Persistent complex bereavement disorder (PCBD), formerly called complicated grief, is a condition defined by an extreme, disabling yearning for a deceased loved one for a prolonged period of time.
Persistent Complex Bereavement Disorder: What Does It Mean?
Bereavement is a time of mourning after a loss—typically the death of a loved one. It usually involves feelings such as sadness, guilt, numbness, and shock, before acceptance of the situation sets in. Going through a period of bereavement after losing a friend or family member in death is normal. Grieving individuals show a general pattern of emotional improvement over time.
Persistent complex bereavement disorder is different from normal grief. People with PCBD experience a disabling grief reaction that impairs their ability to function on a day-to-day basis. They also take a much longer time to reach the acceptance stage than individuals with normal grief.
Stats: How Many Suffer from this Disorder?
Approximately 2.4%-4.8% of people have persistent complex bereavement disorder. The condition affects individuals from all age groups. Females are more likely to experience PCBD than males. An estimated 7%-15% of bereaved individuals are affected by clinically impairing grief.
What Causes Persistent Complex Bereavement Disorder?
There is no specific cause of persistent complex bereavement disorder. However, certain environmental and biological factors have been linked with its onset. Some of these factors include:
- High stress
- Poor social support
- Mood issues
- Trauma or traumatic grief
- Being female
- Serving as a caregiver to the deceased prior to death
Signs and Symptoms of Persistent Complex Bereavement Disorder
Symptoms of persistent complex bereavement disorder typically begin soon after the death of a loved one, but it may take several months or years for the full syndrome to appear. Common symptoms of PCBD include:
- Intense sadness or distress that does not improve as time passes
- Continual yearning for the deceased person
- Difficulty trusting other people
- Digestive issues
- Constantly ruminating on the death
- Emptiness
- Inability to perform daily activities
- Loss of interest in hobbies
- Fatigue
- Hallucinations of the deceased
- Loneliness
- Suicidal ideation
Although people with normal grief may have similar symptoms, individuals with PCBD experience symptoms for a much longer period of time.
What are the Common Behaviors/Characteristics?
People with persistent complex bereavement disorder typically have a lower quality of life, poor work or academic performance, impaired social functioning, as well as increased alcohol and tobacco use. They are at higher risk of medical conditions such as cancer, heart disease, immunological deficiencies, and hypertension. Suicidal ideation is a common symptom. Many individuals with PCBD express frustration with life and a desire to join the deceased.
Testing: What are the Diagnostic Criteria Per the DSM 5?
Persistent complex bereavement disorder is a relatively new mental health issue and the DSM-5 identifies it as a condition for further study. The following criteria must be met for a diagnosis of PCBD:
- The individual experienced the death of someone with whom he or she had a close relationship.
- Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
- Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure.
- Intense sorrow and emotional pain in response to the death.
- Preoccupation with the deceased.
- Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.
- Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: Reactive distress to the death
- Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death.
- Experiencing disbelief or emotional numbness over the loss.
- Difficulty with positive reminiscing about the deceased.
- Bitterness or anger related to the loss.
- Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame).
- Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased).
Social/identity disruption
- A desire to die in order to be with the deceased.
- Difficulty trusting other individuals since the death.
- Feeling alone or detached from other individuals since the death.
- Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased.
- Confusion about one’s role in life, or a diminished sense of one’s identity (e.g., feeling that a part of oneself died with the deceased).
- Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities).
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms.
Persistent Complex Bereavement Disorder and Other Conditions
Persistent complex bereavement disorder may coexist with trauma-related issues, anxiety disorders, depressive disorders, and substance use disorders. Some symptoms of PCBD may also characterize other mental health conditions. It is important to remember that a grief response does not necessarily signal poor mental health. Even individuals with good mental health may show symptoms of PCBD when they are grieving.
Persistent Complex Bereavement Disorder vs Normal Grief
Individuals may go through a bereavement process after losing a loved one in death. Although grieving people have similar symptoms to PCBD, normal grief is not a mental health disorder. Individuals with normal grief tend to improve their emotional regulation and adjust to the loss of a loved one as time passes. Even so, individuals with normal grief may benefit from therapy.
