Grief & Complicated Grief

Grief can be an extremely painful process. It’s something all of us have experienced, or will experience, in our lives. Losing someone or something you love is difficult.

Death has always been a major concern of humanity since the beginning of history, and finding the secret of immortality and escaping death has become the subject of many myths and ancient stories. According to the Central Statistics Office (CSO) in Ireland there were 50,627 deaths in 1916 in Ireland which gave a death rate of 16.1 per 1,000 of the population, (when the population in 1911 was 3.1 million). In 2014 the population had increased to over 4.6 million but the number of deaths had fallen sharply to just 29,095, giving a death rate of 6.3. (CSO, 2016) However, despite the current drop in mortality, the death of a close friend or relative remains one of the most intense, distressing, and traumatic events a person will experience. 

The effects of grief can often resemble depression and some people do go on to develop depression following a significant loss. In some people, grief can be prolonged or more intense, and it may interfere with their ability to cope with everyday life causing what we called Complicated Grief (CG). This paper will present and discuss the concept about Complicated Grief including causes and interventions.

Death has always been a major concern of humanity since the beginning of history. This can be seen in the Middle Ages where thoughts about death, and modern-era ideas can be regarded as a rebellion against pre-Renaissance ideas. Socrates once defined philosophy as “the pursuit of death” and became immortal by his teaching and example of how a philosopher should conduct himself in the face of death. (Gray, 1951 p.113) 

Among philosophers who have addressed the subject of death, such as Nietzsche, Sartre and Heidegger addressed not only immortality and life after death but also the nature of death during one’s existence. Nietzsche argues in Thus Spoke Zarathustra that life is the “consummating death”. As far as he is concerned, death is in no way understood without a relationship to life, and it is not just the absolute fear that should be avoided through procrastination. Nietzsche also spoke about not thinking of death, expressed happiness about that and stated that he considered thoughts about life more desirable than thoughts about death. Understanding Nietzsche’s thanatology is pivotal because his understanding of death is closely related to the meaning of life on earth that he ultimately attempts to seek, and thus penetrates the crucial ideas in his critique of religion in general, Christianity in particular, being deeply rooted in transcendent metaphysics. (Nietzsche, 2006 p.53)

Heidegger thus considers that knowledge about death leads to understanding of Existence and that knowledge of Existence will result in knowing the universe. Heidegger knew death as the full characteristics of humanity, and in his view, only the animal was destroyed and deprived of the property of death. His emphasis on this aspect of human existence was the extent to which he knew the inability to think of death as a disability of one who does not think about death, he knew certain shortcomings associated with being human, and he knew that being an original human depends on thinking about death. (Heidegger, 1393 p. 299)

Finally, In Being and Nothingness, the philosopher Jean-Paul Sartre boldly asserts that death is not a structure of the for-itself (pour-soi) at all. In fact, death is the final ‘fact’ that “alienates us wholly in our life to the advantage of the Other. “To be dead,” Sartre continues, “is to be a prey for the living.” Death, therefore, cannot appear in a situation because death is that which “comes to us from the outside and transforms us into the outside.” (Sartre, 1956 p.543-545).

“The pain is there; when you close one door on it, it knocks to come in somewhere else…”
Irvin D. Yalom (Yalom, 2008)

The loss of a loved one is a tragedy unequalled by any other for most bereaved people. It is an experience that occurs some time or other in nearly everyone’s life, and many suffer losses long before they reach old age, when such events occur with increasing frequency. Because of the intensity of the loss experience, the large number of people it effects, and the systematic variations with which its consequences are distributed across populations, bereavement has far-reaching implications. (Stroebe, Stroebe & Hansson, 2010 p.3)

