PROMOTING EDUCATION & AWARENESS OF LONG-TERM 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 intricated 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:
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 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:
The above symptomology is based on personal experiences of living with CG/PCBD.
Although some of these factors may be symptomatic of 'acute/normal/uncomplicated' grief in the short-term, a person suffering from CG/PCBD 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, dependant 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
-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)
-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)
'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 (CG/PCBD). 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'.
Persistent Complex Bereavement Inventory (DSM-V)
The bereaved person has experienced the death of a loved one.
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
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
-The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
-Distress or impairment is outside of sociocultural 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:
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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