Stages of Grief – Symptoms of Grief

How To Deal With Grief And Loss

Grief is something that every individual gets to deal with in their lifetime, in this article, Sanam Naran takes us through an informative path to understanding what is grief, what are the types of grief and how to identify it.

Losing a loved one can have dire consequence on one’s physical, social and emotional well-being. Loved ones may become deeply entrenched in our lives, that they can be part of our identity. When your daily life is so tightly knit to a loved one, the mere thought of their absence can cause a lot of physical, social and emotional pain.

Grief can be described as an intense emotional response to bereavement or the loss of something or someone you cherish. The effects of grief may differ from person to person, and may present itself in several ways. In this article, I will be discussing Persistent Complex Bereavement Disorder (PCBD) and complicated grief, alternatively called pathological grief, or traumatic grief.

I will begin with an overview of normative bereavement reactions, then I will describe the diagnostic criteria for PCBD and the distinction between PCBD and other disorders. Next, I will describe treatments that have been effective in reducing PCBD symptoms. I will conclude by identifying common components of effective treatments and offering recommendations for practicing clinicians.

Presentation Of Normal Grief

Grief is an individual process, with different phases, which can vary in duration and phases. It cannot be seen as a linear process as it would differ from person to person. In the first year of loss, a large number of individuals may experience the following: cognitive disorganisation, health complications, and impairment in social and occupational functioning (Gotlib & LeMoult, 2014).

There is seen to be a progress from acute grief to integrated grief in most individuals, however, one must be cognizant of their cultural backgrounds and upbringing as this may differ due to that (Barry, Kasl, & Prigerson, 2002).

What is Acute grief? Acute grief can be explained as an intense despair and yearning for the loved one, a desire to meet them, thoughts and memories of them and a feeling of sadness that prevails throughout the day.

What is Integrated grief? Integrated grief can be described as the acceptance of the deceased loved one and a progression to continue with one’s life without that person (Barry, Kasl, & Prigerson, 2002). The Kübler-Ross model explains a normal grieving process in stages as follows: denial, anger, bargaining, depression, and acceptance (Holmes & Rahe, 1967),

Research by Holmes & Rahe (1967) showed that during the six months after a loss, the reality of the loss gradually sets in as the denial gradually fades out. Rag and depression are experienced in five and six months, after which there begins a decline in these stages. After six months, all these stages are less intense, and the individual begins to accept (Holmes & Rahe, 1967).

What are some of the experiences that a grieving person:

Cognitive Disorganisation

Confusion and preoccupation

Individuals will experience feelings of preoccupation with the deceased, a sense of disorganization and confusion (Balk, 2011).

Disturbance of identity

These individuals often feel as if something has been taken away from their identity and their being. Some find that they do things in a similar way to the deceased. They also often contemplate about their own deaths (Gotlib and LeMoult, 2014).

Sense of disrupted future

Most of these individuals are unable to foresee a future without their loved ones and find a lack of motivation to continue on with their lives (Balk, 2011).

Long-term search for meaning

They are often trying to understand their loss and why it has occurred. Most of these individuals find it challenging to make meaning of their loss in the first few months after the death (Balk, 2011).


Distressing emotions in the bereavement process

These individuals will often begin to experience survivor guilt. They may also begin to question what they could have done differently to avoid the death of their loved one. Anger is often directed to the deceased, other family members or God (Gotlib and LeMoult, 2014).

Pining or yearning

It is said that grief only occurred if there was a strong sense of ‘pining’ or yearning for their loved one (Balk, 2011).


An individual will often report feelings of intense loneliness and begin to isolate themselves from others which could cause a deeper sense of loneliness (Balk, 2011).

Health Deficits

Health behaviours and complaints

These individuals may experience health problems associated with appetite, sleep disturbances, breathing problems and palpitations. An increase in mortality rates is also noticed (Gotlib and LeMoult, 2014).

Types of Loss

Ambiguous loss can be described as a type of loss that complicates grief and prevents a type of closure (Boss, 2014). This loss is characterized by the individual not fully understanding the loss and searching for answers to the point where they are not able to accept and resolved their mourning.

There exists three types of grief that can develop from ambiguous loss:

Anticipatory grief occurs before the death of a loved one and becomes anticipated by all members of the family. A loved one with a terminal illness can cause individuals to experience this type of grief (Balk, 2011). The second type of grief is frozen grief that results from physical or psychological disappearance of a loved one. The third type of grief is disenfranchised grief. This occurs when the grief is not taken seriously example the loss of a pet (Gotlib and LeMoult, 2014).


