Grief and Prolonged Grief Disorder: When Grief Becomes a Disorder

What grief is, and how most people adapt

Grief is the natural response to losing someone close — a mix of sorrow, yearning, disbelief, and disrupted routine that follows a death. In the weeks and months after a loss, grief is often intense and intrusive; this early phase is usually called acute grief 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation.

For most people, acute grief gradually eases into a quieter, integrated form. The loss remains meaningful, but it no longer dominates daily life, and the capacity for connection and purpose returns. Integrated grief is typically observed roughly 6 to 12 months after a loss in longitudinal studies, and the majority of bereaved people reach it without formal treatment 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation. Grief does not follow fixed stages or a set timetable, and periods of renewed sadness — around anniversaries, holidays, or reminders — are ordinary, not a sign that something has gone wrong.

Prolonged grief disorder in the DSM-5-TR

A minority of bereaved people do not move toward integrated grief. Instead, grief stays severe, persistent, and disabling. To name this pattern, the American Psychiatric Association added prolonged grief disorder (PGD) to the DSM-5-TR, the 2022 text revision of its diagnostic manual 4Ref 4Donaldson ZR, Shear MK (2023).Neurobiology and treatment advances for prolonged grief disorder.Prolonged grief disorder was added to the DSM-5-TR in 2022; core symptoms are intense, persistent yearning or preoccupation with the deceased plus at least 3 of 8 associated symptoms; targeted grief-focused psychotherapy is efficacious and widely used.

The diagnosis has a time threshold: the death must have occurred at least 12 months earlier for adults, and at least 6 months earlier for children and adolescents 8Ref 8Eisma MC (2023).Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies.DSM-5-TR time criterion: death at least 12 months ago for adults, at least 6 months ago for children and adolescents; verbatim list of the eight accompanying symptoms (identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reintegrating, emotional numbness, meaninglessness, intense loneliness). This waiting period is deliberate — it is meant to separate a lasting disorder from the intense grief that is expected in the first year.

Beyond the time threshold, PGD requires a grief response marked by intense yearning or longing for the person who died, or preoccupation with thoughts or memories of them, present nearly every day for at least the past month 7Ref 7Treml J, Linde K, Brähler E, Kersting A (2024).Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.DSM-5-TR criteria require intense yearning/longing or preoccupation nearly every day for at least the last month plus at least 3 of 8 symptoms, at least 12 months after the death, exceeding social/cultural/religious norms; DSM-5-TR PGD conditional prevalence 4.7% among bereaved respondents and 2.0% population-wide. At least three of eight additional symptoms must also be present 7Ref 7Treml J, Linde K, Brähler E, Kersting A (2024).Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.DSM-5-TR criteria require intense yearning/longing or preoccupation nearly every day for at least the last month plus at least 3 of 8 symptoms, at least 12 months after the death, exceeding social/cultural/religious norms; DSM-5-TR PGD conditional prevalence 4.7% among bereaved respondents and 2.0% population-wide8Ref 8Eisma MC (2023).Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies.DSM-5-TR time criterion: death at least 12 months ago for adults, at least 6 months ago for children and adolescents; verbatim list of the eight accompanying symptoms (identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reintegrating, emotional numbness, meaninglessness, intense loneliness):

• Identity disruption — feeling that a part of oneself has died
• A marked sense of disbelief about the death
• Avoidance of reminders that the person is gone
• Intense emotional pain — anger, bitterness, or sorrow — related to the death
• Difficulty reintegrating into relationships and activities
• Emotional numbness
• A feeling that life is meaningless
• Intense loneliness

The symptoms must cause clinically significant distress or impairment and exceed what would be expected for the person's social, cultural, or religious norms 7Ref 7Treml J, Linde K, Brähler E, Kersting A (2024).Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.DSM-5-TR criteria require intense yearning/longing or preoccupation nearly every day for at least the last month plus at least 3 of 8 symptoms, at least 12 months after the death, exceeding social/cultural/religious norms; DSM-5-TR PGD conditional prevalence 4.7% among bereaved respondents and 2.0% population-wide.

Normal grief versus prolonged grief disorder

The difference between ordinary grief and prolonged grief disorder is not the presence of pain — grief is painful by nature — but its duration, intensity, and interference with life 3Ref 3Boelen PA, Lenferink LIM (2021).Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance.DSM-5-TR PGD criteria structure (yearning/preoccupation plus at least 3 of 8 symptoms causing clinically significant distress or impairment); 10.1% met probable PGD caseness in a bereaved sample; predictors include loss of a child and unnatural/violent death; the disorder is distinguished by persistence and functional impairment.

