What Is Prolonged Grief Disorder? DSM-5-TR Criteria, Diagnosis & Treatment

Last updated: April 2026 · 10 min read

In March 2022, Prolonged Grief Disorder (PGD) was formally added to the DSM-5-TR — making it one of the most significant changes to the bereavement landscape in decades. For clinicians working with bereaved clients, understanding what PGD is, how to identify it, and how it differs from other grief presentations is now a core clinical competency rather than a specialist interest.

This article provides a clinical overview: the DSM-5-TR diagnostic criteria, how PGD differs from major depression and PTSD, who is at risk, what the evidence base says about treatment, and what clinicians need to know when working with a client who may meet criteria.

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What Is Prolonged Grief Disorder?

Prolonged Grief Disorder is a clinical condition characterised by an intense, persistent grief response that significantly impairs daily functioning and does not follow the expected trajectory of bereavement. It is not simply grief that lasts a long time — it is grief that has become clinically stuck, with specific features that distinguish it from normative bereavement and from other mental health conditions.

The core clinical picture involves intense yearning and longing for the deceased that does not diminish over time, difficulty accepting the reality of the loss, and a pervasive sense that life is meaningless or empty without the person who died. Unlike the fluctuating emotional landscape of normal grief — where periods of intense sadness alternate with periods of relative functioning — PGD is characterised by a persistent, unremitting quality that progressively impairs the client's capacity to engage with their life.

PGD was previously discussed in the literature under several terms — complicated grief, prolonged grief, traumatic grief, and pathological grief — and the absence of formal diagnostic criteria created significant inconsistency in research and clinical practice. The DSM-5-TR addition provides a standardised framework for the first time, though debate about the criteria and thresholds continues in the field.

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DSM-5-TR Diagnostic Criteria

The DSM-5-TR criteria for Prolonged Grief Disorder (309.89) require the following:

Criterion A — Bereavement

The death of someone close to the individual (a person with whom the bereaved had a close relationship).

Criterion B — Yearning or preoccupation

Since the death, at least one of the following is present on most days to a clinically significant degree:

• Intense yearning or longing for the deceased
• Preoccupation with thoughts or memories of the deceased (in children and adolescents, this may focus on the circumstances of the death)

Criterion C — Reactive distress

Since the death, at least three of the following symptoms are present on most days to a clinically significant degree:

• Identity disruption — a sense that part of oneself has died with the deceased
• Marked sense of disbelief about the death
• Avoidance of reminders that the person is dead
• Intense emotional pain related to the death — anger, bitterness, or sorrow
• Difficulty reintegrating into relationships and activities since the death
• Emotional numbness — absence of emotion or markedly diminished emotional experience
• Feeling that life is meaningless or empty without the deceased
• Intense loneliness — feeling alone or detached from others

Criterion D — Duration

The disturbance has persisted for an abnormally long period after the bereavement, clearly exceeding expected social, cultural, or religious norms for the individual's context. For adults, this is typically at least 12 months. For children and adolescents, the threshold is at least 6 months.

Criterion E — Functional impairment

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion F — Not better explained by another condition

The bereavement reaction is not better explained by major depressive disorder, PTSD, or another mental disorder, and is not attributable to the physiological effects of a substance or another medical condition.

Clinical note: The DSM-5-TR explicitly notes that the diagnosis requires clinical judgement about what constitutes an "abnormally long" grief response relative to the individual's cultural, religious, and social context. The criteria are not intended as a mechanical checklist — they require integration with a comprehensive clinical assessment. (American Psychiatric Association, 2022)

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Prevalence and Risk Factors

Prevalence

Estimates of PGD prevalence vary depending on the population studied and the criteria applied. The most widely cited figures suggest PGD affects approximately 9–10% of bereaved individuals in the general population, with significantly higher rates in specific populations — including those who have lost a child (up to 30%), those bereaved by suicide or homicide (up to 25%), and those bereaved following sudden or traumatic deaths.

It is more common in women than men, and more common in older adults than younger adults, though it can occur at any age. In clinical settings — where bereaved individuals are more likely to seek help — prevalence rates are substantially higher than in community samples.

