Prolonged Grief Disorder (PGD)

🧠 Overview 

Prolonged Grief Disorder (PGD) is an emotional and psychological condition that occurs after the loss of a loved one in which “grief and yearning” persist intensely for a period longer than what society or culture generally considers “appropriate” — to the point that it begins to interfere with functioning, daily life, and the capacity to create new meaning in one’s continuing life.

Unlike normal bereavement, where sadness and longing gradually diminish over time, PGD continues in a “stuck” fashion, as if the brain cannot fully process the loss. People in this state often feel as if they are trapped in the moment their loved one died, unable to accept the reality or move forward, even though months or years have passed.

DSM-5-TR (2022) formally included PGD, specifying a time criterion of at least 12 months in adults and 6 months in children/adolescents after the loss of a significant person. The individual must have at least one core symptom, such as yearning or preoccupation with the deceased, plus at least three additional symptoms, such as emotional numbness, avoidance of reminders of the deceased, loss of meaning in life, or inability to return to previously enjoyed activities.

In practice, people with PGD often manifest deep grief that does not subside with time — for example, crying when speaking of the deceased, feeling as though a part of themselves died as well, or persistently maintaining the deceased’s possessions, memories, and routines without being able to let go. The longing becomes so preoccupying that it obstructs adaptation to the “new reality.”

From a sociocultural perspective, this condition must be evaluated carefully, because the “duration of mourning” and “expressions of grief” differ across countries and religions. For instance, some cultures view keeping a deceased person’s belongings as normal, whereas others may see it as a sign of non-acceptance of the loss. Clinicians should therefore interpret PGD symptoms within an appropriate cultural context.

ICD-11 (World Health Organization, 2022) uses similar criteria but a shorter duration of at least 6 months, emphasizing diagnosis when grief is “prolonged beyond what is expected in the sociocultural context,” together with intense emotional pain and functional impairment (e.g., inability to work or socialize as usual).

Overall, global research indicates that approximately 4–15% of bereaved individuals develop PGD — especially those who experience sudden or violent losses, or the loss of a child or partner. This group typically needs targeted therapy rather than “letting time heal,” because waiting without care can significantly increase the likelihood of depression, anxiety, or self-harm risk.

In summary, Prolonged Grief Disorder is not merely “sadness that lasts longer than usual,” but rather a stuck state of the attachment circuit in which the brain cannot naturally “recode the loss.” Treatment therefore focuses on helping the brain learn acceptance, construct new meaning, and return to living fully again.

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💔 Core Symptoms (Core symptoms of Prolonged Grief Disorder)

The primary symptoms of Prolonged Grief Disorder (PGD) are not just ordinary “sadness,” but a stuck state of the attachment–loss circuit in which the brain cannot fully “disconnect” the link between the self and the person who was lost. These symptoms reflect both profound emotional pain and dysregulation of the psychological adaptation system.

1. Yearning and Preoccupation

These are the heart of PGD — the bereaved feel “heart-aching longing” or an intense desire to be with the deceased. This feeling often does not diminish with time but remains persistent or recurs frequently, even after many months or years.

Examples: needing to hear the voice, smell the scent, or see the face again; feeling as if the deceased is still in the house; talking regularly to photos/possessions of the deceased.

2. Disbelief / Shock

Even as time passes, the brain cannot “confirm the reality” of the loss. The person may feel as if what happened was a nightmare or is still “waiting for them to come back.” This relates to dysregulation in the hippocampus and medial prefrontal cortex, which are involved in contextual memory processing and accepting events.

3. Identity Disruption

The bereaved often feel as if they “lost a part of themselves,” especially when the relationship formed a core part of identity (e.g., “I don’t know who I am without them”). This is common after the loss of a partner, child, or someone who shaped the person’s identity directly.

4. Intense Emotional Pain

Sadness, anger, bitterness, or guilt persist intensely. The person may cry daily, blame themselves for “not being able to save them,” or feel that “life should not go on.” This pain is not only outwardly expressed; it can also manifest physically as chest tightness, fatigue, or chronic aches.