Ordinary grief comes in waves that gradually become less frequent and less consuming; over time a person can still work, connect with others, and find moments of meaning. In prolonged grief disorder, the yearning and preoccupation remain constant and intrusive a year or more after the death, and they keep the person from re-engaging with life 3Ref 3Boelen PA, Lenferink LIM (2021).Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance.DSM-5-TR PGD criteria structure (yearning/preoccupation plus at least 3 of 8 symptoms causing clinically significant distress or impairment); 10.1% met probable PGD caseness in a bereaved sample; predictors include loss of a child and unnatural/violent death; the disorder is distinguished by persistence and functional impairment.

The diagnosis is intended to identify this disabling minority — not to treat normal grief, however long or heavy, as an illness. Because grief varies so widely across people and cultures, the DSM-5-TR criteria explicitly require that the reaction exceed the person's own cultural, social, and religious expectations before it is considered a disorder 7Ref 7Treml J, Linde K, Brähler E, Kersting A (2024).Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.DSM-5-TR criteria require intense yearning/longing or preoccupation nearly every day for at least the last month plus at least 3 of 8 symptoms, at least 12 months after the death, exceeding social/cultural/religious norms; DSM-5-TR PGD conditional prevalence 4.7% among bereaved respondents and 2.0% population-wide.

How common is prolonged grief disorder

Estimates vary with the criteria used and the population studied. A 2017 meta-analysis of 14 studies in bereaved adults, mostly after non-violent losses, found a pooled prevalence of about 9.8% (95% confidence interval 6.8–14.0) 1Ref 1Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I, O'Connor M (2017).Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis.Pooled prevalence of prolonged grief disorder of 9.8% (95% CI 6.8–14.0) across 14 studies of bereaved adults after mostly non-violent losses. A widely cited clinical review similarly places the figure at roughly 7% to 10% of bereaved people 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation.

When the stricter DSM-5-TR algorithm is applied to general community samples, estimates run lower. One 2024 study found DSM-5-TR prolonged grief disorder in 4.7% of bereaved respondents and 2.0% of the overall sample 7Ref 7Treml J, Linde K, Brähler E, Kersting A (2024).Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.DSM-5-TR criteria require intense yearning/longing or preoccupation nearly every day for at least the last month plus at least 3 of 8 symptoms, at least 12 months after the death, exceeding social/cultural/religious norms; DSM-5-TR PGD conditional prevalence 4.7% among bereaved respondents and 2.0% population-wide. Across studies, rates are consistently higher after sudden or violent deaths — suicide, homicide, or accidents — and after the loss of a child or partner 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation3Ref 3Boelen PA, Lenferink LIM (2021).Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance.DSM-5-TR PGD criteria structure (yearning/preoccupation plus at least 3 of 8 symptoms causing clinically significant distress or impairment); 10.1% met probable PGD caseness in a bereaved sample; predictors include loss of a child and unnatural/violent death; the disorder is distinguished by persistence and functional impairment.

Who is at higher risk

Prolonged grief disorder can follow any loss, but several factors raise the risk 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation:

• The nature of the death — sudden, violent, or unexpected losses (suicide, homicide, accidents) carry higher risk than anticipated deaths 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation3Ref 3Boelen PA, Lenferink LIM (2021).Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance.DSM-5-TR PGD criteria structure (yearning/preoccupation plus at least 3 of 8 symptoms causing clinically significant distress or impairment); 10.1% met probable PGD caseness in a bereaved sample; predictors include loss of a child and unnatural/violent death; the disorder is distinguished by persistence and functional impairment
• The relationship — losing a child or a life partner, or another close kinship, is among the strongest predictors 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation3Ref 3Boelen PA, Lenferink LIM (2021).Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance.DSM-5-TR PGD criteria structure (yearning/preoccupation plus at least 3 of 8 symptoms causing clinically significant distress or impairment); 10.1% met probable PGD caseness in a bereaved sample; predictors include loss of a child and unnatural/violent death; the disorder is distinguished by persistence and functional impairment
• Prior mental health — a history of mood disorders, or depression present early in bereavement, increases risk 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation
• Limited support — low social support that interferes with adapting to the loss 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation
• Demographic factors — the review notes higher rates associated with female gender, older age, and lower socioeconomic status 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation

These are statistical associations, not certainties. Many people with several risk factors still move through grief without developing the disorder.