Risk factors

Research has identified several factors associated with elevated risk of PGD following bereavement:

Loss-related risk factors:

• Sudden, unexpected, or traumatic death (accident, suicide, homicide, sudden cardiac event)
• Death of a child at any age
• Loss of a spouse or life partner
• Violent or stigmatised deaths
• Deaths where the bereaved was present and witnessed traumatic circumstances
• Multiple or concurrent losses

Individual risk factors:

• Anxious or dependent attachment style
• History of previous mental health difficulties, particularly depression or anxiety
• Previous unresolved losses
• Low social support or social isolation
• High dependency on or enmeshment with the deceased
• History of trauma or adverse childhood experiences

Contextual risk factors:

• Inability to be present at the death or funeral (common during COVID-19 bereavement)
• Ongoing practical stressors following the loss — financial hardship, legal complications, childcare demands
• Disenfranchised grief — a loss that is not socially recognised or validated
• Cultural or family environments that discourage open grieving

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Differential Diagnosis: PGD, Major Depression, and PTSD

One of the most clinically important aspects of the PGD diagnosis is distinguishing it from major depressive disorder and PTSD — conditions with which it commonly co-occurs but which require different treatment emphases.

PGD vs. Major Depressive Disorder

PGD and major depression share several features — low mood, social withdrawal, impaired functioning, sleep disturbance, loss of interest in activities. The key clinical distinctions are:

• Focus of distress. In PGD, the client's distress is organised around the loss and the deceased — yearning, preoccupation, separation distress. In MDD, distress is more pervasive and not specifically anchored to the loss.
• Relationship to the deceased. Clients with PGD often report that they can experience pleasure in activities that connect them to the deceased, or that involve others who share the loss. In MDD, anhedonia tends to be more generalised.
• Yearning and preoccupation. Intense yearning for the specific deceased person is the hallmark feature of PGD and is not a criterion for MDD.
• Response to treatment. Antidepressant medication tends to produce a partial response in PGD — it may reduce the depressive symptoms without significantly affecting the grief-specific features. This partial response can be a diagnostic indicator.

Importantly, PGD and MDD frequently co-occur. A client can meet criteria for both — and often does. The co-occurrence does not invalidate either diagnosis, but it does require attention to both in treatment planning.

PGD vs. Post-Traumatic Stress Disorder

When bereavement follows a traumatic death — sudden, violent, or witnessed — PGD and PTSD may co-occur and can be difficult to distinguish. Key distinctions:

• Nature of intrusions. In PTSD, intrusive symptoms typically involve distressing re-experiencing of the traumatic event — flashbacks, nightmares, sensory intrusions. In PGD, intrusions are more commonly positive memories or yearning-based — the client wants to think about the deceased and may actively seek memories, even as this intensifies their grief.
• Avoidance pattern. PTSD avoidance tends to target trauma-related cues. PGD avoidance tends to target reminders of the death itself — confirmation of the reality of the loss.
• Core emotional experience. The dominant affective experience in PGD is grief, longing, and separation distress. In PTSD it is fear, horror, or shame related to the traumatic event.

When traumatic death has occurred and both presentations are present, treatment typically needs to address PTSD first — stabilisation and trauma processing before grief-focused work — as grief processing in the presence of unaddressed trauma can be destabilising.

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Evidence-Based Treatment for Prolonged Grief Disorder

General grief support and bereavement counselling are not sufficient for clients who meet criteria for PGD. The evidence base points clearly toward specific, structured interventions.

Complicated Grief Treatment (CGT)

Developed by Katherine Shear and colleagues at Columbia University, Complicated Grief Treatment is the most extensively researched intervention for PGD. It integrates elements of interpersonal therapy, motivational interviewing, and exposure-based techniques in a structured 16-session protocol.

CGT has two primary components:

• Loss-focused work — directly addressing the grief through revisiting exercises (structured imaginal exposure to the circumstances of the death), working through complicated aspects of the relationship, and processing stuck points
• Restoration-focused work — addressing the secondary consequences of the loss, setting personal goals, rebuilding engagement with life, and strengthening relationships

Randomised controlled trials have consistently shown CGT to produce better outcomes than standard interpersonal therapy for PGD, with response rates of approximately 70% in intent-to-treat analyses. (Shear et al., 2005; 2016)

CBT for Complicated Grief

Paul Boelen and colleagues developed a CBT model for complicated grief that targets three maintaining mechanisms identified in their research: insufficient integration of the loss into autobiographical memory, negative global beliefs (about the self, the world, and the future without the deceased), and anxious and depressive avoidance.