Complicated Grief is characterized by overwhelming grief that persists for at least six months after the death of the loved one. Here are some of the signs of complicated grief:

  1. Profound yearning and powerful longing to be reconnected with the deceased,

  2. Intense separation distress,

  3. Intrusive thoughts about the loved one,

  4. Disturbing images of the deceased or of the death event,

  5. Avoidance of reminders that the loved one has died, and

  6. Proximity seeking to feel closer to the deceased (Stroebe, 2002).

Individuals with complicated grief may experience a sense of worthlessness, be unable to accept the reality of the loss and be unable to move on without the deceased loved one (Prigerson, 2005).

Complicated grief is also caused by confusion about the meaning of life, trusting others, shock, and anger about the loss (Prigerson, 2005). This devastating response to loss has potentially life-threatening consequences. Individuals with complicated grief have higher suicide rates, a poor quality of life, and inhibition in social circumstances; indulge in substance abuse, health deficits and hypersomnia, then those who have been able to resolve their mourning (Prigerson, 2005). It is important that a therapist is able to distinguish between normal grief and complicated grief.


DSM-V Diagnostic Criteria- Persistent Complex Bereavement Disorder

Symptoms of Persistent Complex Bereavement Disorder

An individual suffering from persistent complex bereavement disorder will display symptoms that may include the following:

  • Indefinitely yearning/longing for the deceased
  • Preoccupation with the circumstances of the deceased’s death
  • Intense sorrow and/or distress that does not improve over time.
  • Difficulty trusting others
  • Depression
  • Detachment and/or isolation
  • Difficulty pursuing interests or activities
  • A desire to join the deceased
  • Persistent feelings of loneliness or emptiness
  • Impairment in social, occupational or other areas of life (Wakefield, 2017).

These symptoms are all characteristic of grief more generally, too – for a diagnosis of persistent complex bereavement disorder to be made, the patient will have been found to suffer symptoms over a prolonged period.

Diagnostic Criteria for Persistent Complex Bereavement Disorder

The patient experienced the death of a loved one at least six months previously. At least one of the following symptoms has been present longer than expected, taking into account the person’s social or cultural environment:

  • Intense and persistent yearning for the deceased
  • Frequent preoccupation with the deceased
  • Intense feelings of emptiness or loneliness
  • Recurrent thoughts that life is meaningless or unfair without the deceased
  • A frequent urge to join the deceased in death

At least two of the following symptoms have been recorded for at least one month:

  • Feeling shocked, stunned or numb since a loved one’s death
  • Feelings of disbelief or inability to accept the loss
  • Rumination about the circumstances or consequences of the death
  • Anger or bitterness about the death
  • Experiencing pain that the deceased suffered, or hearing/seeing the deceased
  • Trouble trusting or caring about others
  • Intense reactions to memories or reminders of the deceased
  • Avoidance of reminders of the deceased, or the opposite – seeking out reminders to feel close to the deceased
  • Symptoms cause substantial distress for the sufferer or impact significantly on areas of functioning and cannot be attributed to other causes. (DSM -V, APA, 2013)


A South African Perspective

Culture plays an important role in the process of grieving (Rosenblatt, 2002). Communities also have their own expectations of how an individual should grieve. Factors such as an understanding of what has been lost, rituals, and the survivor’s continuous and future relationship with the deceased attribute to the reaction of death. Rosenblatt (2002)

The conditions of the mourning period are determined by the family of the person who has died and mourning period comes to an end with a special ritual. Christianity, Islam, Hinduism and Judaism are amongst the main religious groups with death and burial rituals in South Africa. If individuals cannot follow the customs and rituals they tend to show signs of complicated grief (Opperman, 2004). South Africans are exposed to several situations which could lead to CG or PCBD.

South Africa is a developing African country with diverse traditional groups, consisting of rural and urban areas. Members of each traditional group are expected to follow the prescribed rituals as developed by the group, thus referring to the rules of society (Doka, 1989). Most children are not prepared for death and communities are discouraged to talk about death. This is more prevalent in the rural areas where tradition and cultural beliefs have not yet been influenced by Westernised ideas.

Multiple losses

In South Africa, it can be seen that a person may experience several losses in a short period of time and is unable to mourn them during the appropriate and stipulated times and therefore becomes a risk for developing complicated grief. In South Africa, most deaths occur in the age group of fifteen to forty-nine (Statistics South Africa, 2010).

It is also said that an individual may not only have to accept the loss of their loved ones, but the loss of an income, social support and control within the household. They may even have to adapt to a child-headed household and become a breadwinner for their family. In this way, multiple losses and symbolic losses are being felt.

Lack of social support

The mode of support that an individual attains is important when faced with bereavement. This may vary from culture to culture. In addition, poor health care and social services can worsen the trauma that an individual experiences through violence, crim or HIV that has caused the death (Opperman, 2004).

