December 2025: Prolonged Grief Disorder and the Complexities of Bereavement

William G. Hoy

As the debate has continued to heat up over the diagnostic label of prolonged grief disorder and its predecessor label, complicated grief , clinicians and scholars alike have grappled with how best to describe the phenomenon. That some bereavement becomes—and remains—functionally debilitating over a long period of time is without question. Anyone who has worked with bereaved individuals long enough has seen cases of bereaved individuals who apparently “got stuck,” although determining the best places to draw a definitive line between “disordered” and “normal” has perplexed bereavement researchers for decades. 

The codification of prolonged grief disorder (PGD) into the Diagnostic and Statistical Manual of Mental Disorders, as well as the more vague diagnosis of the same label in the medical field’s International Classification of Disease has not solved the problem of language or clinical utility. Contrary to much of the press and the apparent “settledness” of the argument in the diagnostic manuals, many clinicians simply are not buying the concept. I am among those who accept that some grief is disordered, but generally object to both the diagnostic name and much of the diagnostic criteria on the basis of its in-applicability to clinical practice.

Throughout much of the debate about prolonged grief, I have been drawn to the simple concept I believe I first heard from my colleague, Dale Larson, who asks two questions: “Are you having trouble with your grief,” and if the answer is affirmative, “Would you like some help with that?” As a clinician, I will ask the bereaved individual to describe for me an expanded explanation of their answers to those questions. However, anything beyond that is likely unnecessary except for epidemiological (population-wide) research studies or for a criteria whereby one can bill private insurance or Medicare. The not-very-quiet negative published reaction to the diagnostic criteria by clinical scholars who have deep experience counseling bereaved individuals indicate the matter is far from settled (Eisma, 2023, Haneveld, et.al., 2022, Schuurman, 2022, Wakefield, 2012).

As I point out in the research-to-practice review below, there has been much ink spilled on this concept; some would say I have been one of the great “spillers of ink!” Though there are many cases I could report, one that caused me great angst was the woman who I screened to join a bereavement group last spring. Her husband of 60+ years, she reported to me, had died about seven months earlier. When the widow cried in the office of her family physician, the young doctor told the new widow that she suffered

from prolonged grief disorder. Of course, the physician was mostly correct in her diagnostic labeling since the physician’s coding manual ( International Classification of Disease ) does permit the diagnosis of PGD at six months-post loss. Since it had been more than six months since this widow’s husband died and, at least in that moment, she demonstrated tearfulness in the doctor’s office (How dare she!), the physician did what physicians too often do: she got way out of her lane of clinical expertise and told this bereaved woman, essentially, she should now be “over it.” I am so glad she found our group.

Those who have followed my work know that my preference is to think of grief, not as a process of recovery , but rather of integration , a process of enfolding the experiences of loss into the rest of one’s life. We do not “get over” our losses; we learn to live in their light. In my own four decades of clinical experience and in interacting with colleagues and their research, over the last 20 years or so, I have defined what I think are three “constellations,” if you will, of factors that can make bereavement more complex. Of course, I am deeply reliant on the work of my colleague and friend, J. William Worden in his discussion of the seven “mediators of mourning (Worden, 2018, pp. 59-76).

I label these three constellations as situation (the circumstances of the death and the position of the bereaved); support (what systems are in place to help the bereaved find their way); and selfhood (the background and history—mental health and all—that the bereaved bring to the mourning process). Like the diagram indicates, these overlap and contribute to one another in the process. For example, a person diagnosed with borderline personality disorder predating the death has likely alienated much of her support system, long before needing those family members and friends in the grief process.

In the months of January through March in this column, I plan to unpack some of the factors that I find potentially make grief more complex. Just like smoking does not predict lung cancer, the presence of these factors does not predict some kind of disordered bereavement; the presence of these factors just increase the risk that grief will be more difficult to navigate and integrate into the rest of life. 

References.

Eisma, M. C. (2023). Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Australian and New Zealand Journal of Psychiatry , 57 (7), 944–951. https://doi.org/10.1177/00048674231154206

Haneveld, J., Rosner, R., Vogel, A., Kersting, A., Rief, W., Steil, R., & Comtesse, H. (2022). Same name, same content? Evaluation of DSM-5-TR and ICD-11 prolonged grief criteria. Journal of Consulting and Clinical Psychology , 90 (4), 303–313. https://doi.org/10.1037/ccp0000720

Schuurman, D. (2022). The grief pill is coming. Mad in America (5 April 2022). https://www.madinamerica.com/2022/04/grief-pill-coming/

Wakefield, J. C. (2012). Should prolonged grief be reclassified as a mental disorder in DSM-5?: Reconsidering the empirical and conceptual arguments for complicated grief disorder. The Journal of Nervous and Mental Disease , 200 (6), 499–511. https://doi.org/10.1097/NMD.0b013e3182482155

Worden, J.W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner, 5th ed. Springer.

The Author: For the last 40 years, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide more effective care. After more than 17 years in hospice care, he served as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas from 2012 to 2024. In his semi-retirement, he continues to write and provide resources and training seminars to colleagues who care for the bereaved. He can be reached at Bill_Hoy@baylor.edu.

