Grief is an unavoidable and normal experience. But it can take intense
forms that surprise a bereaved person, including forms that in other
circumstances would be called a psychiatric disorder. In some cases,
psychiatric treatment may help.
Bereaved persons may suffer not only sadness but anger and suspicions
about the motives of people who offer support. They may ruminate obsessionally
about the events leading up to the death and blame themselves or others
for it. Up to 50% of widows and widowers have symptoms typical of major
depression in the first few months. They may also have hallucinatory
These symptoms are usually normal responses to the loss. They call for
comforting and sometimes explanation, but not treatment. But if the symptoms
linger and become increasingly debilitating, the condition turns into
what is now being called unresolved, protracted, traumatic, or complicated
grief. It has features of both depression and post-traumatic stress disorder
(PTSD). And there is some evidence that a distinct type of treatment
may bring relief.
The most characteristic symptoms are intrusive thoughts and images of
the deceased person and a painful yearning for his or her presence. Other
complications are denial of the death, imagining that the dead person
is alive, desperate loneliness and helplessness, anger and bitterness,
and wanting to die..
The risk of developing complicated grief depends on both the immediate
circumstances of the death and the background against which it occurs.
PTSD is more likely to follow a traumatic experience if the person who
undergoes it regards his reactions as a sign of weakness, fears that
he will lose his sanity, or ruminates about how he or someone else could
have prevented it from happening. These are also risk factors for complicated
grief, and the disorder is more likely to occur after a death that is
traumatic — premature, sudden, violent, or unexpected.
But even normal bereavement can produce complicated grief. Whether that
happens depends on how a person copes, not just with trauma, but with
loss. For anyone who could not respond to earlier losses without losing
emotional equilibrium, complicated grief becomes a greater danger. So
a person with a history of depression, anxiety disorders, or a personality
disorder is more likely to suffer complicated grief after bereavement,
as well as PTSD after a traumatic experience.
Treatment of complicated grief often relies on the idea that grieving
is an experience to be worked through. Some people are thought to be
stuck and unable to free themselves because of problems arising from
emotional instability, previous losses, or difficulties in their relationship
with the person who has died. A promising treatment called traumatic
grief therapy uses cognitive behavioral methods for traumatic symptoms
and stress relief, along with interpersonal techniques to encourage re-engagement
with the world.
Patients tell the story of the death repeatedly and listen to tapes
of the recitation — imaginal exposure. They learn to confront thoughts
and situations they may have been avoiding — in vivo exposure.
They evoke happy memories, and hold imaginary conversations with him
or her under a therapist’s guidance, exploring regrets or resentment.
They are encouraged to think about how to enjoy other activities rather
than dwell on the loss.
In one study, traumatic grief therapy was found to be especially effective
for people mourning a violent death; more than half of them improved,
compared with 13% in standard interpersonal therapy.
Complicated grief is not one of the disorders in the American Psychiatric
Association official diagnostic manual. .Some think a standard diagnosis
is needed to improve research on the symptoms of complicated grief. Others
regard that as simply another variation on PTSD. What matters is not
whether another diagnostic category is introduced, but how to identify
and help the minority of bereaved people who need more than the usual
comfort and support.
December 2006 Update
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