Yet despite this substantial overlap, there are noteworthy differences. PTSD is characterized principally by thoughts and memories related to the traumatic event (i.e., the death in the case of bereavement), avoidance, and alterations in physiological arousal and reactivity. Together, symptoms from these domains make up 14 of the 20 PTSD symptoms, and these symptoms are a primary focus of PTSD treatments. In contrast, thoughts and memories in those with CG include not only thoughts related to the death, but also of the deceased. Similarly, avoidance is not only tied to the death, but also to reminders of the deceased and their absence. The symptoms of heightened arousal so prominent in PTSD are largely absent from diagnostic criteria for CG. Conversely, CG criteria include many symptoms not highlighted in PTSD diagnostic criteria, such as a lost sense of meaning or purpose, confusion about one’s identity, and difficulty imagining one’s personal future. Importantly, the absence of a symptom from a diagnostic criteria set does not mean that the symptom is not part of the phenomenology of the disorder. Indeed, many of the symptoms present in one of these disorders (e.g., difficulty imagining one’s future in CG) have also been observed in those with the other disorder (e.g., a sense of foreshortened future in PTSD). Nonetheless, the non-overlapping symptoms in PTSD and CG suggest that failing to assess one of these disorders following bereavement may limit one’s understanding of what the patient is experiencing and, thus, may hinder efforts to form an appropriate case conceptualization and treatment plan; a possibility illustrated in our clinical vignettes.

Deborah endorses several symptoms of PTSD regarding the death of her son, including frequent and intrusive thoughts about the death, emotional reactivity to reminders of the event, emotional numbness, a sense of foreshortened future, and a feeling of being distant or cut-off from other people since the event. However, she does not report hypervigilance, hyperarousal, or difficulty sleeping. She does not feel that the world was a dangerous place and did not fear events like the one she experienced happening to her again. When she gets lost in intrusive thoughts about the event, her focus is not on the threat to her life, but on her perceived failure to protect her son. Instead of reacting to these memories with fear or horror, she reports intense guilt. She reports that her most intense emotional experience is yearning to be with her son again and a deep sense of emptiness without him. Based on her reporting of these symptoms, a full diagnostic interview would reveal that Deborah meets criteria for CG, but not for PTSD.

Joan yearns for her father, feels overwhelming waves of pain when reminded of his absence, and was hospitalized in the days leading up to the anniversary of his death due to an inability to cope with the overwhelming emotions tied to the loss. She is very bothered by frequent intrusive memories of her father lying dead in a hospital bed and her perception that he appeared to have been in great pain. She avoids all thoughts and reminders of his death, refusing even to say out loud that he had died for months following the death. She reports feeling constantly on guard and worried about her ability to manage without him. She jumps almost every time the phone rang for fear that she will learn that another family member had died. Joan meets diagnostic criteria for both CG and PTSD.

Finally, Matt is seeking treatment for his intense anxiety about driving; anxiety that led him to avoid being in a car at considerable and growing cost to his ability to function. Every time he is in a car, or even thinks about driving, Matt has intense physiological reactivity. In addition, vivid memories of the accident frequently intruded into his thoughts while he attempts to go about his day-to-day life. Matt has been irritable and had difficulty sleeping since the accident, reporting that he is often jumpy and quickly loses his temper. He has withdrawn from many of his friends and family and felt isolated from them. Although Matt greatly misses his wife, he feels he has been able to accept her passing and has begun to move forward in reestablishing his life with his daughters. However, those efforts have been limited by his inability to drive. Matt meets diagnostic criteria for PTSD without CG.

As these vignettes illustrate, the relationship between the type of bereavement and the presence of the PTSD syndrome is not especially straightforward. Deborah experienced a traumatic event by any conceivable definition of the word, yet does not meet diagnostic criteria for PTSD after the shooting death of her son. Joan meets full diagnostic criteria for PTSD under DSM-IV criteria, but under DSM-III or DSM-5 criteria she would be excluded from the diagnosis solely by virtue of the type of loss she experienced. In other words, she would be experiencing the PTSD syndrome despite not having technically experienced a trauma according to the letter of the diagnostic criteria.

Joan’s case suggests that the sudden and unexpected death of one’s father to heart failure is an event capable of eliciting the PTSD syndrome; a clinical anecdote consistent with Breslau’s finding that sudden and unexpected death of a loved one was the most commonly reported event by patients meeting diagnostic criteria for PTSD. Looking beyond these clinical vignettes, it is important to note that, to our knowledge, there is no evidence to suggest that some types of bereavement cannot lead to PTSD. Accordingly, there is no evidence to support categorically excluding any type of bereavement from the definition of trauma. Although certain types of loss may place individuals at greater risk than do others, this does not mean that only those losses with high conditional probability should be considered traumatic. Analogously, although assaultive violence has a higher conditional probability of provoking PTSD than does a motor vehicle accident [12], it does not follow that motor vehicle accidents should no longer qualify as a traumatic event. Indeed, if an event is capable of eliciting the PTSD syndrome, it is unclear whether there is any clinical rationale for excluding that event from the diagnostic criteria for PTSD.