Pathological Grief – It’s Complicated

What’s known for certain about complicated grief (as many before me have predictably punned) is that it’s complicated.

Despite being a well-recognised phenomenon, complicated grief has no standard definition, no universal diagnostic criteria, or even an official name. ‘Prolonged grief disorder’, ‘persistent complex bereavement’, and ‘traumatic bereavement’ are variously used, and there’s a big question mark still hanging over whether to consider it a ‘disorder’ at all.

Here’s what we do know.

  1. ‘Normal’ grief alone can take you to hell, and back again – then straight on into several fresh variations of hell. Manifestations can include any and all of the following: sadness, despair, rage, emptiness, loneliness, nightmares, inability to sleep, oversleeping, exhaustion, weight loss, weight gain, isolation, increased dependence, lack of affect, hallucination… almost anything is ‘normal’ following the trauma of losing forever someone we loved in life, and continue to love through the agony of their absence.
  2. As irritating as the cliche is, time heals. When a loved one dies, it feels as though the world has ended – and yet, it continues to turn. For most people, their ‘normal’ (albeit incredibly disturbing and upsetting) grief symptoms have largely dissipated by 18 months post-loss. While the griever has not necessarily ‘moved on’ or ‘recovered’, the most acutely painful sensations have shifted. As a researcher by the name of Shear put it, over time, “the griever is able to come to an acceptance of irrevocably changed circumstances and reengage in life.” Therapy appears to have little to no benefit in soothing or speeding up this process.
  3. But time doesn’t heal all wounds. For around 10-20% of bereaved individuals, symptoms persist or worsen over time. Speaking generally, these individuals are thought to be suffering from complicated grief, and have become ‘stuck’ or ‘blocked’ in their emotional experience.

Complicated grief is currently listed in the DSM-5 under conditions for which further research is required. Given the working name ‘Persistent Complex Bereavement Disorder (PCBD), it’s typified by the following symptoms:

  • Persistent yearning for the deceased
  • Intense sorrow and frequent crying.
  • Marked difficulty accepting that the individual has died
  • Overcome by distressing memories of the deceased.
  • Anger regarding the loss.
  • Maladaptive appraisals about oneself in relation to the deceased or the death.
  • Avoidance of reminders of the loss.
  • A desire to die in order to rejoin the deceased.
  • Lack of trust in others resulting from the loss.
  • Feelings of isolation.
  • Lacking meaning or purpose in life in the deceased’s absence.
  • A diminished sense of identity.
  • Difficulty engaging in activities, pursuing relationships, or planning for the future.

Without intervention, sufferers have been found to be at greater risk of major depression, PTSD, anxiety, suicidal ideation, functional impairment and overall poorer quality of life.

So far, so tidy. However, there’s some seriously curly questions about when (or whether) it’s acceptable to slap a ‘Not OK’ label on someone else’s grief. Where is the line between depression and grief? Are we moving closer to labelling painful emotional experiences ‘disorders’ even in perfectly reasonable circumstances? What about how bereavement looks across cultures? Grief’ quite literally has no translation in some languages, with the bereaved expected to transition quickly back to normality. On the other hand, some people hold no belief that ‘recovery’ is normal or even desirable. Many more women are thought to suffer from complicated grief than men – but we haven’t been told all our lives to ‘grow some balls’ and ‘get over it’. What makes it OK to impose one set of standards for emotional expression onto our insanely diverse population?

If you haven’t already picked up on it, I have stuck my head down this particular rabbit hole plenty of times. The questions that come up fascinate me, and it took a lot of reading and thinking and chewing peoples’ ears off before I found peace with not having all the answers.

Because ultimately, if you come to me struggling with grief, it’s you who knows what is and isn’t right for you. The treatments shown to be most effective for complicated grief involve inherent respect for the uniqueness of each individual’s grief process rather than following any particular formula. A researcher named Worden said it very eloquently, so I’ll steal his words: “Each person’s grief is like all other people’s grief; each person’s grief is like some other person’s grief; and each person’s grief is like noother person’s grief.” The same can be said of each person’s movement through grief, whether it involves psychotherapy or not.

Leah Royden