Differential Diagnosis and Comorbidity

Some of the symptoms associated with PCBD disorder are also characteristic of other conditions, such as:

  • Normal grief – Both normal grief and persistent complex bereavement disorder may cause similar symptoms. Persistent complex bereavement disorder usually lasts longer, however, interfering with the sufferer’s functioning long after the death.
  • Depressive disorder – Persistent complex bereavement disorder shares features like sadness with major or persistent depressive disorder but this depressed mood is characterized by a focus on the loss.
  • Post-traumatic stress disorder – Individuals with post-traumatic stress disorder may suffer intrusive thoughts about a traumatic event, while those with persistent complex
  • bereavement disorder may suffer thoughts about the deceased or the circumstances of their death.
  • Separation anxiety disorder – Separation anxiety disorder relates to separation from a living individual, whereas sufferers of persistent complex bereavement disorder experience anxiety when separated from the deceased (American Psychiatric Association, 2013).



There is no single treatment method known to cure PCBD. Medical professionals may prescribe medication, therapy or both to help sufferers manage their symptoms (Burke and Neimeyer, 2012


It seems that psychotherapy is the first port of call when it comes to treatment of bereavement. There have been a number of trials that have been studied which show that complicated grief psychotherapy has proved to be successful. This involves allowing the client to speak about any unresolved feelings they may have towards the death of their loved one, in the hopes of moving towards adaptation of their loss. This treatment also focusses on helping the client think about positive aspects of their lives and a future of hope and plans. It also allows for the client to begin thinking of their loved one and their death without being overcome with feelings of melancholia and rage. Weekly monitoring is conducted each week by the therapist and the client is left with homework at the end of each session, which include journalling their feelings and thoughts. It is quite obvious that this has many CBT elements to it, however, it is described as more of a Cognitive Analytic type of therapy (Burke & Neimeyer, 2012).

Group Therapy

There has been some evidence in Germany with a trial involving inpatients with PCBD, who attended group therapy for approximately ten sessions, reported to have a decrease in symptoms. This trial was compared to that of patients who underwent ordinary one-on-one therapy usual (Rosner, Lumbeck, & Geissner, 2011).

It is important to look at this more critically as it has been done in Germany and may not be the same case for South Africa, although, it is worthy to consider. Some of the techniques that were used in this specific trial involved, psychoeducation, confronting the loss, CBT techniques and written letters to the loved one.

There are several types of groups that can be conducted. The first is a self-help group. This is where clients get together and help each other with their various struggles, almost similar to a support group. Through this, group members will begin to foster friendships and lean on each other for ongoing support.

During these group sessions, each member will get a chance to narrate their stories, journal, keep a diary, write letters to their loved one, create albums or scrapbooks with pictures of their loved ones and discuss coping mechanisms with the other members (Rosner, Lumbeck, & Geissner, 2011).

When thinking about interventions and treatment for clients suffering from PCBD, it is important to take into consideration, South Africans who are constantly experiencing loss through trauma, violence, HIV and AIDS and substance abuse. This calls for immediate culturally acceptable treatment plans that consider the vast array of cultures and traditions that inform loss and bereavement in this country. The focus needs to be shifted from the individual to the collective. A community that comes together through their shared experiences as a group, may prove to be beneficial for most people in this country. This may create a network of support, sense of belonging and a sense of safety that could possibly foster change to individuals who may feel powerless (Opperman & Novello, 2006; Kasiram & Partab, 2002).


It is evident that antidepressants has become the most popular medication to prescribe to someone who is suffering with PCBD, however, there has not been enough research done into pharmacotherapy and treating grief. There have, however, been great results with treating Major Depressive Disorder (MDD) stemming from grief. Individuals under this trial have been able to successfully complete the bereavement process and continue with their lives. This must be administered in conjunction with therapy. The detail pertaining to the dosage, length and type of antidepressant, is said to be the exact same for MDD. Serotonin re-uptake inhibitors have proved to be successful in minimizing the depressive symptoms, although tricycle medication has not proved to work for grief-stricken individuals (Jordan & Litx, 2014).


Risk factors play a significant role in the development of PCBD from normal grief. Psychologists would need to play a special role in working with clients that are suffering from grief. This could include advocacy, programmes, workshops and other means of bringing awareness to bereavement in South Africa. Focussing on a collective, rather than the individual is imperative, especially in the context of South Africa. Further research needs to be developed with regards to grief and the several rituals and traditions that we have in this country. The correct interventions and treatment is similarly as important to consider in South Africa, and using a Western model of treatment may not prove successful for our population (Noyoo, 2004).

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