5. Avoidance of Reminders of the Deceased

Some choose to “escape” cues that trigger memories of the deceased — avoiding the same room, places they went together, songs, or mutual acquaintances. Avoidance may reduce pain temporarily but prevents the brain from learning acceptance and adapting to reality.

6. Emotional Numbness

Some gradually lose the capacity to feel emotions at all — feeling “hollow-hearted” or that “everything is empty.” This is a defensive mechanism against pain, but when prolonged it becomes emotional detachment, which hinders forming new connections.

7. Difficulty Reintegrating into Ordinary Life

The person may no longer be able to engage in previously enjoyable activities, work, or socialize. Life feels “stuck there,” with no goals or motivation to begin new things, even ones that were once deeply meaningful.

8. Intense Loneliness

Even when surrounded by others, the person often feels alone in the world. This loneliness is different from simply “being alone”; it reflects an absence of emotional bonding with others, a key factor maintaining symptoms.

9. Meaninglessness

The person may ask, “What is the purpose of the life I have left?” or feel that the world has no meaning anymore. This is linked to dysregulation of the ventromedial prefrontal cortex, which evaluates personal value and life goals.

Overall, these core symptoms persist beyond what society or culture considers normal and cause clear functional impairment in daily life — e.g., self-care, work, or social relationships.

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🩸 Diagnostic Criteria 

According to DSM-5-TR (American Psychiatric Association, 2022)
These criteria aim to distinguish PGD from normal mourning and major depression, and require all of the following components:

A. Loss of a loved one

The person has experienced the loss of someone with a strong emotional bond (e.g., partner, child, parent, or close friend).

B. Time since the loss

• Adults: at least 12 months
• Children and adolescents: at least 6 months

C. At least 1 core symptom (occurring nearly every day in the past month):

• Yearning — an intense longing/desire for the deceased to be present again
• Preoccupation — persistent, repetitive thoughts about the deceased or the death event

D. Additional symptoms (at least 3), occurring nearly every day in the past month:

• Disbelief that the person is truly gone
• Avoidance of reminders of the loss
• Intense emotional pain (sadness, anger, guilt)
• Emotional numbness
• Loss of meaning or life goals (meaninglessness)
• Feeling that life can no longer be enjoyable (life feels empty)
• Difficulty returning to daily life or engaging in important activities (difficulty reintegration)
• Feeling isolated or withdrawn from others (isolation, loneliness)
• Identity disruption (e.g., “I don’t know who I am anymore”)

E. The symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.

F. The symptoms persist beyond what is appropriate within the cultural/religious context and are not better explained by another mental disorder such as MDD, PTSD, or Adjustment Disorder.

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According to ICD-11 (World Health Organization, 2022)

WHO also defines PGD with a structure similar to DSM-5-TR but emphasizes contextualized cultural assessment and a shorter duration.

Key criteria:

• Loss of a loved one (close and emotionally significant)
• Intense longing for the deceased or preoccupation with the deceased

• Ongoing emotional pain such as:

  Intense sadness and yearning
• Self-blame or anger
• Non-acceptance/denial of the loss
• Loss of meaning in life / not knowing how to go on
• Duration at least 6 months
• Grief prolonged “beyond what is expected in the sociocultural context,” causing functional impairment in daily life

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💬 Clinical Notes

• DSM-5-TR emphasizes a symptom-based structure, suitable for health systems with intensive psychiatric frameworks.
• ICD-11 emphasizes contextualized criteria suitable for global public health systems that must accommodate diverse rituals, beliefs, and mourning styles.
• Both systems agree that PGD is distinct from Major Depressive Disorder (MDD): the core is not “pervasive sadness,” but yearning and non-acceptance of the loss.
• Diagnosis of PGD should be made by professionals who understand both the cultural context and the nature of the bereaved-deceased relationship, as these factors strongly influence symptom interpretation.

