HOW TO TELL IF YOU HAVE GRIEF COMPLICATIONS

The significant differences between 'uncomplicated' grief and 'complicated' grief pertain to both the style of mourning for lost loved ones and the amount of time spent in mourning following the loss (Craig White 2013 pp16-20).


*Style of mourning for lost loved ones


People experience death and the subsequent feelings of bereavement and loss in very individual ways, all of which depend significantly upon the situation and circumstances regarding the death, the type of relationship with the deceased and the (pre-)disposition of the bereaved towards dealing with death. A range of other personal issues may also have bearing, all of which can be not only particular but unique to the individual. All of these factors may be deeply associated with the profound sense of loss that becomes people's idiosyncratic experiences of grief. 


*Amount of time spent in mourning following the loss


When the grief is persistent, at least persistently intermittent, over time i.e. years/decades this is indicative of what is often referred to as 'unprocessed' grief, in other words grief that hasn't been negotiated and worked through within the short to medium term. In cases where the grief perdures and becomes a significantly long-term feature of a person's life it may be the case that they are suffering from complications pertaining to it.


For more information on the differences between 'Acute/Normal/Uncomplicated' Grief and 'Complicated' Grief please use the following LINK:

MAIN FEATURES OF CG/PCBD/PGD

Although there is some conjecture regarding the length of time that needs to elapse for grief to be considered 'complicated' it can be defined as prolonged grief symptoms that last for at least one month following six months of bereavement (Holly Prigerson et al 2009, Katherine Shear et al 2011). 


These denote atypical, pathological mourning styles and patterns that are both prolonged and remain overly intense and relatively unchanging over time. This can include particularly strong feelings and longing for the person who has died, affecting an individual's ability to return to routine aspects of living and restoring their quality of life. There may be inability to deal with or process the death and the circumstances around it, leading to a range of grief complications including profound emotional pain and intense preoccupation with the deceased (Craig White 2013 pp14-15).


Symptoms of CG/PCBD 


The following are symptomatic of Complicated Grief/Persistent Complex Bereavement Disorder:


  1. Intense longing or pining for the deceased (feelings of not being able to live without the person who has died, recurrent urges to die in order to join the deceased)
  2. Problems accepting the death (unreal/surreal feelings that can't be processed in relatively straight-forward ways
  3. Numbness or detachment (blocking-out/relegating/ignoring certain emotions and feelings, relationship problems e.g. commitment, responsibility, forming and maintaining attachments
  4. Preoccupation with the sorrow (focus on memento mori, dressing in funereal shades, listening to funeral dirges, attending the funerals of others, attending places of death such as churches and cemeteries, close affinities with death and death subjects)
  5. Preoccupation with memories of the deceased (geographical locations as sites of memory/sites of struggle e.g. homes, churches, crematoria, graveyards, focus on significant past life events e.g. anniversaries of death)
  6. Extreme focus on the loss and reminders of the loved one OR extreme avoidance of the same (artefacts such as photos/audio/video recordings, material possessions of the deceased e.g. jewellery/clothing)
  7. Bitterness about the loss (senses of injustice, senses of regret, difficulties with 'positive' reminiscing i.e. bitter-sweetness)
  8. Sense of persecution (feelings of being cursed, punishment/castigation, a perpetual feeling of 'unfairness')
  9. Feeling that life holds no meaning or purpose (anhedonia, feelings of ennui i.e. vacuous time-space, suicidal thoughts/scripts, continuous reckoning with mortality via religion and philosophy etc)
  10. Inability to enjoy life or severe impairment of enjoyment (seeing the world through a veil or a shroud, negative and pessimistic dispositions/outlooks, hopelessness for the future, a flat/dull/blank outlook on life)
  11. Depression or deep sadness (mild to severe depression for years/decades, intermittent feelings of 'wellness' and 'illness' normalised over time, feelings of helplessness
  12. Waves of painful emotion (dull aches and sensations that pertain to deep sadness and/or sorrow, chronic emotional dysregulation, a continuous sense of feeling overwhelmed)
  13. Trouble carrying out regular routines (tendency to withdrawal and aloneness, inability/reluctance to get-up/go out, impaired mental and physical functioning)
  14. Withdrawal from social activities (failure to maintain social appointments, letting people down at short notice, erratic/unpredictable behaviours etc)
  15. Prolonged dysfunction in work/study activities (long-term 'sick leave' and 'compassionate leave', inability to focus and maintain motivation and/or performance levels, reluctance and/or inability to work in teams)
  16. Visual and auditory ideation (seeing visions/apparitions of the deceased, hearing voices of the deceased, feelings of being haunted, even possessed by spirits)
  17. Issues with time (a constant need to go back and forward in time, a perpetual desire to live in the past rather than the present, the feeling of 'losing' time, the feeling of time constantly 'looping')
  18. Excessive preoccupation with past events (as if the past becomes an artifice for the present, imaginary lives with the deceased i.e. as if they hadn't died
  19. Playing out 'rôles' (developing and maintaining public faces/personas as 'alter-egos' in order to deal with changing life situations, maintaining façades, 'acting' out being in certain states/moods, divorcement from a 'real' sense of self)
  20. Irritability or agitation (a short temper with predisposition towards verbal violence, tiring of company very quickly)
  21. Unpredictable or surprising outbursts (verbal, physical and/or emotional
  22. Physical ailments (erratic sleep patterns, appetite loss, hair loss, being prone to illness, a feeling of being constantly 'run-down'
  23. Lack of trust in others (feeling like behaviours are some type of a conspiracy, believing that others will let you down, feeling that people, even friends, are real or potential enemies
  24. Engagement in destructive behaviours (patterns of addictive behaviour e.g. alcohol/narcotics, binge-eating, crash-dieting, engaging in dangerous activities
  25. Combinations of the above factors, causing further complications, the principle catalyst having been the death of a loved one


