Prolonged grief - a new diagnosis in ICD-11

What prolonged grief disorder is

Prolonged grief disorder, also referred to as prolonged or complicated grief disorder, is a mental disorder included in ICD-11 under code 6B42. ICD-11 stands for the eleventh revision of the International Classification of Diseases, that is, the global catalogue of disease entities maintained by the World Health Organization.

This diagnosis describes a situation in which the response to the death of a loved one persists for an unusually long time and reaches an intensity that goes beyond the expected course of grief. Two words in the name are key here. Prolonged means that the symptoms last longer than would be expected in the given context. Complicated indicates that the process of grieving has become stuck and is not moving toward a gradual coming to terms with the loss.

Prolonged grief disorder is a relatively new diagnosis. In the previous version of the classification, ICD-10, there was no separate category for a complicated grief reaction. Clinicians could capture it only indirectly, for example within the framework of a reaction to severe stress. ICD-11 diagnostics singles out this disorder in order to make it possible to recognise and help people in whom grief has taken on a pathological form.

In ICD-11, prolonged grief disorder belongs to the same group as other disorders specifically associated with stress, alongside post-traumatic stress disorder and adjustment disorder. What unites all these categories is that a condition for the diagnosis is an identifiable stressful or traumatic event. In the case of prolonged grief disorder, that event is always the death of a loved one.

Healthy grief versus complicated grief

Grief in itself is not a disorder. It is a natural, albeit painful, reaction to the loss of a loved one. Sadness, longing, crying, difficulty concentrating, a temporary withdrawal from activities - all of this falls within the expected course of grief and does not require a psychiatric diagnosis.

In most people the intensity of suffering gradually eases. A person in grief is, over time, able to return to everyday matters, regains the capacity to experience other feelings as well, and the memory of the deceased, though still painful, ceases to dominate life entirely. This does not mean forgetting or an absence of longing, but a regaining of balance.

Prolonged grief disorder is diagnosed only when this natural process becomes blocked. The suffering not only lasts a long time, but remains intense, all-encompassing, and makes normal functioning impossible. It is important not to treat every long or deep grief as pathology. The line is set not by pain itself, but by its entrenchment, severity, and impact on life.

Criteria for the diagnosis according to ICD-11

Diagnosing prolonged grief disorder in accordance with the ICD-11 guidelines rests on a persistent and all-encompassing grief reaction. At its core is an enduring longing for the deceased or a constant, all-consuming preoccupation with thoughts of them, combined with intense emotional suffering.

This suffering can manifest in many ways. It includes profound sadness, guilt, anger, denial of the loss, blaming oneself or others, difficulty accepting the death, a sense of having lost a part of oneself, an inability to experience positive feelings, emotional numbing, and difficulty engaging in social and other activities.

The second condition is duration. The grief reaction must persist for an atypically long period after the loss, clearly exceeding the norms expected in the given social, cultural, and religious context. The ICD-11 guidelines point here to a period of at least several months; however, they emphasise that the mere passage of time is not sufficient - it is the whole picture that decides.

The third condition is a significant impairment in functioning. The symptoms must cause significant distress or impair personal, family, social, occupational, or other important areas of life. The reaction must also clearly go beyond what is regarded as expected within the given cultural and religious context.

The role of cultural and religious context

ICD-11 places clear emphasis on situating the assessment of grief within the person's cultural and religious context. Norms regarding how long and how intensely grief is expressed differ considerably between communities. In some traditions grief involves formalised, lengthy rituals; in others the period of expected intense grief is shorter.

What in one cultural context would be regarded as a prolonged and concerning reaction falls, in another, within accepted norms. For this reason the clinician should not apply a rigid time threshold in isolation from the patient's cultural background. ICD-11 diagnostics requires an assessment of whether the reaction goes beyond what is expected for the given person and their environment.

This has practical significance. It is an error both to overlook complicated grief because the symptoms were regarded as a manifestation of custom, and to hastily regard as illness a reaction that is consistent with a culturally accepted way of experiencing loss. A good assessment takes into account how grief is experienced by other members of the same community.