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Subtypes or Specifiers

(There are no standardized specifiers specific to PGD in DSM-5-TR — e.g., formal “with… features.” However, assessment should document contextual factors — such as sudden/violent loss, loss of a child/partner, culture/religion, and comorbidities — to guide care planning.) American Psychiatric Association

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🧬 Brain & Neurobiology

Prolonged Grief Disorder (PGD) is not only about emotions or behavior; it reflects neural mechanisms stuck in an attachment mode even though the target of attachment is gone. The brain shows a maladaptive reinforcement/reward loop, akin to mechanisms underlying addiction at a deep level.

1. Attachment–Reward Circuitry

Key circuits include the nucleus accumbens (NAc) and ventral tegmental area (VTA) — the dopaminergic core for reward and motivation.
In PGD, cues related to the deceased (images, voice, personal items) hyperactivate the NAc — as if the brain interprets “the hope of reunion” as a reward.
This increased dopamine signaling creates a reinforcement loop that sustains yearning and repetitive thinking, as if the brain refuses to learn that “meeting again” is impossible.

🔍 Research by O’Connor et al. (2020) found significantly heightened NAc responses to images of the deceased in PGD, whereas in normal bereavement the response diminishes over time.

2. Roles of Neurotransmitters

PGD is linked to dysregulation in several neurochemical systems governing bonding, soothing, and emotional pain:

• Dopamine: anticipation of reward; a stuck circuit keeps signaling “they might come back.”
• Oxytocin: the bonding hormone fluctuates markedly after significant loss, amplifying yearning/attachment.
• Endogenous opioids: normally reduce pain and create safety; in PGD, this system misfires, leaving the brain “in pain” from absence.
• Serotonin and GABA: imbalances may contribute to persistent anxiety and depressive tone.

Overall, the PGD brain “remembers” the attachment so deeply that processing keeps interpreting the relationship as “unfinished” — yearning results from repeated reward prediction error signaling.

3. Emotion–Memory Network

Three major components are dysregulated:

• Amygdala: hyperreactive to loss-related stimuli, maintaining strong emotional memories.
• Hippocampus: reduced contextual memory function prevents fully placing the event in the past — it feels as if it is still “happening now.”
• Medial Prefrontal Cortex (mPFC): normally inhibits the amygdala and updates reality; reduced function sustains non-acceptance.

🧩 In short: the PGD brain is “immersed in memory” and lacks mechanisms to close the attachment circuit.

4. Autonomic and Stress Responses

PGD is also associated with autonomic dysregulation:

• Elevated heart rate and cortisol (hyperarousal), similar to PTSD.
• Chronic stress weakens immunity and raises long-term risks for depression and cardiometabolic disease.

💡 Neuroscience Summary

PGD is being “stuck in the attachment loop,” where the brain fails to update that “the loved one is gone.” Dopamine–oxytocin–opioid loops keep operating as if the person still exists, and prefrontal control cannot fully sever the connection, resulting in enduring yearning, non-acceptance, and emotional pain.

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⚖️ Causes & Risk Factors

PGD emerges from the convergence of biological, psychological, social, and cultural factors that turn normal mourning into stuck grief.

1. Nature of the Loss

• Sudden or violent losses (e.g., accidents, homicide, suicide, pandemic) leave the brain unprepared, prolonging shock.
• Loss of a child or partner carries the highest risk because these are often core attachment figures.
• Not being present at the end or not saying goodbye (unresolved goodbye) deprives the brain of a “closure signal.”

2. Relationship Factors

• High dependence/codependence (e.g., “I can’t live without them”) increases PGD risk.
• Anxious or fearful-avoidant attachment styles show more prolonged grief than secure attachment.
• Pre-death conflict can create guilt and “unfinished business,” triggering ruminative loops.

3. Individual & Biological Factors

• Female sex: prevalence about 1.5–2× higher than males, possibly linked to emotional expression and social bonding sensitivity.
• Older age: higher risk due to multiple losses and reduced support networks.
• Perfectionistic/over-responsible traits: strong self-blame following loss.
• History of depression, anxiety, PTSD, or other psychiatric conditions: strong predictors of PGD.
• Biology: dysregulation of the HPA axis keeps the stress system “on.”

