When grief becomes complicated

This page is for people grieving someone who died of cancer, and for those who worry their grief is not easing. It explains normal grief, the signs of complicated grief, and where to find help.

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 recognize. NCI lists numbness, shock, disbelief or denial, and anxiety about being separated from the person who died. People usually accept the loss over time and keep up daily activities, even when it is hard.

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.

The key sign is that symptoms do not ease over a long time and keep a person from taking part in daily life. If that sounds like you or someone you love, talk with a doctor or counselor.

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 behavioral therapy (CBT), a form of talk therapy. It helps a person learn skills that change negative thoughts and behaviors 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 counseling.

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. NCI says psychotherapy during antidepressant use can improve depression and reduce the intensity of grief.

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:

• Ages two to three may confuse death with sleep.
• Ages three to six may see it as reversible and use magical thinking.
• Ages 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? NCI's guidance for adults 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
• 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 says people with serious grief reactions or symptoms of distress may find treatment helpful. Asking for help is not an admission that you are grieving wrongly. If you ever feel you might harm yourself, call or text 988 (the Suicide and Crisis Lifeline) or call 911.