Grief is supposed to hurt. When someone we love dies, the pain can be overwhelming, disorienting, all-consuming. In the weeks and months after a loss, intense grief is expected and normal.
But for some people, grief doesn't follow the typical trajectory. Instead of gradually integrating into life, grief remains as raw and debilitating months or years later as it was in the beginning. The yearning doesn't ease. The world still feels meaningless. Life feels impossible to resume.
This is Prolonged Grief Disorder (PGD)—a recognized mental health condition that affects about 10% of bereaved people. It's not a character flaw or a failure to "move on." It's a condition with identifiable symptoms, clear diagnostic criteria, and effective treatment.
If you're wondering whether your grief has become something more than "normal grief," this article explains what Prolonged Grief Disorder is, how it's diagnosed, who's at risk, and what treatment looks like.
What Is Prolonged Grief Disorder?
Prolonged Grief Disorder is a mental health condition characterized by grief that remains intense, debilitating, and functionally impairing long after a loss. It was officially added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) in 2022 and is classified under "Trauma- and Stressor-Related Disorders."
The core features are:
- • Intense yearning or longing for the deceased person
- • Preoccupation with thoughts or memories of the deceased
- • Additional symptoms causing significant distress or impairment
- • Duration of at least 12 months (6 months for children) since the death
This is distinct from normal grief, where pain gradually integrates into life over time. With PGD, grief becomes "stuck"—the natural healing process is blocked, and the person remains in acute grief indefinitely.
Why It's Called "Prolonged" Grief
The name emphasizes duration: this is grief that persists beyond the typical timeframe. While there's enormous individual variation in grieving, most people begin to adapt to loss within several months to a year. With PGD, that adaptation doesn't happen—grief remains at acute levels.
You may also hear this condition called "complicated grief" (the term used in research before the DSM-5-TR formalized the diagnosis). The concepts are very similar.
DSM-5-TR Diagnostic Criteria
For a formal diagnosis of Prolonged Grief Disorder, all of the following criteria must be met:
Criterion A: The Loss
The death of someone close to the individual at least 12 months ago (at least 6 months for children and adolescents).
Criterion B: Core Symptoms
Since the death, the individual has experienced on more days than not, to a clinically significant degree, one or both of the following:
- • Intense yearning/longing for the deceased
- • Preoccupation with thoughts or memories of the deceased (in children, this may focus on circumstances of the death)
Criterion C: Additional Symptoms (at least 3 of 8)
Since the death, at least three of the following symptoms have been present most days, to a clinically significant degree:
- 1. Identity disruption: Feeling as if part of oneself has died
- 2. Disbelief: Marked sense of disbelief about the death
- 3. Avoidance: Avoiding reminders that the person is dead
- 4. Intense emotional pain: Related to the death (anger, bitterness, sorrow)
- 5. Difficulty moving on: Problems reintegrating into life (engaging with friends, pursuing interests, planning for the future)
- 6. Emotional numbness: Since the death
- 7. Life feels meaningless: Without the deceased
- 8. Intense loneliness: As a result of the death
Criterion D: Functional Impairment
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criterion E: Cultural Context
The duration and severity of the grief clearly exceed expected social, cultural, or religious norms for the individual's culture and context.
Criterion F: Rule Out Other Causes
The symptoms are not better explained by another mental disorder (such as major depression, PTSD, or substance use disorder) and are not due to the effects of a substance or another medical condition.
How Is This Different From Normal Grief?
This is the question people often struggle with most: How do I know if my grief is "normal" or something more?
It's important to understand that intense grief is normal. Crying daily for months, feeling like the world has lost its color, struggling to function at work—these can all be part of normal grieving, especially in the early months.