4. Social & Cultural Factors

• Lack of social support (living alone, no supportive listeners).
• Disruption of mourning rituals (e.g., during COVID-19), halting acceptance processes.
• Religious/cultural beliefs: some contexts view prolonged displays of grief as “unnatural” or “sinful,” leading to suppression that paradoxically worsens symptoms.
• Economic strain after losing a breadwinner overlays grief with survival stress.

5. Cumulative Grief

• Repeated losses without adequate healing (e.g., multiple close deaths in a short time) exhaust the loss-processing system.
• High grief load pushes the brain into self-protection by “staying in the past” to avoid new pain.

🧭 Etiological Summary

PGD typically arises from the intersection of three domains:
🧠 Biology – dopaminergic and stress systems stuck “on”
💔 Psychology – intense attachment or unresolved guilt
🌍 Society/Culture – inadequate mourning structure or support

When these converge, the adaptive process of “adjusting to loss” that should gradually unfold becomes “being stuck in grief,” the essence of Prolonged Grief Disorder.

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Treatment & Management

The mainstay is grief-focused psychotherapy specific to PGD.

• Prolonged/Complicated Grief Therapy (PGDT/CGT): a 16-session manualized program that helps with “accepting the reality of the loss + restoring roles/meaning in life.” RCTs versus IPT show higher and faster response with CGT/PGDT (NNT ≈ 4.3), including in older adults. JAMA Network+2PMC+2
• CBT-based grief interventions (including online formats, letter writing to the deceased, narrative disclosure, reducing experiential avoidance): evidence supports symptom reduction, including for children/adolescents. American Psychiatric Association
• Sleep: CBT-I helps when comorbid insomnia is present. American Psychiatric Association
• Peer/bereavement groups: reduce loneliness and increase social scaffolding. American Psychiatric Association
• Medications: there is no medication that directly treats “grief” itself; consider pharmacotherapy for comorbid conditions (e.g., MDD/anxiety/insomnia) as indicated. American Psychiatric Association

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Notes (Differential & Assessment Points)

• Distinguish from normal bereavement: typical grief gradually eases and functioning returns; in PGD, painful affect and yearning/preoccupation persist and impair functioning.
• Distinguish from MDD: MDD centers on pervasive low mood/anhedonia and global worthlessness/self-blame not specific to the loss; PGD centers on “bonding–yearning–non-acceptance” toward the deceased.
• Distinguish from PTSD: PTSD centers on threat/fear and re-experiencing a life-threatening event; PGD centers on yearning/loss of meaning.
• Time criteria: DSM-5-TR: adults ≥ 12 months (children/adolescents ≥ 6 months); ICD-11: ≥ 6 months and “longer than expected” in the cultural context — cultural judgment is crucial. American Psychiatric Association+1

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📚 References

American Psychiatric Association. Prolonged Grief Disorder. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). Washington, DC: APA; 2022.

World Health Organization. International Classification of Diseases 11th Revision (ICD-11): Prolonged Grief Disorder. Geneva: WHO; 2022.

Shear MK, Frank E, Houck PR, Reynolds CF. Treatment of Complicated Grief: A Randomized Controlled Trial. JAMA. 2005;293(21):2601-2608.

Shear MK, Reynolds CF, Simon NM et al. Complicated Grief Treatment in Elderly Persons: A Randomized Clinical Trial. JAMA Psychiatry. 2014;71(11):1287-1295.

Szuhany KL, Malgaroli M, Miron O, Simon NM. Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Psychotherapy. 2021;58(3):373-387.

Kakarala SE, O’Connor MF. The Neurobiological Reward System in Prolonged Grief Disorder: Dopamine, Oxytocin, and the Nucleus Accumbens. Front Psychiatry. 2020;11:553.

Eisma MC, Boelen PA, Lenferink LIM. Prolonged Grief Disorder in ICD-11 and DSM-5-TR: A Comparative Review. Current Opinion in Psychiatry. 2023;36(1):46-52.

O’Connor MF, Sussman TJ. Neural Mechanisms of Grief and Its Complications: Reward, Attachment, and Meaning. Trends Cogn Sci. 2020;24(9):751-763.

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