Persistent complex bereavement disorder is a serious mental health issue. People with PCBD experience severe grief symptoms that interfere with their ability to function long after the death of a loved one. They are often unable to accept the loss and are stuck in the grieving process for at least 12 months. Some individuals with PCBD report not wanting to move on from bereavement because they feel they would be betraying the deceased.
Persistent Complex Bereavement Disorder vs Complicated Grief
Persistent complex bereavement disorder and complicated grief refer to the same syndrome of clinically impairing grief. While the condition is called “persistent complex bereavement disorder” in the DSM-5, it is called “complicated grief” in the DSM-IV.
The DSM-5 and DSM-IV have similar criteria for diagnosing clinically impairing grief. The primary differences are the time required for a diagnosis (12 months for PCBD versus 6 months for complicated grief) as well as the type and number of symptoms required for criteria B and C.
Recent research suggests DSM-5 proposed criteria for identifying clinically impairing grief may need to be adjusted. In a study with bereaved military family members, the DSM-5 criteria for persistent complex bereavement disorder excluded 99% of non-clinical cases but only identified 53% of clinical cases. By comparison, the DSM-IV criteria for complicated grief excluded 98% of non-clinical cases and accurately identified more than 90% of clinical cases.
Related Conditions
The symptoms that characterize persistent complex bereavement disorder are also associated with many other mental health issues. Conditions that have similar symptoms include:
- Posttraumatic stress disorder (intrusive thoughts, traumatic grief)
- Separation anxiety disorder (anxiety when separated from the deceased)
- Major depression (low mood)
Persistent Complex Bereavement Disorder In Adults/Children
Persistent complex bereavement disorder affects people of all ages. Symptoms may appear shortly after the death of a close family member or friend, however, a diagnosis is not made unless symptoms continue for at least 12 months. Children may be diagnosed with PCBD if symptoms persist beyond 6 months.
Cultural Considerations
Many symptoms of persistent complex bereavement disorder are seen across different cultures. However, the condition has not been extensively studied in socioculturally diverse populations. Some individuals may display grief responses that are specific to their cultural setting. For example, some non-Western cultures may have mourning rituals or other specific events that are a part of the grief process.
Some components of the diagnostic criteria for PCBD may need to be adjusted for use in non-Western settings. A diagnosis of PCBD may be given if symptoms are severe, persistent, and go beyond the cultural norm.
Example Case of Persistent Complex Bereavement Disorder
Peter, 29, tells his therapist that since his wife committed suicide 15 months ago, he has been unable to function. He thinks about her every day and believes she would still be alive if he had not told her he felt trapped in their marriage. Peter explains that he feels angry, guilty, alone, confused, and unmotivated on most days. For the past year, he has been unable to go to work and avoids his family and friends. He has seriously considered committing suicide so he can be with his wife again. After their discussion, the therapist diagnoses Peter with persistent complex bereavement disorder and prescribes a combination of psychotherapy and antidepressant medication. After 6 months of weekly sessions, Peter reports improved functioning, increased social activity, and a brighter hope for the future.
How to Deal/Coping With Persistent Complex Bereavement Disorder
If you have persistent complex bereavement disorder, there are several steps you can take to cope with the condition. You can:
- Stick to your treatment plan
- Exercise regularly
- Eat healthy food and get enough rest
- Stay connected with family and friends
- Find healthy ways to relieve stress
- Get involved in spiritual activities
- Join a support group
- Plan ahead for anniversaries or special dates that may remind you of the deceased
- Learn new skills to care for your needs
Look out for These Complications/Risk Factors
A number of risk factors have been linked with the onset of persistent complex bereavement disorder. Individuals with controlling parents, a history of abuse during childhood, a first-degree relationship to the deceased, mood issues, chronic stress, or an emotional dependency on the deceased may be at higher risk of developing the condition.
Persistent Complex Bereavement Disorder Treatment
There is no specific cure for persistent complex bereavement disorder. However, there are clinically-proven methods that may help to alleviate symptoms and get your life back on track. Healthcare professionals may recommend cognitive behavioral therapy, medication, or a combination of both approaches. Individuals who stick to their treatment plan may find that their condition improves over time.
