HealthComplicated Grief and Separation Anxiety Often Occur Together After the Loss of...

Complicated Grief and Separation Anxiety Often Occur Together After the Loss of a Close Loved One

Recent research indicates that adults experiencing complicated grief are also highly likely to have separation anxiety and worse depression symptoms, among other mental health challenges.

In a 2016 research study, Dr. Camilla Gesi and colleagues examined the relationship between complicated grief (CG) and separation anxiety disorder (SEPAD). The study involved a sample of adults seeking help for CG1. The researchers wanted to understand how common SEPAD is among people experiencing CG, and if those with both CG and SEPAD were more likely to suffer from other mental health problems, too.

What Is Complicated Grief?

Complicated grief, also known as traumatic grief or prolonged grief disorder, can occur after the death of a very close loved one. Research suggests that it affects between 10 to 20 percent of bereaved people2, and it is associated with a negative impact on physical and mental health3.

While everyone endures grief and emotional pain after the passing of a loved one, adults may be diagnosed with complicated grief if they also report persistent yearning, longing, and sorrow for at least 12 months (or six months for children). They must also report at least six of the following:

    • significant difficulty accepting the death
    • disbelief over the loss
    • difficulty with positive reminiscing about the deceased
    • anger
    • self-blame
    • avoidance of reminders of the loss
    • social/identity disruption

What Is Separation Anxiety Disorder?

Separation anxiety disorder is usually considered something seen only in children. But research shows that people can experience SEPAD over their lifespan, and it can even begin in adulthood in some cases4. People who have SEPAD report intense and impairing anxiety about actual or imagined separations with their loved ones or home environment, leading to a need to maintain physical proximity. SEPAD is thought to occur in about 23 to 40 percent of people with mental health problems5.

High Rates of Co-Occurrence

Among the sample of 151 adults seeking treatment for CG, researchers found that nearly 70 percent also had SEPAD, which is a significantly higher rate than in previous studies. The individuals experiencing comorbid (simultaneous) CG and SEPAD were also more likely to report CG symptoms from the loss of a loved one other than a parent, spouse, or child. Interestingly, there were no differences in how the deaths occurred (either violently or nonviolently) between individuals with comorbid SEPAD and CG when compared to those with CG alone.

Further, individuals who had comorbid SEPAD and CG were more likely to report symptoms consistent with posttraumatic stress disorder (PTSD) and panic disorder over the course of their lifetimes. And those who reported having both CG and SEPAD also reported having more severe CG, as well as greater difficulties in their work, school, leisure, and family relationships.

The group with comorbid CG and SEPAD also reported more peritraumatic dissociative symptoms, which include increased confusion, altered time perceptions, feelings of unreality, and feeling as if they were in a dream while awake. And this group reported more depression symptoms. The results of this study suggest that individuals who experience CG and SEPAD have a lot of distress — significantly more than those who suffer from CG alone.

A Theory May Explain the Relationship

The researchers in this study suggest that the high correlation between symptoms of CG and SEPAD may be explained by attachment theory. Its central assumption is that as humans, we have an innate motivation to form and maintain close emotional bonds to meet our emotional and instrumental needs. This process of seeking and forming attachments is hardwired in our neurobiological systems6.

The British psychologist John Bowlby, a central figure in attachment theory, coined the term “internal working model,” which is a mental representation of significant others derived from our history with them. This internal working model helps us develop expectations of caregivers and family, and it helps us predict how we will be treated by others.

When people are faced with a loss of a loved one, acute grief (as opposed to complicated grief) can disrupt the attachment system. The period of acute grief allows us to integrate the death of the loved one into our internal working model of the deceased and process the meaning of the loss. However, when we do not fully process or accept the death of a loved one, complicated grief can emerge7.

The loss of a loved one can also trigger the onset of separation anxiety. Therefore, the findings in the study of high correlations between CG and SEPAD suggest that a common feature of both is separation distress. It is important to note that CG and SEPAD are still considered distinct disorders, but this research may indicate that the lived experiences of these two disorders may be similar, with the core emotions being fear and distress at the separation from loved ones.

Some Limitations

This research is presented from only one point in time, so we can’t conclude that CG caused SEPAD or that SEPAD caused CG. Also, we can’t determine if people who had SEPAD as children might be more vulnerable to developing CG in adulthood when faced with the loss of a very close loved one.


1. Gesi, C., Carmassi, C., Shear, K., Shwartz, T., Ghesquiere, A., Khaler, J., Dell’ Osso, L. (2016). Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates. Comprehensive Psychiatry (72), 6-12.

2. Shear, M.K. (2015). Clinical practice. Complicated grief. New England Journal of Medicine (372), 153–160.

3. Prigerson, H.G., Bierhals, A.J., Kasl, S.V., Reynolds, C.F. III, Shear, M.K., Day, N., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry (154), 616–623.

4. Pini, S, Abelli, M., Shear, K.M., Cardini, A., Lari, L., Gesi, C., et al. (2010). Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatrica Scandanavia. 2010 (122), 40–46.

5. Silove, D.M., Marnane, C.L., Wagner, R, Manicavasagar, V.L., & Rees, S. (2010). The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic. BMC Psychiatry (10), 10–21.

6. Bowlby, J. Attachment and Loss, Volume III: Loss, Sadness and Depression. (1980). New York: Basic Books.

7. Shear, K., Monk, T., Houck, P., Melhem, N., Frank, E., Reynolds, C., et al. (2007). An attachment-based model of complicated grief including the role of avoidance. European Archives of Psychiatry Clinical Neuroscience (257), 453–461.

Research Psychologist at VA Boston Healthcare System

Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.


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