The main implication of loss is foremost grief, which is defined as an universal human experience; however, it is also a very individual and subjective one. (Larsson, P.,2013) This means that even though the feelings experienced when grieving, such as sadness and yearning, might be similar across cultures how we manage and make sense of these feelings is both individual and context dependent. In other words, how we cope with the experience of loss depends on a number of factors, for example, our own individual psychology, our age and stage of development, gender, the nature of the relationship to the deceased, the culture we live in, the beliefs we have about the world which are related to that culture (our religious beliefs for example, or nonreligious beliefs for that matter), and others. (Larsson, P.,2013)

In addition, the authors specialised in the field , Stephen R. Shuchter and Sidney Zisook  defines it as a natural phenomenon with individualized process, that varies from person to person and moment to moment. (Stroebe, Stroebe & Hansson, 2010 p.3)  What these definitions say is that bereavement and grief is a process, which might begin before an individual has passed (for example, when a family member has been diagnosed with a terminal illness the grief process may already begin as there is an anticipation of loss), and then there is the loss itself, and perhaps most importantly, how we adjust to living with the loss. (Larsson, P.,2013)

Bereavement refer to the experience of having lost a loved one, not the response to such a loss. Grief refers to the psychobiological response to bereavement. Acute grief is the initial response, often intense and disruptive. Integrated grief is the permanent response after adaptation to the loss, in which satisfaction in ongoing life is renewed. (Shear, Ghesquiere & Glickman, 2013)

Elisabeth Kübler-Ross and David Kessler conceptualize grief adapted in 5 stages in their book On Grief and Grieving. The five stages, denial, anger, bargaining, depression and acceptance are a part of the framework that makes up our learning to live with the one we lost. The stages have evolved since their introduction and have been very misunderstood over the past four decades. The authors stated that it was never meant to help tuck messy emotions into neat packages. (Kübler-Ross & Kessler, 2005 pp. 7-28) This model was firstly introduced by Kübler-Ross in her 1969 book, On Death and Dying. See listed in order the five stages of grief:

  • Denial

Denial is usually only a temporary defence for the individual. This feeling is generally replaced with heightened awareness of situations and individuals that will be left behind after death. Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death of course is not particularly easy to avoid or evade indefinitely. 

  • Anger

Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps keep detached and non-judgmental when experiencing the anger of someone who is very upset. The individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy. 

  • Bargaining                                                                                                              

Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. This stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, “I understand I will die, but if I could just have more time…” 

  • Depression 

Also referred to as preparatory grieving. It’s a sort of acceptance with emotional attachment. It’s natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality. In that stage the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect oneself from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed. 

  • Acceptance 

In this last stage, the individual begins to come to terms with their mortality or that of their loved one. Moreover this stage definitely varies according to the person’s situation, although broadly it is an indication that there is some emotional detachment and objectivity.  (Kübler-Ross & Kessler, 2005 pp. 7-28)

This model originally was based off her work with terminally ill. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief. Often, people will experience several stages in a “roller coaster” effect switching between two or more stages, returning to one or more several times before working through it. (Kübler-Ross & Kessler, 2005 pp. 7-28)

In sum, according to the literature the grieving stages are not linear and it is highly personal and should not be rushed, nor lengthened, on the basis of an individual’s imposed time frame or opinion. One should merely be aware that the stages will be worked through and the ultimate stage of “Acceptance” will be reached. 

The Diagnostic and statistical manual of mental disorders (DSM), published by the American Psychiatric Association, is a compendium of mental disorders, a listing of the diagnostic criteria used to diagnose them, and a detailed system for their definition, organization, and classification. (A. Marty & L. Segal, 2015)

For many years, there have been calls for a diagnostic category in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) to reflect grief that signals departure from the normal course of accommodating loss and which warrants clinical attention. The diagnostic term for complications that arise in the course of grieving has been variously defined over the past 30 years, with a multitude of adjectives used to describe variations from normal grief. These terms include absent, abnormal, complicated, distorted, morbid, maladaptive, atypical, intensified and prolonged, unresolved, neurotic, dysfunctional, chronic, delayed, and inhibited. (Rando et al., 2012)