Possible Medications for Persistent Complex Bereavement Disorder
Antidepressant medications called serotonin reuptake inhibitors may be prescribed to help manage symptoms of PCBD.
Home Remedies to help Persistent Complex Bereavement Disorder
There are no FDA-approved home remedies that treat PCBD.
Living with Persistent Complex Bereavement Disorder
If you have been diagnosed with persistent complex bereavement disorder, your mood, functioning, and relationships may be affected. You may have a desire to surround yourself with your loved one’s possessions to feel closer to him or her. Alternatively, you may avoid places, people, or things that remind you of the deceased. You may also begin to resent other people who have not experienced a similar loss.
There may be occasions when you believe you hear or see the deceased. A persistent desire to be with your loved one may cause you to feel depressed. This low mood may impact your ability to work, go to school, maintain your relationships, or handle your personal responsibilities. You may also have thoughts of committing suicide.
Remaining physically active and staying in contact with family and friends are effective ways to combat the low moods associated with PCBD. It is also vital that you keep your therapeutic appointments and cooperate with your treatment plan.
Insurance Coverage for Persistent Complex Bereavement Disorder
The DSM 5 classifies persistent complex bereavement disorder as a condition that merits further study. However, your insurance plan may provide coverage for this mental health issue. Contact your insurance provider to confirm your coverage and obtain any authorization you may need before you visit your healthcare provider.
How to Find a Therapist
Speak with your doctor if you have grief symptoms that last for a long time and impair your ability to function. Your doctor will refer you to a licensed mental health professional who can provide the help you need.
What Should I be Looking for in an LMHP?
Therapists are trained to help people with conditions such as persistent complex bereavement disorder. Ask your therapist about his/her experience in bereavement care and in treating PCBD during your initial meeting. Other important qualities to look for include:
- Empathy
- Strong communication skills
- Good listening skills
- Warmth
- Positivity
If you do not feel comfortable with your therapist, it may be best to ask for a referral.
Questions to Ask a Potential Therapist
Here are a few questions you can ask your therapist:
- Do you have experience helping with the bereavement process?
- Am I experiencing normal grief?
- Is PCBD a lifelong condition?
- Are there any co-occurring issues?
- What treatment do you recommend?
- Do I need to take any medications?
- What are the side-effects?
- How long does treatment last?
- Is there anything I can do to help myself?
Persistent Complex Bereavement Disorder Resources and Support Helpline
Individuals with persistent complex bereavement disorder may consider suicide. If you have regular thoughts of suicide, speak with someone you trust. If you believe you may act on suicidal feelings, please call any of the following numbers immediately:
- 911 or your local emergency services number
- The National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) to speak with a trained therapist
- Suicide Prevention Services Crisis Hotline at 800-784-2433
- Suicide Prevention Services Depression Hotline at 630-482-9696
Coping with the death of a loved one is extremely difficult. Whether you are experiencing a normal grief process or persistent complex bereavement disorder, help is available! Take advantage of the mental health resources in your community. With professional care, you can overcome your grief, move forward, and find real joy in your life again.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Cozza, S. J., Fisher, J. E., Mauro, C., Zhou, J., Ortiz, C. D., Skritskaya, N., . . . Shear, M. K. (2016). Performance of DSM-5 Persistent Complex Bereavement Disorder Criteria in a Community Sample of Bereaved Military Family Members. American Journal of Psychiatry, 173(9), 919-929. doi:10.1176/appi.ajp.2016.15111442.
Fleming, K. (2018). Persistent complex bereavement disorder. Retrieved from https://www.theravive.com/therapedia/persistent-complex-bereavement-disorder-dsm–5
Kerkar, P. (2018, April 2). Treatment for persistent complex bereavement disorder or complicated grief disorder. Retrieved from https://www.epainassist.com/mental-health/treatment-for-persistent-complex-bereavement-disorder-or-complicated-grief-disorder
Kim, J., Tol, W. A., Shrestha, A., Kafle, H. M., Rayamajhi, R., Luitel, N. P., . . . Surkan, P. J. (2017). Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows. Psychiatry, 80(1), 1-16. doi:10.1080/00332747.2016.1213560
