GRIEF COMPLICATIONS: A MEDICAL OVERVIEW

BACKGROUND 

 

In evaluating the origins of CG/PCBD/PGD, it is important to bear in mind that this is a “hybrid” disorder concerning maladaptive grief, the specific criteria for which can be traced back to several schools of thought regarding its essential nature and distinguishing features (Julie Kaplow et al 2014). These schools of thought include “pathological grief” (Mardi Horowitz et al 1993), “prolonged grief disorder” (Holly Prigerson et al 2009), and “complicated grief” (Katherine Shear et al 2011).


On this website the conditions being outlined above are referred to throughout as 'Complicated Grief' (CG), 'Persistent Complex Bereavement Disorder' (PCBD) and 'Prolonged Grief Disorder' (PGD). This is the manner in which they have been described and are currently being described according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), up to and including the latest 5th Edition (DSM-V).


There is an entry for ‘Complicated Grief’ in DSM-IV, whereas this is referred to as ‘Persistent Complex Bereavement Disorder’ in DSM-V (there is no entry for ‘Complicated Grief’ in DSM-V). The choice to include PCBD as an appendix disorder in DSM-V is an acknowledgement of the important contributions made to date by prolific researchers in helping to map out the general landscape of grief and in identifying indicators of bereavement-related pathology (Julie Kaplow et al 2014).


Instead of adopting the name of any previously studied grief construct (e.g. complicated grief, prolonged grief disorder, patholgical grief) a new name - 'Persistent Complex Bereavement Disorder' - was selected for the disorder. In outlining 'conditions for further study', the DSM is thereby inviting further research that can be used to more carefully delineate the syndrome (Kenneth Doka 2017). 


In addition to the DSM, the World Health Organisation's (WHO) International Classification of Diseases (ICD) is a particularly useful manual. It's related to, though distinct from, the DSM. While the DSM is essentially a product of American psychiatry, the ICD is broader both in authorship and scope as it recognises all diseases and conditions, not just mental disorders (Jonathan Raskin 2018).     

The latest version of the ICD (ICD-XI) has included 'Prolonged Grief Disorder' (PGD) as a new category for severe, enduring grief. ICD does not require a specified number of symptoms but rather provides “diagnostic guidance that is sufficiently flexible to allow for cultural variation and clinical judgment” (Geoffrey Reed 2010).


This is a particularly significant development and is likely to provide a great impetus for research and treatment development for bereaved persons suffering with protracted grief (Maarten Eisma & Lonneke Lenferink 2018).

DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS (DSM)

First introduced in 1952 by the American Psychological Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM) offers a common language and standard criteria for the classification of mental disorders. It is now in its fifth edition - DSM-V - published in 2013. 


DSM-V recognises that there are more complicated variants of grief than were previously considered under former DSM categories. In acknowledging it's unique symptomology, therefore, the DSM-V Workgroup is seeking to establish that complex mourning is a recognisable and diagnosable syndrome, distinct from diagnostic 'nearest neighbours' including Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD) and Generalised Anxiety Disorder (GAD) (Kevin Fleming 2018, James Hawkins 2015/2016). 


Exclusion of Grief from Adjustment Disorders


The DSM-V removed the exclusion of grief from Adjustment Disorders. There is specific notation that such symptoms are beyond the cultural expectations of normal bereavement (Kenneth Doka 2017).


Inclusion of Separation Anxiety Disorder to adults 


The DSM-V makes the distinction that while grief involves yearning for the deceased, fear of separation, perhaps triggered by a loss, from other attachment figures is important. Thus the DSM-V allows Separation Anxiety Disorder - once a diagnosis exclusively used with children and adolescents - to be applied to adults (Kenneth Doka 2017).


Exclusion of Bereavement from Major Depressive Disorder (MDD)


The removal of the bereavement exclusion criterion in DSM-V excludes uncomplicated bereavement of brief duration, however, it does not exempt depressive reactions to other losses, including longer-term cases of complicated bereavement (Jerome Wakefield & Michael First 2012).


The 'Medicalisation' of Grief 


The ways in which the definition and subsequent (re-)categorisation of this condition is being considered in both medical/non-medical contexts raises genuine concerns and has profound implications for those affected e.g. the exclusion of grief from Adjustment Disorders and the application of Separation Anxiety Disorder to adults (Kenneth Doka 2017). 


In particular the exclusion of bereavement from Major Depressive Disorder in DSM-V has profound implications for both diagnosis and treatment of CG/PCBD. Front-line medical services may be more likely to conflate CG/PCBD with depression and treat the condition with anti-depressants, both distorting the loss-adjustment process and (over)-medicalising the issue (Kenneth Doka 2017). 


Substantial conjecture exists as to whether protracted grief complications actually pertain to mental illness and whether or not it should be designated/diagnosed as such (Leeat Granek 2010, 2014, Leeat Granek & Meghan O'Rourke 2012). Given that there is no background of psychological disorder, medication should arguably only be used as a last resort. Medications can be used in treatment but sparingly in order to prevent dependence and so as not to hamper the necessary and vital process of grieving. 