Treatment: what the evidence supports

Prolonged grief disorder responds to treatment, and the strongest evidence is for grief-focused psychotherapy rather than medication 5Ref 5Shear MK, Reynolds CF 3rd, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B, Skritskaya N (2016).Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.Four-arm RCT: complicated grief treatment (CGT) with placebo produced an 82.5% response versus 54.8% for placebo alone; citalopram alone produced a 69.3% response, not significantly different from placebo; adding citalopram to CGT (83.7%) did not improve grief outcomes; grief-focused psychotherapy (CGT) is the treatment of choice for complicated grief.

Complicated grief treatment (CGT) — also described as prolonged grief disorder therapy — is a structured, roughly 16-session program that combines elements of cognitive behavioral and interpersonal therapy with specific work on accepting the reality of the loss and restoring the capacity for meaning and connection 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation. In a randomized trial in older adults, CGT produced a response in 70.5% of participants, more than double the 32.0% response to interpersonal psychotherapy, an established treatment for depression 6Ref 6Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A (2014).Treatment of Complicated Grief in Elderly Persons: A Randomized Clinical Trial.In older adults, complicated grief treatment produced a 70.5% response versus 32.0% for interpersonal psychotherapy, a proven depression treatment.

A four-arm randomized trial tested CGT and the antidepressant citalopram, alone and in combination. CGT with placebo produced a response in 82.5% of participants versus 54.8% with placebo alone; citalopram alone produced a 69.3% response, which was not significantly different from placebo; and adding citalopram to CGT (83.7%) did not improve grief outcomes, though it helped co-occurring depression 5Ref 5Shear MK, Reynolds CF 3rd, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B, Skritskaya N (2016).Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.Four-arm RCT: complicated grief treatment (CGT) with placebo produced an 82.5% response versus 54.8% for placebo alone; citalopram alone produced a 69.3% response, not significantly different from placebo; adding citalopram to CGT (83.7%) did not improve grief outcomes; grief-focused psychotherapy (CGT) is the treatment of choice for complicated grief. The authors concluded that grief-focused psychotherapy is the treatment of choice for complicated grief 5Ref 5Shear MK, Reynolds CF 3rd, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B, Skritskaya N (2016).Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.Four-arm RCT: complicated grief treatment (CGT) with placebo produced an 82.5% response versus 54.8% for placebo alone; citalopram alone produced a 69.3% response, not significantly different from placebo; adding citalopram to CGT (83.7%) did not improve grief outcomes; grief-focused psychotherapy (CGT) is the treatment of choice for complicated grief.

Antidepressants on their own have not been shown to relieve grief symptoms 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation5Ref 5Shear MK, Reynolds CF 3rd, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B, Skritskaya N (2016).Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.Four-arm RCT: complicated grief treatment (CGT) with placebo produced an 82.5% response versus 54.8% for placebo alone; citalopram alone produced a 69.3% response, not significantly different from placebo; adding citalopram to CGT (83.7%) did not improve grief outcomes; grief-focused psychotherapy (CGT) is the treatment of choice for complicated grief. Medication has a clearer role when a person also has a treatable condition such as major depression or an anxiety disorder, which frequently accompany prolonged grief 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation.

When grief needs professional or urgent attention

Grief itself is not a medical emergency, and most people never need formal treatment. Professional assessment is reasonable when grief remains intense and disabling roughly a year or more after a death, when it prevents working, caring for oneself, or maintaining relationships, or when alcohol or other substances are being used to cope 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation.

Prolonged grief is associated with an elevated risk of suicidal thoughts, and reducing that risk is one of the measured benefits of grief-focused therapy 2Ref 2Szuhany KL, Malgaroli M, Miron CD, Simon NM (2021).Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment.Roughly 7–10% of bereaved people develop prolonged grief; most reach integrated grief 6–12 months post-loss without treatment; risk factors (sudden/violent death, loss of a child or partner, prior mood disorder, low social support, female gender, older age, lower socioeconomic status); CGT is a 16-session intervention efficacious versus interpersonal therapy; antidepressants alone lack grief-specific efficacy; CGT reduces suicidal ideation5Ref 5Shear MK, Reynolds CF 3rd, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B, Skritskaya N (2016).Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.Four-arm RCT: complicated grief treatment (CGT) with placebo produced an 82.5% response versus 54.8% for placebo alone; citalopram alone produced a 69.3% response, not significantly different from placebo; adding citalopram to CGT (83.7%) did not improve grief outcomes; grief-focused psychotherapy (CGT) is the treatment of choice for complicated grief. Thoughts of not wanting to be alive, or of joining the person who died, warrant immediate help. In the United States, the 988 Suicide and Crisis Lifeline is available 24/7 by call or text.