Prolonged grief disorder in ICD-11: symptoms, diagnosis and differentiation from depression and adjustment disorder

What is prolonged grief disorder in ICD-11?

Prolonged grief disorder is a separate diagnostic category in ICD-11. It belongs to the group of disorders specifically associated with stress, alongside PTSD, complex PTSD and adjustment disorder. In prolonged grief disorder, the event that triggers the symptoms is always the death of a loved one.^[3]

ICD-10 did not include a separate category for prolonged or complicated grief reactions. In practice, people with this clinical picture could receive diagnoses such as depression, PTSD, adjustment disorder or reaction to severe stress. The problem was that these diagnoses did not always capture the specificity of suffering organised around the loss of a particular person. Separating PGD in ICD-11 reflects the view that prolonged grief disorder has its own symptom core and requires separate differential diagnosis.^[4]

It is important not to confuse PGD with pathologising grief. Intense sadness, crying, yearning, temporary disorganisation, insomnia or difficulty returning to daily life can be natural parts of grief. The diagnosis applies when the reaction to loss remains fixed, dominant, very painful and clearly limits further functioning.

When does grief become a clinical problem?

Grief becomes a clinical problem not because it is strong, but because it remains rigid, dominant and disorganising for a period that clearly exceeds the expected course in the person's context. In prolonged grief disorder, suffering not only lasts a long time; it also blocks gradual adaptation to life after the loss.

The most characteristic feature is the core linked to the deceased: persistent yearning, constant preoccupation with the deceased, difficulty accepting the death, a sense of having lost part of oneself, the belief that life without this person has no meaning, or emotional fixation around the circumstances of death. This may be accompanied by deep sadness, guilt, anger, emotional numbness, avoidance of places and conversations that remind the person of the loss, inability to experience positive emotions and marked social withdrawal.

The fact that someone misses a deceased person for a long time is not enough for diagnosis. The key issue is whether yearning or preoccupation is so intense and persistent that it genuinely disorganises life: work, relationships, responsibilities, self-care, the ability to plan the future or engagement in other areas.

Natural grief vs prolonged grief disorder

A diagnosis of prolonged grief disorder does not measure the depth of love for the deceased and does not impose how long one is 'allowed' to suffer. It concerns situations in which grief becomes so dominant that it prevents the gradual rebuilding of life after loss.

The role of time and cultural context - ICD-11 and DSM-5-TR

ICD-11 and DSM-5-TR describe a similar phenomenon, but they differ in how they frame time. ICD-11 takes a more culturally flexible approach: symptoms must persist for an unusually long time after the loss, more than 6 months as a minimum, and clearly exceed the person's social, cultural or religious norms.

DSM-5-TR uses a more fixed threshold: the loss must have occurred at least 12 months earlier in adults and at least 6 months earlier in children and adolescents. DSM-5-TR also requires a specified number of accompanying symptoms and their persistence for the required period before diagnosis.

This difference matters in practice. ICD-11 leaves more room for assessing cultural, religious and social context, whereas DSM-5-TR sets a more concrete time boundary. In both systems, however, the core remains the same: yearning or preoccupation with the deceased, intense emotional pain and functional impairment.

Prolonged grief disorder vs depression - key differential diagnosis

Prolonged grief disorder and a depressive episode can look similar. Both may involve sadness, tearfulness, insomnia, low energy, social withdrawal, concentration problems and reduced daily activity. The difference lies mainly in what the suffering is organised around.

In prolonged grief disorder, the centre of the symptoms is the loss of a specific person. Yearning, preoccupation with the deceased, difficulty accepting the death, the sense of emptiness after this person and the pain of their absence dominate. The person may say: 'I cannot live without him', 'everything reminds me of her', 'I keep waiting for them to come back', 'I cannot accept that they are really dead'.

In depression, suffering is usually more generalised. Low mood, anhedonia, feelings of worthlessness, slowing, sleep disturbance, appetite loss, hopelessness or suicidal thoughts do not have to be focused on one person or the loss itself. The patient may experience a broader sense of meaninglessness and lack of pleasure, independently of the specific relationship with the deceased.

Studies and reviews indicate that PGD, depression and PTSD partly overlap, but they are not the same phenomenon. In PGD, yearning, preoccupation with the deceased and difficulty integrating the loss are more characteristic, whereas in depression generalised anhedonia, hopelessness and a negative self-view are more central.

Prolonged grief disorder vs depression

The key clinical question is whether the patient's suffering is mainly focused on the inability to psychologically integrate the death of a specific person, or whether a broader, generalised depressive picture has developed. These states may also co-occur.

Can PGD and depression co-occur?

PGD and a depressive episode are not mutually exclusive. The same person may have both symptoms of prolonged grief disorder and a full depressive syndrome. This matters because missing one of these pictures can lead to an incomplete support plan.