Comorbity


Grief complications may be 'comorbid' i.e. present with one or more additional disorders. The most common mental health disorders to accompany grief complications are Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD) and Generalised Anxiety Disorder (GAD) (Kevin Fleming 2018, James Hawkins 2015/2016).


Factor analytic studies suggest that the symptoms of complicated or prolonged grief are a unitary construct distinct from the more transient symptoms of depression and anxiety that characterize normal bereavement (Holly Prigerson et al 2008). Although symptoms are different to these diagnostic 'nearest neighbours' there may be similarities (Kevin Fleming 2018). This may lead to differential diagnosis and potentially mis-diagnosis, in some cases. 


Associated Health Risks/Issues


Grief complications impact on mental, emotional, physical and social functioning and have long-term effects on health (Patrizia Lannen et al 2008). A prolonged state of abnormal grief has been associated with elevated rates of suicidal ideation and suicide attempts. Over time certain symptoms can be exacerbated and may include cancer, hypertension and cardiac events, all of which are more likely after several years.  Immune disorders and evidence of immune dysfunction are also more frequent. In addition, adverse health behaviours are more frequent, and reported functional impairment is greater with health care services used to a greater extent and higher rates of sick leave. 


Positive Benefits (?)


There are positive benefits to be derived from the long-term grieving process, which may explain, at least partially, why grief issues tend to perdure in certain cases. 


Since the brain of a 'complicated' grief sufferer processes grief differently i.e. activation in brain imaging of the nucleus accumbens, which is not seen in 'non-complicated' grief suffers, this suggests that reminders of the deceased may activate the neural reward system and interfere with adaptation (Mary-Frances O’Connor et al 2008). 


The pleasure derived from suffering as well as pain might explain why people suffering complex grief are unable to get better over time. 


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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

Eisma, Maarten & Lenferink, Lonneke (2018), Response to Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability, European Journal of Psychotraumatology 2018, 9(1): 1512249  


Killikelly, Clare & Maercker, Andreas (2017), Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability, European Journal of Psychotraumatology 2017, 8(6): 1476441 


Horowitz, Mardi, Bonanno, George & Holen, Are (1993), Pathological grief: Diagnosis and explanation, Psychosomatic Medicine, 55, pp.260-273


Kaplow, Julie, Layne, Christopher & Pynoos, Robert, 'Persistent Complex Bereavement Disorder as a Call to Action’, Posted 21st January 2014 in StressPoints 


Lannen, Patrizia, Wolfe, Joanne, Prigerson, Holly, Onelov, Eric, & Kreicbergs, Ulrika (2008), Unresolved grief in a national sample of bereaved patients: Impaired physical and mental health 4 to 9 years later, Journal of Clinical Oncology 26(36), pp.5870-5876


O’Connor, Mary-Frances, Wellisch, David, Stanton, Annette, Eisenberger, Naomi, Irwin, Michael & Lieberman, Matthew (2008), Neuroimage, 42(2): pp.969-972


Prigerson, Holly, Vanderwerker, Lauren, & Maciejewski, Paul (2008), 'A case for the inclusion of prolonged grief disorder in DSM-5' in Stroebe, Margaret, Hansson, Robert & Schut, Henk (Eds), Handbook of Bereavement Research and Practice: Advances in Theory and Intervention (pp.165-186)

Washington DC (US): American Psychological Association


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)       


Reed, Geoffrey (2010), Toward ICD-11: Improving the clinical utility of WHO’s International Classification of mental disorders, Professional Psychology: Research and Practice, 41(6), pp.457–464


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


Wakefield, Jerome & First, Michael (2012), Validity of the bereavement exclusion to major depression: Does the empirical evidence support the proposal to eliminate the exclusion in DSM-5? Posted in World Psychiatry: Official journal of the World Psychiatric Association, 11(1): pp.3-10, February 2012


'Complicated Grief is Complicated - Grief in the DSM-5 by Kenneth Doka, Article posted 3rd January 2017, Psychology Today On-line

https://www.psychologytoday.com/gb/blog/good-mourning/201701/complicated-grief-is-complicated


'Persistent Complex Bereavement Disorder DSM-5' by Kevin Fleming, article posted on Theravive https://www.theravive.com/therapedia/persistent-complex-bereavement-disorder-dsm--5


'Complicated Grief - how common is it?' by James Hawkins, Good Medicine, Originally added 24th September 2015, Updated 28th January 2016 http://goodmedicine.org.uk/stressedtozest/2015/09/complicated-grief-how-common-it


What's New In The International Classification of Diseases' by Jonathan Raskin, Article posted 25th July 2018, Psychology Today On-line https://www.psychologytoday.com/gb/blog/making-meaning/201807/what-s-new-in-the-international-classification-diseases


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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