At the time many authors called to the field reiterating that complicated grief is complicated and cannot be confined to just one syndrome or disorder. In other words, there is not just a single form of complicated grief, but rather many forms of it. No single form should be construed to contain the full range of complicated grief. Instead, more comprehensive and robust perspective be maintained regarding this phenomenon and that future endeavours seek to identify other forms of complicated grief. (Rando et al., 2012) 

Eventually, the removal of the bereavement exclusion in the diagnosis of major depression was perhaps the most controversial change from DSM-5 was one of the most contentious decisions the DSM-5 work groups made and, by some lights, the most controversial decision by the American Psychiatric Association (APA) since homosexuality was removed from the list of psychiatric disorders in 1973. (Pies, 2014) The bereavement exclusion was eliminated from the DSM-5 for two main reasons: 

  1. There have never been any adequately controlled, clinical studies showing that major depressive syndromes following bereavement differ in nature, course, or outcome from depression of equal severity in any other context or from MDD appearing “out of the blue”. 
  1. Major depression is a potentially lethal disorder, with an overall suicide rate of about four percent. Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving interventions. (Pies, 2014)

The final criteria was be available when DSM-5 was completed and published in spring 2013. (APA, 2013) To conclude, while the studies to date are not conclusive, the best available evidence suggests that the DSMS was justified when it eliminated the bereavement exclusion, not, “medicalizing” a normal grief.

Loss of a loved one usually leads to acute grief characterized by yearning and longing, decreased interest in ongoing activities, and frequent thoughts of the deceased. For most, acute grief naturally evolves into a state of integrated grief, where the bereaved is able to reengage with everyday activities and find interest or pleasure.  

Complicated Grief (CG) is a form of prolonged acute grief, some authors says the term complicated still used in the clinical sense of a superimposed process that impedes healing. (Shear, Ghesquiere & Glickman, 2013) According to the definitions by Prigerson et al. (2009) and Shear et al. (2011), these symptoms must be present for at least six months after the death and cause significant impairment. (Prigerson et al. 2009) The term ‘‘Complicated Grief’’ was developed by Horowitz and colleagues (Horowitz et al., 1997), whereas ‘‘Traumatic Grief’’ was used by Prigerson and colleagues (Prigerson et al., 1997). The concepts evolved and criteria and definitions varied in the process. This variation makes it difficult for non-professionals to differentiate between the competing concepts.  In addition, CG is also characterized by preoccupying and disabling symptoms that can persist for decades such as an inability to accept the death, intense yearning or avoidance, frequent reveries, deep sadness, crying, somatic distress, social withdraw, and suicidal ideation. In sum, CG is distinct from grief or major depression (Miller, 2012)

Losses generally include spouses, siblings and peers, and less commonly adult children and grandchildren, the latter of which are generally perceived as unnatural and unfair. Margaret Stroebe, Henk Schut, and Wolfgang Stroebe, suggest that the causes of GC can vary from the long-lasting presence of the initial symptoms associated with intense grief (rumination, preoccupation with thoughts of the deceased, and depressed mood) and the absence of apparent progress in coming to terms with the loss of a loved one. These suggestions correlates CG to relationships and attachments (Stroebe, Schut & Stroebe, 2005)  Additionally, Prigerson et al. (2013) suggest that the causes and clinical correlations of CG including a history of childhood separation anxiety, controlling parents, parental abuse or death, a close kinship relationship to the deceased (e.g., parents), insecure attachment styles, marital supportiveness and dependency, and lack of preparation for the death. (Prigerson et al., 2013)

