What is complex grief?
Summary
The loss of a loved one is one of the most stressful life experiences a human being can endure. Although grief is not an illness and most people manage to adapt without professional intervention, the experience of grief is often associated with a period of intense suffering, with significant physical, emotional, and social repercussions.
Research shows that grief can have a real impact on both mental and physical health: an increased risk of mortality, especially in the first few months after the loss, and a greater likelihood of experiencing cardiovascular problems, sleep disorders, depression, or suicidal thoughts. These effects are not the same for everyone and depend on multiple factors, such as the circumstances of the death, the relationship with the loved one, personal resources, and available social support.
It is precisely this variability that compels us to view grief with a careful and nuanced perspective. In fact, only a minority of people develop serious or persistent complications in the grieving process, but these individuals do exist and require specific support.
Understanding grief not as an illness, but as a risk factor, and recognizing when the pain is more complex or when there is a greater risk of it becoming chronic, does not mean pathologizing grief, but rather identifying situations of vulnerability in order to offer appropriate support and prevention.
Why is it important to differentiate between the types of grief?
The terms complex grief, prolonged grief disorder, and pathological grief are often used interchangeably. This can lead to confusion, both professionally and socially.
It is therefore necessary to differentiate each situation:
Complex grief
Complex grief describes situations where the process of coping with loss is complicated by factors that hinder its progress or intensify suffering, without necessarily implying the presence of a mental disorder. In these cases, complex grief expresses a particularly demanding experience of loss.
We are talking about grief that is more intense, long or painful due to difficulties that may be related to the circumstances of the death (traumatic, sudden, multiple losses), with personal characteristics (previous history of vulnerability, age, type of bond) or with the relational context (lack of support, family conflicts).
In these cases, grief remains an adaptive, albeit costly, process. There is movement, fluctuation, moments of connection with life, and a capacity—albeit fragile—for processing. The person suffers, but is not necessarily trapped in the pain. Complex grief is not a clinical diagnosis, but rather a way of describing grief with a higher risk.
Key idea: It's not a pathology, but rather increased vulnerability. It requires support, not a diagnosis.
Complex grief disorder (or prolonged grief disorder)
Complex grief disorder is a recognized diagnostic category (DSM-5-TR and ICD-11) that describes a specific and rare condition. It occurs when the pain of loss remains intense, persistent, and debilitating over time, beyond what is culturally expected, and clearly interferes with daily life .
People who meet the criteria for prolonged grief disorder experience a combination of symptoms such as persistent and painful longing, severe difficulty accepting the death, feelings of emptiness or lack of meaning in life, and significant interference in their personal, social, or work life. Scientific evidence indicates that these individuals have an increased risk of serious health problems , including suicidal thoughts, associated mental disorders, and poorer physical health.
Prolonged Grief Disorder (PGD) has generated debate and controversy since its inclusion in international diagnostic manuals. One of the main misconceptions is the idea that this diagnosis pathologizes normal grief (Prigerson et al. 2022). Research clearly shows that PGD only applies to a minority of grieving individuals—those who experience intense, persistent, and clearly debilitating suffering, far beyond what is expected in a typical grieving process. Ignoring this suffering under the argument that "grief is normal" can leave people who truly need help without it.
People experiencing prolonged grief want and can benefit from targeted treatments. Studies show that psychological interventions specifically designed for prolonged grief are effective, while standard treatments for depression don't always yield good results in these cases. Recognizing prolonged grief doesn't mean medicalizing the pain, but rather opening the door to appropriate, evidence-based care focused on alleviating deep and sustained suffering.
Key idea: not all complex grief is a disorder; it only becomes one when the process becomes chronic. In these cases, specialized treatment is indicated and helpful.
Why is the term pathological grief out of use?
The term "pathological grief" is older, less precise, and currently not recommended. It has been used historically to describe "abnormal" grief, but it tends to medicalize suffering without clear or agreed-upon criteria, potentially leading to stigmatization.
Unlike complex grief disorder, the concept of pathological grief does not have specific diagnostic or operational criteria, and has often been used indiscriminately to refer to any intense or prolonged grief.
Key idea: today it is preferred to speak of grief with complexity factors or complex grief disorder, avoiding the term "pathological".
To remember:
Complexity in grief
- Difficult but adaptive grief
- It's not a disorder, it indicates a risk.