It is also worth remembering that some experiences widely regarded in a given culture as a normal part of grief, for example a sense of the deceased's presence or talking to them, do not in themselves indicate a disorder. ICD-11 emphasises that such experiences are assessed in the light of the norms of the patient's community, and are not automatically treated as a pathological symptom.

Differentiation from depressive disorders

The most common diagnostic challenge is distinguishing prolonged grief disorder from a depressive episode, for example single episode depressive disorder (6A70) or recurrent depressive disorder (6A71). Both categories involve sadness, withdrawal, and a loss of the capacity to experience joy, so the distinction requires care.

At the core of prolonged grief disorder are longing for the deceased and preoccupation with thoughts of them. The suffering is centred on a specific loss. In depressive disorder the lowering of mood is more general and pervasive, encompasses a wide range of life matters, and characteristic features also include a persistent sense of worthlessness and thoughts of giving up that are not linked solely to the deceased.

In grief the capacity to experience positive feelings usually returns in waves, for example in memories of the deceased, whereas in depression a persistent absence of such capacity often dominates. It should be remembered that both entities can co-occur - after the loss of a loved one, both prolonged grief disorder and a separate depressive episode are possible in the same person, which the clinician assesses individually.

Differentiation from PTSD and adjustment disorder

When the death of a loved one occurred in traumatic circumstances, for example in an accident, an act of violence, or a disaster, post-traumatic stress disorder (6B40) or complex post-traumatic stress disorder (6B41) also comes into play. The core of PTSD, however, consists of re-experiencing the event, avoidance of stimuli associated with it, and a sense of current threat, not longing for the deceased.

If a person is dominated by intrusive memories of the traumatic circumstances of the death and by a sense of threat, a diagnosis from the group of post-traumatic disorders may be appropriate. If the central place is occupied by enduring longing and preoccupation with the deceased, prolonged grief disorder is the more accurate diagnosis. Both categories can also co-occur, when both post-traumatic symptoms and complicated grief are present.

Prolonged grief disorder should also be distinguished from adjustment disorder (6B43). Adjustment disorder is a reaction to a stressful event that is usually less severe, lacks the characteristic core of longing for and preoccupation with the deceased, and usually subsides as the person adapts to the new situation. If the reaction to a loss meets the criteria for prolonged grief disorder, this is a more accurate diagnosis than adjustment disorder.

Risk factors and course

Certain circumstances increase the likelihood that grief will take on a complicated form. Guidelines and the clinical literature point here, among other things, to a sudden or violent death of a loved one, the loss of a child, a very strong emotional dependence on the deceased, prior mental disorders, and a lack of social support after the loss.

Prolonged grief disorder usually has a chronic course if it is not recognised and help is not provided. The suffering does not fade on its own as it does in healthy grief, but may persist for years, restricting the affected person's occupational, family, and social life.

Not every person exposed to risk factors develops complicated grief. These factors merely increase the likelihood, and the final assessment is always based on the whole clinical picture, not on the list of circumstances alone.

In ICD-11 diagnostics, risk factors play a supporting role. They help the clinician remain vigilant, for example toward a parent after the loss of a child or a person deprived of the support of loved ones, but they do not replace an assessment of the symptoms. The diagnosis of 6B42 is made on the basis of the core symptoms, duration, and impact on functioning, not on the basis of the history of loss alone.

The importance of an accurate diagnosis

Singling out prolonged grief disorder in ICD-11 has a practical justification. It makes it possible to notice and name the suffering of people in whom grief has ceased to be a process moving toward balance and has become an entrenched state restricting life. Without a separate category, such people often did not receive adequate help.

At the same time, the existence of this diagnosis does not mean that grief is to be pathologised. ICD-11 diagnostics clearly distinguishes the natural, albeit painful, process of grieving from its complicated form. The diagnosis of 6B42 is reserved for situations in which the criteria of duration, severity, and impact on functioning are met, with the cultural context taken into account.

It should be remembered that no article or tool supporting ICD-11 diagnostics replaces a clinical examination. A diagnosis of prolonged grief disorder and decisions about further management are always made by a qualified mental health specialist on the basis of a full assessment of the situation of the person in grief.

Frequently asked questions