Day # 102: Grief and Bereavement

We are continuing our current theme of trauma and stressor related disorders. Today we will discuss normal bereavement (acute grief) and compare that with persistent complex bereavement.

Today's Content Level: Intermediate

INTRODUCTION 1

• Grief is the powerful emotional response that occurs following the death of a loved one or other difficult "losses" in life.

• In this article we will focus specifically on grief secondary to the death of a loved one, but other possible losses include ending a relationship, development of a serious illness, losing physical mobility or independence, etc.

• Grief is typically a normal, natural, and necessary way we have evolved to respond to difficult losses.

• Grief is not a single emotion but rather an "experience" and is unique to each person. Many individuals will experience some or all of the features listed in the next section.

• The majority of survivors heal over time and their symptoms of grief gradually improve as they resume their routines and activities. They are able to function in their life.

• The stages of normal grief are well-known but sometimes debated. See more detail here if interested. These stages do not necessarily occur in order:

  1. Denial and isolation (sometimes called numbness-disbelief)

  2. Anger (sometimes called separation distress)

  3. Bargaining

  4. Depression (sometimes called mourning)

  5. Acceptance (sometimes called recovery)

• Complicated grief occurs when grief responses are considered excessive. Individuals do not progress through the normal healing process and have continued symptoms and dysfunction.

• Occurs more days than normal and persist for > 12 months in adults (>6 months in children).

• Complicated grief has gone by many different terms -> pathological grief; abnormal grief; chronic grief; complicated grief disorder; persistent complex bereavement disorder (DSM-5).

NORMAL (ACUTE) GRIEF vs COMPLICATED GRIEF 2

CRITERIA FOR COMPLICATED GRIEF 3

• Persistent complex bereavement disorder is actually not yet included in the stressor related disorder section in DSM-5. Currently it is included in the "conditions for further study" section and the following is the *proposed* criteria.

• Experiences the death of a loved one or someone they had a close relationship with.

• Symptoms occur more days than not for >12 months after the death (>6 months if patient is a child).

  • Symptoms may include persistent yearning/longing/preoccupation for the deceased, intense emotional pain/sorrow, or a preoccupation with the circumstances of the death. (at least one of the above)

  • Symptoms of reactive distress: difficulty accepting the death, avoidance of reminders, emotional numbness, bitterness/anger, self-blame, or difficulty with positive reminiscing about the deceased.

  • Symptoms of social/identity disruption: difficulty trusting others, feeling alone/detached, feeling that life is now meaningless, diminished sense of identity, difficulty maintaining interests/hobbies, or desire to die in order to be with the deceased.

  • At least six combined symptoms of reactive distress and social/identity disruption.

• Specify if associated with traumatic bereavement. Includes bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death.

CLINICAL PEARLS 4, 5, 6, 7

• Lifetime prevalence of complicated grief is ~ 2.5-5%. The conditional prevalence of developing complicated grief after acute grief is ~ 7%.

• More common in women than men.

• Risk factors for development of complicated grief include:

  • Type of relationship lost: increased risk after loss of a child or spouse

  • Circumstances of the loss: unexpected, violent, or loss from a chronic/terminal illness

  • Demographics: female gender; older age (>61); non-caucasian race; low socioeconomic status

  • History of mental anxiety or depression or PTSD

• Screen all adults who have bereaved for 12 months, children for 6 months, and all bereaved individuals who seek treatment for suicide risk and mood/anxiety disorders.

• Examples of screening questions: How much are you having trouble accepting the death of your loved one? How much does your grief interfere with your life? Are there things you used to do when they were alive that you don't feel comfortable doing anymore, or that you avoid? Example screeners include the Brief Grief Questionnaire and the Inventory of Complicated Grief.

• Other important features of the clinical interview include:

  • Duration and intensity of symptoms; avoidance behaviors; social withdrawal; sleep; appetite; hallucinations; thoughts regarding the deceased/self/others.

  • Screen for additional stressful events or trauma.

  • Substance history.

  • Family history of psychiatric disorders and suicide.

  • Suicide risk assessment. Suicidal ideation and behavior occurs in 40-60% of individuals with complicated grief after controlling for comorbidities.

  • Rule out normal bereavement, adjustment disorder, depressive disorders, anxiety disorders, acute stress disorder, and PTSD.

TREATMENT 8, 9, 10, 11

• Acute grief: As mentioned previously, the majority of survivors heal over time and their symptoms of grief gradually improve as they resume their routines and activities. Does not typically require clinical treatment, however screening for and treating comorbid conditions is important as grief can worsen psychiatric illness.

• Complicated grief: Close outpatient monitoring and education is important in these patients since individuals with complicated grief have greater risk for suicide, worsening of comorbid conditions, and in general have a greater risk of adverse health outcomes. They should be considered for clinical intervention.

• Psychotherapy: Randomized controlled data support the efficacy of targeted psychotherapy and include a menu of options such as cognitive behavioral therapy (CBT), interpersonal therapy (IPT), behavioral activation, and a relatively new method called complicated grief therapy (CGT). CGT is drawn from attachment therapy with roots in IPT and CBT and has proven to be effective. Therapeutic elements include repeatedly telling the story of the death (exposure) and focusing on personal goals and relationships,

• Pharmacotherapy: Medications are not typically recommended for the treatment of acute grief. More research is needed in order to provide a firm recommendation for medications in complicated grief. Preliminary studies suggest antidepressant medications (ex: SSRIs, SNRIs, TCAs) may be helpful, however the data is mixed and shows they may be more efficacious for depressive symptoms than for grief-specific symptoms. A study in 2016 showed addition of citalopram to therapy was no more effective than placebo with therapy.

CONCLUSION

Nice work today. I hope this was a helpful comparison post. We are continuing our trauma and stressor related disorders theme and next post we will discuss an introduction to post-traumatic stress disorder.

Resources for today's post include Pocket Psychiatry and DSM-5.

Bullet Psych is an Amazon Associate and we receive a small commission if you use our links for the purchase of our recommended resources.