The treatment involves cognitive restructuring of grief-specific distortions, graduated approach to avoided situations and memories, and narrative processing of the loss. It has demonstrated efficacy in multiple RCTs and is well-suited to clinicians already working within a CBT framework. (Boelen, de Keijser & van den Hout, 2011)

Pharmacological Treatment

The evidence base for pharmacological treatment of PGD is limited relative to psychotherapy. Antidepressants — particularly SSRIs — may reduce co-occurring depression and anxiety, but do not appear to significantly affect the core grief-specific features of PGD. Citalopram has been studied in combination with CGT, with the combination showing no advantage over CGT alone. (Shear et al., 2016)

Current clinical consensus is that psychotherapy should be the primary treatment for PGD, with pharmacological support considered for significant co-occurring depression, anxiety, or sleep disturbance rather than as a standalone intervention for grief.

Group-Based Interventions

Group formats for PGD treatment have been studied with promising results, particularly for populations with shared loss characteristics — parents bereaved by child death, suicide loss survivors, or those bereaved in mass casualty events. The combination of structured psychoeducation and peer support in a group setting addresses both the clinical and social isolation dimensions of PGD.

The evidence base for PGD treatment is still developing, and access to CGT-trained clinicians remains limited in many regions including Australia. Clinicians without specific CGT training working with a suspected PGD presentation should seek supervision from a clinician experienced in complicated grief work, and should consider whether referral is appropriate. (Currier, Holland & Neimeyer, 2010)

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Clinical Considerations for Australian Practitioners

A few considerations particularly relevant to clinicians working in the Australian context:

CGT training and access. Formal training in Complicated Grief Treatment is limited in Australia. Clinicians working with complex bereavement presentations may find it useful to seek supervision from practitioners trained in CGT or the Boelen CBT model, or to access training through institutions offering online CGT programmes.

Medicare and NDIS pathways. Bereavement-related presentations are eligible for Medicare Better Access sessions under relevant MBS item numbers where they meet diagnostic criteria. Clients who meet PGD criteria have a formal DSM-5-TR diagnosis that supports mental health care plan referrals. Clinicians should ensure their referral documentation reflects the diagnosis accurately where appropriate.

Cultural considerations. Australia's diverse population means that grief presentations are shaped by a wide range of cultural, religious, and community contexts. Mourning practices, beliefs about death, timelines for grieving, and the role of community in bereavement vary significantly. The DSM-5-TR criteria explicitly acknowledge this — the "abnormally long" duration criterion is assessed relative to the individual's cultural context, not a universal norm. First Nations bereavement, in particular, often involves collective grief, community loss, and cultural mourning practices that require culturally safe and responsive clinical approaches.

COVID-19 bereavement. A significant number of clients presenting with grief-related difficulties in recent years were bereaved during the COVID-19 period — often under conditions that significantly elevated PGD risk: inability to be present at the death, restricted or absent funerals, disrupted social support, and in some cases, traumatic circumstances of death. This cohort warrants careful assessment.

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What This Means in Practice

For most clinicians, the practical implications of the PGD diagnosis come down to three things:

Know the criteria. Familiarity with the DSM-5-TR criteria means you can identify when a grief presentation has moved into clinical complication — and when general bereavement support is no longer sufficient.

Assess systematically. A structured approach to grief assessment — covering the nature of the loss, the relationship, current functioning, duration, and specific PGD features — gives you the clinical picture you need to make good treatment decisions. This is where structured worksheets serve a genuine clinical function: a PGD check-in tool creates a consistent assessment framework and generates material for clinical discussion.

Know your limits. General grief counselling training does not prepare clinicians for PGD treatment. If you are working with a client who meets or approaches criteria, seeking supervision or considering referral to a clinician with specific complicated grief training is the appropriate clinical response.

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Resources for Clinicians

• Grief & Loss Worksheet Bundle — 20 done-for-you worksheets across five clinical phases, including the Prolonged Grief Check-In tool
• Best Grief Counselling Worksheets for Therapists — curated guide to grief tools across all frameworks
• How to Support Clients Through Grief: A Therapist's Clinical Guide — full clinical arc from assessment to rebuilding
• Best Therapy Worksheets for Therapists — Done-For-You — broader resource guide across modalities