If only depression is diagnosed, the specific grief core requiring work with the process of loss, the relationship with the deceased and integration of the loss may be missed. If only prolonged grief disorder is diagnosed, a severe depressive episode requiring separate assessment may be overlooked, including suicide risk assessment and possible pharmacological treatment.

Situations requiring urgent assessment include suicidal thoughts, strong thoughts of giving up, the belief that life without the deceased has no meaning, guilt linked to wanting to 'join' the deceased, or serious neglect of self-care.

Prolonged grief disorder vs adjustment disorder

Adjustment disorder and prolonged grief disorder both belong in ICD-11 to the group of disorders specifically associated with stress, so they can be confused. The key difference concerns the type of stressor and the symptom core.

In adjustment disorder, the stressor may be many different events: separation, job loss, illness, family conflict, moving home, overload of responsibilities or a difficult life change. The core is preoccupation with the stressor and difficulty adapting to the new situation, leading to impaired functioning.

In prolonged grief disorder, the stressor is always the death of a loved one, and the suffering is organised around this specific loss. The key issue is not general overload from change, but persistent yearning for the deceased, preoccupation with them and inability to emotionally integrate the fact that the person has died.

Prolonged grief disorder vs adjustment disorder

In practice, if after the death of a loved one the dominant features are yearning, preoccupation with the deceased and the sense of being unable to live without that person, PGD should be considered. If symptoms are a more general difficulty adapting to a life change, without the dominant core of yearning and preoccupation, adjustment disorder may be more likely.

Death of a loved one and PTSD - when should both diagnoses be considered?

The death of a loved one does not automatically lead to prolonged grief disorder. It may trigger natural grief, adjustment disorder, a depressive episode, PTSD, CPTSD or several of these states at the same time. The fact that symptoms began after a loss is not enough for a PGD diagnosis.

PTSD should be considered especially when the death was sudden, violent or traumatic, for example due to an accident, violence, disaster or suicide of a loved one. In PTSD, the central core is re-experiencing the traumatic event in the present, avoiding trauma-related stimuli and a persistent sense of current threat.

In PGD, the central core is yearning for the deceased, preoccupation with them and inability to emotionally integrate the loss. For example, a person after the sudden accidental death of a loved one may have intrusive images of the accident itself, which points toward PTSD, and at the same time may be unable to imagine life without the person, which may correspond to PGD. Both pictures require separate assessment.

Prolonged grief disorder in children and adolescents

In children and adolescents, prolonged grief disorder may look different than in adults. A child cannot always verbally describe yearning, emptiness or difficulty accepting the death. Symptoms may appear through behaviour: regression, irritability, separation anxiety, outbursts of anger, school problems, withdrawal, play repeatedly focused on the loss, or repeated questions about the deceased.

In young children, the level of understanding of death is also important. A child may ask repeatedly when the deceased will return, not because they are 'refusing the diagnosis', but because they do not yet understand the permanence of death in the same way as an adult. In adolescents, grief may appear as withdrawal, rebellion, risky behaviour, loss of motivation, depressive symptoms or tension in relationships.

It is especially important when the deceased person was the child's main caregiver. Grief may then combine with separation anxiety, a changed sense of safety, loss of environmental stability and attachment problems. Assessment should rely not only on self-report, but also on observation, information from caregivers and analysis of functioning at home and school.

Risk factors, course and when to seek help

Some circumstances increase the risk of prolonged grief disorder, although they do not by themselves justify the diagnosis. These include sudden or violent death, death of a child, very strong emotional dependence on the deceased, previous mental disorders, lack of social support, traumatic circumstances of death and difficulty accessing farewell rituals.

The diagnosis is based on the current symptom picture, not only on a list of risk factors. Not every person after a violent loss develops PGD, just as prolonged grief disorder may also occur after an expected death if the process of integrating the loss becomes blocked.

It is worth seeking help if, for many months after the death of a loved one, yearning, preoccupation with the deceased, emptiness and inability to continue life remain very intense, do not ease, block daily functioning or lead to isolation, self-neglect, substance misuse, abandonment of responsibilities or suicidal thoughts. In immediate danger to life or health, urgent help should be used.

Summary

Prolonged grief disorder in ICD-11 does not mean that grief itself is an illness. It names a specific situation in which the reaction to the death of a loved one remains persistent, intense and disorganising for a period clearly exceeding cultural norms and causes significant functional impairment.

The most important point in differential diagnosis is to establish what the suffering is organised around. In PGD, the core is yearning for the deceased and preoccupation with the loss. In depression, suffering is more generalised. In adjustment disorder, the core is difficulty adapting to a stressor. In PTSD, re-experiencing the traumatic event, avoidance and a sense of threat dominate.

Accurate diagnosis helps avoid pathologising natural grief, while also preventing clinicians from missing situations in which a person genuinely needs specialist help.

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