The key differences are:
Normal Grief vs. Prolonged Grief Disorder
| Normal Grief | Prolonged Grief Disorder |
|---|---|
| Intensity gradually decreases over months | Intensity remains constant or worsens after 12+ months |
| Grief comes in waves, with breaks | Grief is constant, with little relief |
| Able to acknowledge the death is real | Persistent disbelief or inability to accept the death |
| Painful feelings mix with positive memories | Memories trigger only pain, not comfort |
| Gradually re-engages with life | Unable to resume activities, relationships, or planning |
| Maintains sense of identity | Feels like part of self died with the deceased |
| Can imagine meaningful future | Life feels permanently meaningless |
The 12-month threshold is important but not absolute. Some people with PGD recognize the pattern earlier; others don't seek help until years later. If you're experiencing these symptoms and they're interfering with your life, it's worth talking to a professional regardless of exactly how long it's been.
Who Is at Risk for Prolonged Grief Disorder?
Research has identified several factors that increase the risk of developing PGD:
Risk Factors for Prolonged Grief Disorder
- Nature of the death:
- • Sudden or unexpected death
- • Violent death (accident, homicide)
- • Death by suicide
- • Multiple losses close together
- Relationship to the deceased:
- • Loss of a child (highest risk)
- • Loss of a spouse or partner
- • Very dependent relationship
- • Conflicted or ambivalent relationship
- Personal factors:
- • Prior history of depression, anxiety, or PTSD
- • Previous unresolved losses
- • Insecure attachment style
- • Lower education levels
- Social factors:
- • Lack of social support
- • Stigmatized loss (death by suicide or overdose)
- • Inability to engage in mourning rituals
The COVID-19 pandemic created conditions that elevated risk: sudden deaths, inability to be present at the end of life, disrupted funeral rituals, and reduced social support during lockdowns. Research has documented elevated rates of PGD following pandemic losses.
However, it's important to note that most people exposed to these risk factors do not develop PGD. Having risk factors doesn't mean PGD is inevitable—it just means the risk is higher than average.
PGD, Depression, and PTSD: What's the Difference?
Prolonged Grief Disorder can look similar to other conditions—particularly depression and PTSD. A proper diagnosis requires distinguishing between them, though they can also co-occur.
PGD vs. Major Depressive Disorder
- • Focus: In PGD, distress centers on the deceased person. In depression, sadness is more generalized.
- • Yearning: Intense longing for the deceased is central to PGD but not to depression.
- • Triggers: PGD symptoms are triggered by reminders of the deceased. Depression feels more constant regardless of triggers.
- • Self-esteem: Depression often involves pervasive worthlessness. In PGD, self-esteem is usually intact except in relation to the loss.
PGD vs. PTSD
- • Focus: PGD centers on the absence of the deceased. PTSD centers on the traumatic event itself.
- • Intrusions: In PGD, intrusive thoughts are about missing the person. In PTSD, intrusions involve reliving the traumatic event.
- • Avoidance: Both involve avoidance, but in PGD it's avoiding the reality of the death; in PTSD it's avoiding trauma reminders.
These conditions can co-occur. Someone can have PGD and depression, or PGD and PTSD. A mental health professional can assess what's present and tailor treatment accordingly.
Treatment for Prolonged Grief Disorder
The good news about PGD is that treatment is highly effective. Unlike normal grief (where professional intervention has modest effects), specialized treatment for PGD produces significant improvement.
Complicated Grief Treatment (CGT)
Developed by Dr. M. Katherine Shear, Complicated Grief Treatment (CGT) is the most well-researched intervention for PGD. It typically involves 16 sessions and includes:
Components of CGT
- Understanding grief: Education about grief and PGD, normalizing your experience
- Loss-focused work: Revisiting the story of the death, processing traumatic elements, confronting avoided reminders
- Restoration-focused work: Rebuilding engagement with life, setting goals, reconnecting with others
- Continuing bonds: Finding healthy ways to maintain connection with the deceased
Randomized controlled trials show CGT achieves response rates around 70%—significantly better than standard interpersonal therapy (about 30% response rate) or antidepressant medication alone.