The above symptomology is based on personal experiences of living with CG/PCBD/PGD. It is not intended to be an exhaustive list of symptoms and manifest behaviours, nor is it intended to be read in any particular order.


Although some of these factors may be symptomatic of 'acute/normal/uncomplicated' grief in the short-term, a person suffering from CG/PCBD/PGD is disposed to develop these symptoms over a long period of time i.e. in terms of years and decades. These symptoms are not necessarily mutually exclusive, they may exist in combination with each other and change over time, each manifesting in various ways, dependent upon situations and contexts as well as feelings and moods. 


Relevant Precictors/Risk Factors 


A number of predictors have been identified for the development of grief complications after bereavement (Carol Ott et al 2007). These may include any or all of the following:


-First-degree relationship to the deceased


-Separation anxiety in childhood


-Controlling parents


-Abuse by or death of parents during childhood


-A poorly-functioning marriage/relationship 


-Insecure attachment style(s)


-Emotional dependency on the deceased


-Nature of relationship (bereaved teenager, bereaved mother, bereaved male spouse) 


-Family members/friends of patients with life-threatening illnesses (terminal illness, palliative care, acute care settings)


-Pre-existing mental health issues (stress, anxiety, psychiatric disorders etc.)


-Substance abuse issues (alcohol, narcotics, steroids etc.)


-Lack of preparation for the death (a sudden or shocking death)


-Traumatic death 


-Violent death 


-Discovering and/or identifying the body (violent death)


-Recency of the death 


-Death in hospital 


-Pessimistic outlook (especially after deaths


-Low self-reported social support (especially after funerals


DIAGNOSTIC CRITERIA

'UNCOMPLICATED' GRIEF VS. 'COMPLICATED' GRIEF


There are a number of recognised inventories/scales that can be used to indicate Complicated Grief/Persistent Complex Bereavement Disorder/Prolonged Grief Disorder (CG/PCBD/PGD). However, diagnosis is still a problematic area and there is a certain amount of conjecture regarding the application and efficacy of these measures.