- It requires support and accompaniment
Complex/prolonged grief disorder
- Persistent and disabling grief
- Specific clinical diagnosis
- It requires specialized treatment
Pathological grief
- An old and imprecise term, to be avoided
- Not recommended at this time
- Risk of stigmatization
Understanding complex grief
Circumstances that can make grief more complex
It is essential to recognize these factors of complexity, as many appear from the very beginning:
Situational factors: when the manner of dying impacts grief
Situational factors refer to the objective circumstances of the loss, which can hinder the grieving process from the outset. Sudden or unexpected deaths do not allow for a process of anticipation or gradual farewell, leaving the bereaved person in a state of shock that can be prolonged. This initial impact can block the ability to assimilate the reality of the loss.
Deaths under traumatic circumstances —such as suicide, murder, abuse, or serious accidents—add elements of horror, guilt, anger, or incomprehension to the pain of grief. In these cases, grief can become intertwined with traumatic responses that hinder its emotional processing.
The necessary attention for people who have lost someone to suicide
Multiple or cumulative losses , especially when they occur in a short period, and ambiguous losses, where there is no body or clear confirmation of death, also contribute to the complexity of the situation. These circumstances make it difficult to accept reality and keep the person in a state of painful uncertainty that prevents them from beginning the grieving process.
Finally, the death of a child or adolescent constitutes one of the situational factors with the greatest impact, since it breaks the expected life order and calls into question the fundamental meanings of life, justice and meaning.
Personal factors: vulnerability, previous history, and attachment
Personal factors relate to the characteristics, history, and internal resources of the bereaved person. The age at which the loss occurs is a key element: grief in childhood, adolescence, or at very advanced ages can be especially complex, as it coincides with periods of great emotional vulnerability or dependency.
The type of relationship with the deceased person also plays a decisive role. Highly dependent, enmeshed (where there is a loss of individuality), or ambivalent relationships can generate a more intense and confusing grief, with contradictory feelings of guilt, anger, and need, which hinder emotional reorganization.
The presence of personal history , such as unresolved grief, depressive episodes, or other mental health disorders, increases the risk of complications in the current grief process. In these cases, the loss can reactivate old wounds that had not been healed.
Furthermore, the lack of personal resources, such as economic stability, work, interests, life projects or self-care capacity, can leave the person without elements of support, causing grief to occupy all of their living space.
Interpersonal factors: social support, family and community
Interpersonal factors refer to the relational, familial, and social context surrounding the bereaved person. Although a family may share the same loss, the meaning of that loss differs for each member. These different meanings and coping styles can generate misunderstandings, conflicts, or silences that hinder mutual support.
The lack of real or perceived social and familial support is one of the most important prognostic factors for complex grief. Not feeling heard, validated, or accompanied can intensify suffering and contribute to emotional isolation.
Grief can also be complicated by situations of disconnection from traditional support systems, as often happens to people who have migrated or are far removed from their cultural, religious, or social community. The loss of the community fabric leaves the person without rituals, points of reference, and shared spaces for mourning.
Finally, difficulties in intra-family communication —avoiding talking about death, protecting each other with silences, or not respecting the different rhythms of grief—can turn the environment into an emotionally unsafe space, increasing the feeling of loneliness.
Signs that indicate grief needs more attention
Parkes (2013) pointed out that it was necessary to be especially alert if the person met more than five of these factors four weeks into bereavement:
- Children in care
- lower social class
- Lack of work
- Intense rage
- High longing (intense and persistent nostalgia)
- High guilt (constant self-recrimination)
- Lack of social relationships
- Inadequate coping styles
And Worden (1997) established a list of indicators or behaviors to observe in order to determine if the bereaved person is at risk:
- He cannot speak of the dead person without experiencing very intense pain.
- He/She exhibits very intense emotional reactions to seemingly unimportant events.
- Mummification: preserves the belongings of the deceased intact, turning the home into a sanctuary-house.
- Make radical lifestyle changes, avoiding everything related to the deceased person.
- Masked grief, with the appearance of physical symptoms similar to those of the deceased person.
- Prolonged subclinical depression, marked by persistent guilt and low self-esteem.
- Compensatory identification, with a compulsive need to imitate the dead person.
- Impulsive or destructive behaviors, including addictions (alcohol, drugs, pyromania, etc.).
- Intense and inexplicable sadness at certain times of the year (anniversaries, significant dates).
- Fear of illness or death.
- Avoidance of cemeteries, rituals, or activities related to death.
- Absence of family or social support during the grieving process.
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