Other Evidence-Based Approaches
- • Cognitive Behavioral Therapy for grief: Addresses unhelpful thoughts and avoidance patterns
- • Exposure-based interventions: Gradual approach to avoided memories and reminders
- • Meaning-making interventions: Finding sense and purpose in the loss and aftermath
Medication
Antidepressants (particularly SSRIs) are sometimes used alongside therapy, especially when depression co-occurs with PGD. However, medication alone is not considered first-line treatment for PGD. The psychological processing that happens in therapy appears essential for resolving prolonged grief.
What to Expect in Treatment
If you pursue grief counseling for PGD, here's what the process typically involves:
The Treatment Journey
- 1. Assessment (1-2 sessions): Your therapist will assess your symptoms, history, and circumstances to confirm a PGD diagnosis and rule out other conditions.
- 2. Education and rapport: Learning about PGD helps many people feel less alone and less "crazy." Understanding that this is a recognized condition with effective treatment brings hope.
- 3. Processing the loss: Gradual, supported work with painful memories and avoided reminders. This is difficult but essential—avoidance keeps grief stuck.
- 4. Rebuilding engagement: Gradually returning to activities, relationships, and goals. Managing the guilt that can come with moving forward.
- 5. Integration: Finding a new relationship with the deceased that allows both continued connection and engagement with life. Preparing for triggers.
Treatment is not about "getting over" the person or forgetting them. It's about unsticking grief so that you can carry the loss without being disabled by it. People who complete treatment don't stop grieving—they find ways to grieve while also living.
Frequently Asked Questions
What is Prolonged Grief Disorder?
Prolonged Grief Disorder (PGD) is a mental health condition characterized by intense, persistent grief that interferes with daily functioning. Added to the DSM-5-TR in 2022, it involves intense yearning for the deceased, preoccupation with the loss, and at least three additional symptoms (like disbelief, avoidance, emotional numbness, or identity disruption) lasting at least 12 months in adults (6 months in children).
How is Prolonged Grief Disorder different from normal grief?
Normal grief, while painful, gradually integrates into life over time. With Prolonged Grief Disorder, grief remains intense and debilitating beyond what's typical—usually after 12 months. Key differences include: constant (not wave-like) yearning, inability to accept the death, avoidance of reminders OR inability to stop focusing on the loss, significant impairment in work and relationships, and feeling life is meaningless without the deceased.
What causes Prolonged Grief Disorder?
Risk factors include: the nature of the death (sudden, violent, or by suicide); losing a child or spouse; a dependent or complicated relationship with the deceased; lack of social support; prior mental health conditions (depression, anxiety, PTSD); previous unprocessed losses; and lower education levels. The COVID-19 pandemic, which disrupted traditional mourning rituals, has also been associated with increased rates of PGD.
How is Prolonged Grief Disorder treated?
The most effective treatment is Complicated Grief Treatment (CGT), a specialized therapy that achieves about 70% response rates. CGT involves processing traumatic aspects of the death, gradually approaching avoided reminders, rebuilding engagement with life, and developing continuing bonds with the deceased. Some people also benefit from medication (antidepressants), though therapy is the primary treatment.
How common is Prolonged Grief Disorder?
Approximately 10% of bereaved people develop Prolonged Grief Disorder. Rates are higher after certain types of loss—particularly sudden deaths, violent deaths, suicide, and the death of a child. Most people who experience grief, even intense grief, do not develop PGD. Those who do can benefit significantly from specialized treatment.
Related Resources
References & Further Reading
American Psychiatric Association. (2022). Prolonged Grief Disorder. DSM-5-TR Fact Sheet.
Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372(2), 153-160.
Szuhany, K. L., et al. (2021). Prolonged grief disorder: Course, diagnosis, assessment, and treatment. Focus, 19(2), 161-172.
Boelen, P. A., et al. (2022). Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance. Frontiers in Psychiatry, 13, 878442.