The following is a summary/overview of the proposed diagnostic criteria for 'Persistent Complex Bereavement Disorder' (PCBD) in the Diagnostic & Statistical Manual of Mental Disorders - 5th Edition (DSM-V). 


*Note that this diagnostic criteria differs to that of 'Complicated Grief'. 

**Note that this diagnostic criteria also differs to that of 'Prolonged Grief Disorder' 


Persistent Complex Bereavement Inventory (DSM-V)


Criterion A: 


The bereaved person has experienced the death of a loved one.


Criterion B: 


Since the death at least one of these four symptoms has been experienced on more days than not and have persisted at least twelve months after the death:


-Persistent yearning/longing for the deceased


-Intense sorrow and emotional pain in response to death 


-Preoccupation with the deceased


-Preoccupation with the circumstances of the death 


Criterion C: 


Since the death, at least six of twelve symptoms have been experienced more days than not and have persisted for at least twelve months:


-Marked difficulty accepting death 


-Experiencing disbelief or emotional numbness 


-Difficulty with positive reminiscing about the deceased 


-Bitterness, or anger related to the death


-Maladaptive appraisals about oneself in relation to the deceased or the death (e.g. self-blame)


-Excessive avoidance of reminders of the loss


-A desire to die in order to be with the deceased 


-Difficulty trusting other individuals since the death


-Feeling detached from other individuals since the death

 

-Feeling 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 own identity 


-Difficulty or reluctance to pursue interests since the loss or to plan for the future 


Criterion D: 


-The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.


Criterion E 


-Distress or impairment is outside of socio-cultural norms 


Although the above criteria related to in DSM-V (Persistent Complex Bereavement Disorder) have not been adopted formally they may be instrumental in terms of the specification of the manifestations, the severity of symptoms and ways in which complicated grief may be distinguished from 'uncomplicated' grief.


For more information on the Medical Case of 'Complicated Grief' and 'Persistent Complex Bereavement Disorder' please use the following LINK:

DISCLAIMER

 Please note that the information presented on these web-pages is not a substitute for medical advice or for seeking professional help through therapy and/or other forms of treatment.  

REFERENCES

Ott, Carol, Lueger, Robert, Kelber, Sheryl & Prigerson, Holly (2007), Spousal bereavement in older adults: common, resilient and chronic grief with defining characteristics, Journal of Nervous Mental Disorders, 195(4): pp.332-341


Prigerson, Holly, Horowitz, Mardi, Jacobs, Selby, Parkes, Colin, Aslan, Mihaela, Goodkin, Karl, Raphael, Beverley, Marwit, Samuel, Wortman, Camille, Neimeyer, Robert, Bonnano, George, Block, Susan, Kissane, David, Boelen, Paul, Maercker, Andreas, Litz, Brett, Johnson, Jeffrey, Michael, First & Maciejewski, Paul (2009), Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11, PLoS Medicine, 6(8)


Shear, Katherine, Simon, Naomi ,Wall, Melanie, Zisook, Sidney, Neimeyer, Robert, Duan, Naihua, Reynolds, Charles, Lebowitz, Barry, Sung, Sharon, Ghesquiere, Angela, Gorscak, Bonnie, Clayton, Paula, Ito, Massaya, Najajima, Satomi, Konishi, Takako, Melhem, Nadine, Meert, Kathleen, Schiff, Miriam, O’Connor, Mary-Frances, First, Michael, Sareen, Jitender, Bolton, James, Skritskaya, Natalia, Mancini, Anthony & Keshaviah, Aparna (2011), Complicated grief and related bereavement issues for DSM‐5, Depression and Anxiety, 28, 103-117


White, Craig (2013), Living with Complicated Grief

London: Sheldon Press 


Diagnostic & Statistical Manual of Mental Disorders - 4th Edition (DSM-IV/DSM-4) Washington DC (US): 


American Psychiatric Association 

Diagnostic & Statistical Manual of Mental Disorders - 5th Edition (DSM-V/DSM-5)

Washington DC (US): American Psychiatric Association 



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