All suggesting that attachment issues are salient in creating a vulnerability to CG. For example, we find that feelings of emotional dependency on the dying patient is associated with symptoms of grief, but not with symptoms of depression in patient caregivers and recently bereaved persons. They also found that childhood separation anxiety uniquely predicts CG, but not major depressive disorder (MDD), posttraumatic stress disorder (PTSD), or generalized anxiety disorder (GAD) following bereavement later in life. (Prigerson et al., 2013) After all CG symptoms also demonstrate incremental validity in that they are associated with elevated rates of suicidal ideation and attempts, cancer, immunological dysfunction, hypertension, cardiac events, functional impairments, hospitalization, adverse health behaviours, and reduced quality of life in adults and in children and adolescents, after controlling for the effects of depression and/or anxiety. (Prigerson et al., 2013)

According to Shear, Ghesquiere & Glickman (2013) research about 7% of bereaved older adults will develop the mental health condition of CG. In CG, the movement from acute to integrated grief is derailed, and grief symptoms remain severe and impairing. (Shear, Ghesquiere & Glickman, 2013)  Moreover, Mark D. Miller in his clinical research breaks the number of 70% of bereaved people will cope adaptively with the pain of their loss and the restorative process to a new state of function without their lost loved one, either by their own innate coping ability, support from family, friends or spiritual leader. (Miller, 2012). Additionally, according to him 30% of grievers will face a complication such as major depression (15%), PTSD (depending upon the circumstances of the death), or complicated grief (10% to 20%). Major depression secondary to bereavement and CG are often comorbid, but each can also exist without the other. (Miller, 2012)

Studies of psychotherapy approaches for Complicated Grief (CG) support a targeted psychotherapy in order to support clients. The literature suggest that Complicated Grief Therapy is one of the best practices  in terms of psychotherapy approach. Complicated Grief Therapy was significantly more effective than interpersonal psychotherapy, which focuses more on relationship issues. Complicated grief therapy emphasizes loss processing and restoration of life without the deceased, using a range of techniques including cognitive behavioural therapy, interpersonal therapy, and motivational interviewing. (Simon N. M. 2013)

Complicated Grief Therapy (CGT) has roots in both IPT and CBT and is based on attachment theory, which holds that humans are biologically programmed to seek, form, and maintain close relationships. Attachment figures are people with whom proximity is sought and separation resisted; they provide a “safe haven” of support and reassurance under stress and a “secure base” of support for autonomy and competence that facilitates exploration of the world. (Loebach Wetherell, 2012)

In addition, teaching about what CG is and how it develops, termed Psychoeducation, is also included as very effective therapy. Growing evidence supports interventions that include repeatedly telling the story of the death has beneficial effects. Psychoeducation and the use of the disease model of complicated grief aim toward helping patients to accept their behaviour in their situation of grief (normalization). According to Rosner (2011), Psychoeducation also enables patients to actively reflect on the advantages and disadvantages of treatment and helps them to define their treatment goals. (Rosner, Pfoh & Kotoučová, 2011)

In relation to pharmacology, several studies have shown that antidepressant medications can relieve depressive symptoms that are bereavement  related. For instance, Zisook (2001) treated bereaved individuals with major depression with bupropion shows a robust response in reducing depression but only modest decreases in grief severity. (Zisook, Shuchter, Pedrelli, Sable & Deaciuc, 2001) 

Another study from Zygmont (1998) suggests  Paroxetine may be an effective agent in the treatment of traumatic grief symptoms. A comparison of the paroxetine-treated group with a nortriptyline-treated group suggests that both agents have comparably beneficial effects on the symptoms of traumatic grief (as well as those of depression). However, the higher rate of diagnostic comorbidity in the paroxetine-treated group, together with the greater chronicity of their symptoms and the greater safety of paroxetine in overdose, leads us to favour paroxetine over nortriptyline for traumatic grief symptoms in general psychiatric practice. Further controlled evaluation of paroxetine for traumatic grief is necessary. (Zygmont et al., 1998)

Since the early works of Freud and Lindemann, a considerable number of conceptual and empirical studies on grief have been performed. Explicit measures for assessing perceived grief are necessary for examining the causal link between grief and psychological, behavioural, and physical outcomes. (Tomita & Kitamura, 2002) According to the literature the best known measures, specifically for Complicated Grief is  the Inventory of complicated Grief (ICG ) and for grief in general are the Texas Inventory of Grief  (TRIG) and the Grief Evaluation Measure (GEM).  

