Complicated grief disorder

In psychiatry, complicated grief disorder (CGD) is a proposed disorder for those who are significantly and functionally impaired by prolonged grief symptoms for at least one month after six months of bereavement.^[1] It is distinguished from non-impairing grief^[2] and other disorders (such as major depressive disorder^{[3][4][5][6][7][8]} and posttraumatic stress disorder).^{[4][5][6][9][10]} This disorder has been reviewed by the DSM-5 work groups, who have decided that it be called Persistent complex bereavement disorder and placed it in the chapter on Conditions for Further Study in the new DSM-5.^[11]

Description

Complicated grief is considered when an individual’s ability to resume normal activities and responsibilities is continually disrupted beyond six months of bereavement. Six months is considered to be the appropriate point of CGD consideration, since studies show that most people are able to integrate bereavement into their lives by this time.^{[12][13][14][15][16]}

Symptoms

The symptoms of complicated grief are mentioned in the most-recently-proposed diagnostic criteria; they include maladaptive thoughts and behaviors related to the death or the deceased, continuous emotional dysregulation about the death, social isolation and suicidal ideation.^[1]

Causes and predictors

Although more research is needed to determine the multiple pathways to complicated grief disorder, preexisting conditions (such as major depression, PTSD, and sleep disorders) are thought to exacerbate the interruption of the natural healing process.^[1]

There are some known predictive characteristics for CGD.^[1] An individual is at risk for CGD if they are:

• Female^[5][17]
• Pessimistic^[18][19]
• Previously diagnosed with a mood disorder^[4][6]
• Low self-reported social support^[20]
• An insecure attachment^{[21][22][23][24][25]}
• High stress^[20]
• A positive caregiving experience and dependency on the deceased^[26][27][28]

Consequences

Untreated CGD has clinically significant consequences. A high level of impairment can be pervasive,^{[3][4][6][10][17][29][30][31][32][33][34][35][36]} including destructive thoughts and behaviors (such as substance abuse).^[16][37] CGD may worsen the course of preexisting disorders and contribute to the development of new ones.^[38][39]

Proposed diagnostic criteria

According to Shear et al. (2011):^[1]

• The person has been bereaved (i.e. experienced the death of a loved one) for at least six months
• At least one of the following symptoms of persistent, intense, acute grief has been present for a period longer than is expected by others in the person’s social (or cultural) environment:
  • Persistent intense yearning or longing for the person who died
  • Frequent intense feelings of loneliness, or that life is empty or meaningless without the person who died
  • Recurrent thoughts that it is unfair, meaningless or unbearable to live when a loved one has died, or a recurrent urge to die in order to find (or join) the deceased
  • Frequent preoccupying thoughts about the person who died; e.g. thoughts or images of the person intrude on activities or interfere with functioning
• At least two of the following symptoms are present for at least one month:
  • Frequent, troubling rumination about the circumstances (or consequences) of the death (concerns about how or why the person died, about not being able to manage without their loved one, thoughts of having let the deceased person down, etc.)
  • Recurrent feeling of disbelief or inability to accept the death
  • Persistent feeling of shock; feeling stunned, dazed or emotionally numb since the death
  • Recurrent feelings of anger or bitterness related to the death
  • Persistent difficulty trusting or caring about other people, or envy of others who have not experienced a similar loss
  • Frequently experiencing pain (or other symptoms) that the deceased person had, hearing the voice of (or seeing) the deceased person
  • Experiencing intense emotional or physiological reactivity to memories of the person who died or to reminders of the loss
  • Changes in behavior due to avoidance (or its opposite, excessive proximity-seeking—refraining from going places, doing things, or having contact with things that are reminders of the loss; feeling drawn to reminders of the person—wanting to see, touch, hear or smell things to feel close to the person who died). Both symptoms may coexist in the same individual.
• Duration of symptoms and impairment of at least one month
• Symptoms cause clinically significant distress or impairment in social, occupational or other major areas of functioning, where impairment is not explicable as a culturally appropriate response

Incidence

CGD is an atypical grief response, occurring only in a minority of the bereaved population.^[16][22] It is considered more common in those experiencing disasters,^{[5][17][40][41]} violence^{[42][43][44][45]} or the loss of a child.^[46][47][48]

It has also been found in family members (or friends) of:

• Patients with life-threatening illnesses^{[26][49][50][51]}
• Suicides and homicides^[44][52]

CGD is found to be prevalent cross-culturally in Europe,^{[18][21][53][54][55][56][57][58][59]} the Middle East,^[40][60] Africa,^[61] and Asia.^{[26][62][63][64][65][66]}

Treatment

CGD is relatively unresponsive to antidepressants^[67] or interpersonal psychotherapy;^[68] however, recent studies support the use of CG-targeted psychotherapy^[49][69][70] (similar to PTSD-targeted psychotherapy). Other methods of psycho-pharmacological treatment are under investigation.

CGD and bereavement-related adjustment disorder

Although the DSM-5 work groups have suggested using "adjustment disorder, specified as bereavement-related" to diagnose complicated grief, opposing opinions contend that this does not fit the nature of CGD and is an inappropriate diagnosis for those suffering from CGD.^[1][71]

Ethical considerations

Medicalizing (or misdiagnosing) normal grief

Following the DSM-5 work groups’ recommendation to remove the bereavement-exclusionary criteria,^[72] there is some concern that the addition of CGD may increase the possibility of medicalizing the grieving process. However, proponents of CGD claim that with proper clinical assessment only those with abnormally incapacitating levels of grief will receive this diagnosis and benefit from treatment. Furthermore, despite the possibility of diagnosis-related stigma the clinical necessity for treatment is a priority for those suffering from CGD.^[1]

Cultural norms for grief

An individual’s culture plays a large role in determining an inappropriate pattern of grief, and it is necessary to consider cultural norms before reaching a CGD diagnosis.^[1] There are cultural differences in expected emotional levels, their expression and duration; the external symptoms of grief differ in non-Western cultures, presenting increased somatization.^[73]

See also

• Ghost sickness

References

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External links

• Complicated Grief Program
• Is mourning madness?
• After a Death, an Extreme Form of Grieving
• APA’s Ethical Principles of Psychologists and Code of Conduct