A. The individual experienced the death of someone with whom he or she had a close relationship.
B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
- Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure.
- Intense sorrow and emotional pain in response to the death.
- Preoccupation with the deceased.
- Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.
C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
Reactive distress to the death
- Marked difficulty accepting the death. In children, this is dependent on the child's capacity to comprehend the meaning and permanence of death.
- Experiencing disbelief or emotional numbness over the loss.
- Difficulty with positive reminiscing about the deceased.
- Bitterness or anger related to the loss.
- Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame).
- Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased).
- Social/identity disruption
- A desire to die in order to be with the deceased.
- Difficulty trusting other individuals since the death.
- Feeling alone or detached from other individuals since the death.
- Feelings that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased.
- Confusion about one's role in life, or a diminished sense of one's identity (e.g., feeling that a part of oneself died with the deceased).
- Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities).
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The bereavement reaction is out of proportion is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms.
- With traumatic bereavement: Bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death (often in response to loss reminders), including the deceased's last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death.
Persistent complex bereavement disorder is distinguished from normal grief by the presence of severe grief reactions that persist at least 12 months (or 6 months in children) after the death of the bereaved. It is only when severe levels of grief response persist at least 12 months following the death and interfere with the individual's capacity to function that persistent complex bereavement disorder is diagnosed.
Persistent complex bereavement disorder, major depressive disorder, and persistent depressive disorder (dysthymia) share sadness, crying, and suicidal thinking. Whereas major depressive disorder and persistent depressive disorder can share depressed mood with persistent complex bereavement disorder, the latter is characterized by a focus on the loss.
Individuals who experience bereavement as a result of traumatic death may develop both posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder. Both conditions can involve intrusive thoughts and avoidance. Whereas intrusions in PTSD revolve around the traumatic event, intrusive memories in persistent complex bereavement disorder focus on thoughts about many aspects of the relationship with the deceased, including positive aspects of the relationship and distress over the separation. In individuals with the traumatic bereavement specifier of persistent complex bereavement disorder, the distressing thoughts or feelings may be more overtly related to the manner of death, with distressing fantasies of what happened. Both persistent complex bereavement disorder and PTSD can involve avoidance of reminders of distressing events. Whereas avoidance in PTSD is characterized by consistent avoidance of internal and external reminders of the traumatic experience, in persistent complex bereavement disorder, there is also a preoccupation with the loss and yearning for the deceased, which is absent in PTSD.
Separation anxiety disorder is characterized by anxiety about separation from current attachment figures, whereas persistent complex bereavement disorder involves distress about separation from a deceased individual.