Certain symptoms of grief have been shown to be distinctive from bereavement-related depression and anxiety, and to predict long term functional impairments. In order to assess these symptoms that we characterize as CG the Inventory of Complicated Grief (ICG) was developed. The Inventory of Complicated Grief (ICG) was devised by Prigerson, et al. (1995) to assess indicators of pathological grief, such as anger, disbelief, and hallucinations. (It contrasts with the TRIG which assesses more normal grief symptoms. The Inventory of Complicated Grief, a brief 19-item self-report questionnaire that identifies complicated grief, should enhance their skills regarding counselling bereaved patients, monitoring their progress over time, and learning how to identify and refer patients experiencing complicated grief.

Furthermore, in relation to the grief in general, Faschingbauer (1981) developed the Texas Inventory of Grief that assessed an array of past and present loss-related thoughts, emotions, and behaviours. This measure was expanded into the Texas Revised Inventory of Grief (TRIG), which was composed of 13 items measuring “present grief” (TRIG-Present) and 8 items assessing “past disruption due to loss”. The TRIG has been used in numerous studies and represents one of the most widely used and well known grief measures. The TRIG assesses “normal” versus pathological grief symptoms. It includes a “Present Feelings” index consisting of 13 first-person statements. (Faschingbauer, T., 1981) 

Finally, The Grief Evaluation Measure (GEM) was designed to provide grief counsellors with information that is both immediately useful in treatment planning and that helps with assessing the risk that a bereaved individual will develop a complicated mourning response. The GEM provides a quantitative and qualitative assessment of risk factors, including the mourner’s loss and medical history, coping resources before and after the death, and circumstances surrounding the death. It is designed to provide an in-depth evaluation of the bereaved adult’s subjective grief experience and associated symptoms. (Jordan, Baker, Matteis, Rosenthal & Ware, 2005)

The limitation for Complicated Grief starts with its own concept. The concepts evolved and criteria and definitions varied in the process. This variation makes it difficult for non-professionals to differentiate between the competing concepts.  Also, in relation to the treatment according to the literature preventive treatments for those who are bereaved, but do not show signs of CG or other disorders are not effective. There is a limited number of studies on CG and treatments evaluated in those studies incorporate exposure and cognitive restructuring. 

In sum, data is lacking from randomized trials of the use of antidepressant medication for complicated grief, clinical experience and limited observational data suggest that this option warrants consideration, either in conjunction with psychotherapy or alone if the patient has no access to or interest in psychotherapy. Benefits may be derived from treatment with serotonin selective reuptake inhibitors antidepressants. Finally, grief is a universal human experience; however, it is also a very individual and subjective one. The concept Complicated Grief (CG) helps to differentiate those whose grief appears to be stuck, and whose suffering and debilitation is unremitting for extended period or even decades. CG require specialised treatment to be able to help the person return to premorbid level function. The interventions such as Complicated Grief Therapy and Psychoeducation has shown promise toward the goal of restoration. Also, the antidepressant medication combined with the appropriate treatment can present great outcome. 

Besides Complicated Grief (CG) is distinct from normal grieving and complex, given theoretical constructs, multiples variables influencing the manifestation of grief, and the many parameter that can be used to measure aspects of bereavement outcome. In conclusion, Diagnoses and researches into the dimensions of pathological grief should , at least, account for pre-existing character pathology, culturally determined mourning practices, anxiety/depression, post-traumatic stress disorder, and somatic responses. 

The News

I should have known,

death wouldn’t come

with fife and drum

but in the late-night ringing of the phone

the neighbour standing awkward at the door

the neat, new-empty bed,

the nurse’s tone

I should have known. 

Christy Kenneally (Kenneally, 1999)


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