When grief becomes complicated

Start here, because this is where most people's worry lives. NCI's summary is clear. Most bereaved people recover naturally, without any treatment. Feeling wrecked after someone dies is not a disorder.

What NCI calls normal grief has a shape you can recognise. Early on there is numbness, shock and disbelief. That is strongest when the death was unexpected. Then comes anxiety about separation, crying, intrusive thoughts and anger. Long stretches of sadness follow, with broken sleep and a poor appetite.

It has a rhythm too. NCI describes grief bursts, or pangs. These are short periods of very intense distress, lasting 20 to 30 minutes. Something that brings the person to mind sets them off.

On timing, NCI reports that for most people symptoms diminish somewhere between six months and two years after the loss. It also stresses that recovery varies considerably.

NCI's description of complicated grief has four parts. The symptoms do not improve. They last a long time. They cause extreme distress. And they affect multiple areas of a person's life, interfering with daily functioning.

What sets it apart is the pattern, not the intensity. In ordinary grief, distress goes up and down. There are terrible days, then bearable ones, then terrible again. In complicated grief, NCI notes the symptoms remain constant rather than fluctuating.

The question is not how bad the worst day was. It is whether there are any good days at all, and whether the picture has changed since the beginning.

NCI lists factors that raise the risk of complicated grief:

• Being highly dependent on the person who died, such as a spouse, or coping with distress by thinking about it all the time.
• Younger age.
• Being male, after the loss of a spouse.
• Low self-esteem, or feeling one has little control over life.
• Inadequate social support.
• A loss that was unexpected.

These are risk factors, not predictions. Several can apply to someone who then grieves without any complications.

NCI describes cognitive behavioural therapy, a form of talk therapy. It helps a person learn skills that change negative thoughts and behaviours about grief. NCI reports a clinical trial in which people treated with CBT improved more, in grief symptoms and in general mental distress, than those given counselling.

On medicines, NCI is measured. Antidepressants may address grief-related depression. But NCI notes they provide less relief and take longer to work than they do for depression not related to grief. It reports that combining psychotherapy with medication appears most effective.

Treatment is described as helping people with serious grief reactions or symptoms of distress. It is not for everyone who is grieving.

NCI's summary notes that children grieve intermittently rather than continuously. What they understand depends on their stage of development. Children aged two to three may confuse death with sleep. Those aged three to six may see it as reversible and use magical thinking. Those aged six to nine understand it is final, but often think it happens only to old people. From about nine, children grasp that death is universal and permanent.

NCI names three worries children often have. Did I cause this? Will it happen to me? Who will take care of me? Its advice is to use accurate words such as "died" rather than softer phrases. Give explanations that suit the child's age. Include children in memorial services. And reassure them that they are safe and will still be cared for.

A child who seems to grieve for ten minutes and then goes back to playing is grieving the way children grieve.

If a hospice was involved, start by asking them what bereavement support they offer.

NCI's guidance on the final days puts it simply. People who feel unable to cope with their loss may be helped by grief counselling or grief therapy with trained professionals. Asking for that is not an admission that you are grieving wrongly. It is using something that exists because grief is hard.