, with at least 1 of 4 features present from Criterion B and at least 6 of 12 present from Criterion C. Put more simply, some commonly agreed-upon elements of complicated grief include:
  • Separation distress, with intense longing and yearning for the deceased
  • Anger and bitterness
  • Shock and disbelief; Difficulty accepting that the loss has occurred
  • Estrangement from others
  • Hallucinations of the deceased
  • Behavior change: Over involvement in activities related to the deceased or excessive avoidance.
In screening for pathologic grief in your patients, consider the use of the Brief Grief Questionnaire, a 5-item tool scored on a 0-2 Likert scale (‘not at all,’ ‘somewhat,’ ‘a lot’). A score or 5 or higher warrants referral to a mental health professional (Shear 2006).

  1. How much of the time are you having trouble accepting the death of _____?
  2. How much does your grief interfere with your life?
  3. How much are you having images or thoughts of _____ when he or she died or other thoughts about the death that really bother you?
  4. Are there things that you used to do when _____ was alive that you don’t feel comfortable doing more, that you avoid? How much are you avoiding these things?
  5. How much are you feeling cut off or distant from other people since _____ died, even people you used to be close to, like family or friends?

An intervention should be considered if a person has persistently high symptom severity, lack of temporal improvement in the grief response, functional impairment, treatment-seeking behaviors, hopelessness, and/or suicidal thoughts or behaviors.

Complicated grief may co-occur with other psychiatric conditions. In a recent multisite randomized controlled trial conducted by Charles Reynolds and his colleagues, two-thirds of the 400 complicated-grief patients enrolled also had major depressive disorder, and one-third had PTSD (Simon 2007).

Dr. Reynolds notes the significance of these “strong, complex patterns of co-occuring disorders” (personal communication). If a patient has persistent negative affect, endorses anhedonia, and/or suicidal ideation, appropriate treatment of depression needs to be considered.

Treatment: Patients and caregivers who seem to be experiencing normal grief reactions should be offered supportive psychoeducation clarifying and normalizing characteristics of normal grief. Referral for local grief counseling is also appropriate.

For more extended or severe grief studies are ongoing to establish the best treatments. There are randomized controlled trials supporting the use of cognitive behavioral therapy for prolonged grief (PG-CBT) and of an internet based therapist-assisted cognitive-behavioral indicated prevention intervention for prolonged grief disorder (Healthy Experiences After Loss, or HEAL) for prevention of PGD (Rosner 2014, Litz 2014). There are also studies supporting use of a targeted complicated-grief treatment (CGT) which is based on attachment theory and employs “techniques derived from prolonged exposure, IPT [interpersonal psychotherapy], and motivational interviewing.” A recent randomized controlled trial in elderly patients compared CGT to IPT, an evidence-based treatment for depression, and CGT showed significantly better outcomes (Shear 2014).

The role for medications remains unclear, as studies have had mixed results. Patients who develop clinical depression or anxiety disorders as complications of grieving should be treated appropriately for those conditions with medications (such as SSRIs) and/or therapy.

Case Resolution: 

Ms. K’s daughter’s intense and persistent grief response to her husband’s death years ago appears to be consistent with a prolonged/complicated grief reaction. Though it might have been a feature of normal grief for her feelings to intensify with a reminder of the loss, such as her mother’s impending death, the history she provides of ongoing struggle over the last several years suggests complicated grief.

Ms. K was transferred to an inpatient hospice setting for management of her pain and delirium. Prior to transfer, I made contact with the hospice agency who would be caring for her and her family to alert them to her daughter’s signs of prolonged grief from a prior loss. Hospice care will include 13 months of bereavement support for Ms. K’s family, and the agency’s bereavement counselor planned to contact Ms. K’s daughter prior to the death as well.


  1. Strada, EA. Grief and Bereavement in the Adult Palliative Care Setting. Portenoy RK, editor. New York: Oxford University Press; 2013. 118p.
  2. Simon, NM. Clinical Crossroads: Treating Complicated Grief. JAMA 2013;310(4):416-423.
  3. Shear KM, et al. Screening for complicated grief among project liberty service recipients 18 months after September 11, 2001. Psychiatr Serv. 2006;57:1291-7.
  4. Simon NM, et al.  The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry. 2007 Sep-Oct;48(5):395-9
  5. Rosner R, Pfoh G, Kotoucova M, Hagl M. Efficacy of an outpatient treatment for prolonged grief disorder: A randomized controlled clinical trial. J Affect Disord. 2014;Oct(167):56-63.
  6. Litz BT, Schorr Y, Delaney E, et al. A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder. Behav Res Ther. 2014;Oct(61):23-34.
  7. Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry. 2014 Nov;71(11):1287-95.

Many thanks to Bob Arnold and Charles Reynolds for valuable input in presenting this topic.

Original Case by Lisa Podgurski, MD
Case Conferences Editor - Christian Sinclair, MD
University of Pittsburgh Medical Center

Image Credit: Grief is Not... Christian Sinclair for Pallimed. Image licensed via Canva.

Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. It is published as a means to illustrate important teaching points in healthcare. Patient details may have been changed by Pallimed editors to help with anonymity. Links and minor edits are made for clarity and Pallimed editorial standards.

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