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BRIDGING RESEARCH AND PRACTICE

Thieleman, K., Cacciatore, J., & Mangiapane, V. (2025). “I would feel misunderstood and diminished:” Perceived helpfulness of a grief diagnosis among grievers, Death Studies, EPub ahead of print (12 December 2025). https://doi.org/10.1080/07481187.2025.2598316

Much ink has been spilled, both in the popular press and among scholarly journals in the bereavement field, over the diagnosis of prolonged grief disorder. While PGD has been codified into the Diagnostic & Statistical Manual of Mental Disorders ( DSM-5.TR) and the World Health Organization’s International Classification of Disease (ICD-11), many clinicians have significant misgivings about the diagnosis in general, and specifically, in the non-nuanced ways it is being utilized. Any diagnosis in the medical record can follow a patient for life, effectively disqualifying them from many services. If unsure of that claim, try getting long-term care insurance after a head injury or having a diagnosis, of say major depressive disorder or PTSD removed from your clinical record!

One “selling point” for the new diagnostic category has been the implied benefit to individuals exhibiting symptoms that meet the PGD criteria would be “relieved” to finally have a name to describe their experience. Those of us who work with large numbers of bereaved people have often doubted that wisdom since we have rarely found our own patients to be “comforted” by diagnostic language that suggest, in some ways, their bereavement is “disordered.”

To that end, the authors of the current study who are clinician/researchers at Arizona State University, one of the nation’s leading bereavement clinical research programs, undertook a study that enrolled 755 respondents (91% female and 89% white). Interestingly, one of the criticisms of research leading to the PGD diagnostic criteria was its lack of cross-cultural sensitivity, and this study nearly replicated the respondents of many studies from which have emerged the hypothetical idea that “a diagnosis is helpful.”

In the present study, 36% met the criteria for prolonged grief disorder with 44% indicating some functional impairment in life as a result of their loss. Yet, when asked if they felt their experiences were “understandable and normal,” an astounding 98% responded “Yes.” Of those meeting the PGD criteria, when asked if told by a mental health professional that their grief was a mental disorder, 68.2% reported it would not be helpful, 13.4% reported it would be helpful, and 18.4% indicated they were unsure. Even among people who meet the broad criteria for PGD, a small subset indicates a diagnostic label would be helpful.  

Researchers then inquired in their survey, ““Can you say more about why you answered that way?” and responses ranged from one to 213 words (p. 4). Researchers summarized the responses:

“In this context, receiving a grief-related diagnosis was generally viewed unfavorably: ‘Having a mental

disorder would imply that my grief differs from what is normal.’ This view was widely shared.” The researchers continued, “Throughout the data, respondents reiterated the idea that grief is ‘normal, expected, and part of being human,’ resisting the idea of classifying even intense grief as a disorder: ‘It’s not a disorder. I wasn’t mentally ill before my child’s death. I’m not mentally ill afterwards. Just heartbroken,’” in the words of one bereaved parent (pp. 4-5).

While diagnostic labels might be useful in some contexts (especially for epidemiological/population-wide research and for insurance billing purposes), diagnostic language may or may not contribute to better treatment decisions. Differentiating between bereavement, major depression, trauma disorders, and generalized anxiety is a vital skill. However, on the basis of both this study and much clinical wisdom, caregiving professionals are well-advised to be very careful with the use of diagnostic language that implies that normal bereavement, even when extraordinarily painful and even functionally debilitating, is actually a mental health disorder.

BOOKSHELF

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Gilats, A. (2022). After effects: A memoir of complicated grief . University of Minnesota Press.

Reviewed by Molly A. Keating, MA, CT
Editor,  GriefPerspectives

This memoir aims to offer an in-depth illustration of life stuck inside a complicated grief disorder. Andrea Gilats writes about the loss of her husband in 1998 after a brief, 5-month battle with cancer. She contrasts her grief journey with a friend and colleague that lost her husband to cancer just 3 months prior. It wasn’t until nearly 20 years later when Andrea looked back at letters she wrote to her deceased husband that she could clearly see the differences in their trajectories, experiences, and outcomes.
 
Gilats cites Dr. Katherine Shear, the founder and director of Columbia University’s Center for Complicated Grief, and says that in Dr. Shear’s work she finally recognized herself and her unique bereavement experience. While Gilats believes experiences like hers to be much more common that the literature would hint, it seems important to consider our insights from Dr. Hoy who, I think,  would caution us away from considering her experience is in any way usual.
 
This memoir is offered here to showcase a self-declared experience of “complicated grief.” Gilats describes writing letters to her husband daily for over 2 years. While there is nothing at all odd or wrong about continuing a relationship with our deceased loved ones (see book Continuing Bonds by Klass, Silverman and Nickman), Gilats writes that she was trying to “[sustain] our marriage by writing him daily letters.” Someone attempting to sustain a marriage when the spouse has died is very different than someone trying to remain connected to the spirit and presence of their departed loved one. Her language, honesty, and reflection offer many examples of what life stuck in “complicated grief” might look like. In her examples we see someone experience grief but not in a productive mode. Her acts and rituals do not move her forward because she is, in fact, trying to remain where she was before the death.

Her story does end in hope as she shares at last arriving at a moment of accepting and reconciling herself to a life of her own that could be lived without her husband. Gilats' story is unique and unlike other grief memoirs that follow more typical bereavement expectations. 

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