Natalia Skritskaya

Complicated grief and related bereavement issues for DSM‐5

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over‐and under‐diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over‐diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders. Depression and Anxiety, 2011.

Treatment of complicated grief in elderly persons: a randomized clinical trial.

IMPORTANCE Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population. OBJECTIVE To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline. INTERVENTIONS Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly. MAIN OUTCOMES AND MEASURES Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale. RESULTS Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age. CONCLUSIONS AND RELEVANCE Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01244295.

The impact of losing a child on the clinical presentation of complicated grief

BACKGROUND It is unclear whether bereaved parents with Complicated Grief (CG) struggle with their grief differently than others with CG. This study addressed this question by comparing CG severity, CG-related symptoms, thoughts and behaviors, and comorbid psychiatric diagnoses of bereaved parents with CG to the diagnoses and symptoms of others with CG. METHODS Baseline data from 345 participants enrolled in the Healing Emotions After Loss (HEAL) study, a multi-site CG treatment study, were used to compare parents with CG (n=75) to others with CG (n=275). Data from the parent group was then used to compare parents with CG who had lost a younger child (n=24) to parents with CG who had lost an older child (n=34). Demographic and loss-related data were also gathered and used to control for confounders between groups. RESULTS Parents with CG demonstrated slightly higher levels of CG (p=0.025), caregiver self-blame (p=0.007), and suicidality (p=0.025) than non-parents with CG. Parents who had lost younger children were more likely to have had a wish to be dead since the loss than parents who had lost older children (p=0.041). LIMITATIONS All data were gathered from a treatment research study, limiting the generalizability of these results. No corrections were made for multiple comparisons. The comparison of parents who lost younger children to parents who lost older children was limited by a small sample size. CONCLUSIONS Even in the context of CG, the relationship to the deceased may have a bearing on the degree and severity of grief symptoms and associated features. Bereaved parents with CG reported more intense CG, self-blame, and suicidality than other bereaved groups with CG, though this finding requires confirmation. The heightened levels of suicidal ideation experienced by parents with CG, especially after losing a younger child, suggest the value of routinely screening for suicidal thoughts and behaviors in this group.

Performance of DSM-5 Persistent Complex Bereavement Disorder Criteria in a Community Sample of Bereaved Military Family Members

OBJECTIVE The purpose of this article was to examine the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder in identifying putative cases of clinically impairing grief and in excluding nonclinical cases. Performance of criteria sets for prolonged grief disorder and complicated grief were similarly assessed. METHOD Participants were family members of U.S. military service members who died of any cause since September 11, 2001 (N=1,732). Putative clinical and nonclinical samples were derived from this community sample using cutoff scores from the Inventory of Complicated Grief and the Work and Social Adjustment Scale. Items from a self-report grief measure (Complicated Grief Questionnaire) were matched to DSM-5 persistent complex bereavement disorder, prolonged grief disorder, and complicated grief criteria. Endorsed items were used to identify cases. RESULTS Criteria sets varied in their ability to identify clinical cases. DSM-5 persistent complex bereavement disorder criteria identified 53%, prolonged grief disorder criteria identified 59%, and complicated grief criteria identified more than 90% of putative clinical cases. All criteria sets accurately excluded virtually all nonclinical grief cases and accurately excluded depression in the absence of clinical grief. CONCLUSIONS The DSM-5 persistent complex bereavement disorder criteria accurately exclude nonclinical, normative grief, but also exclude nearly half of clinical cases, whereas complicated grief criteria exclude nonclinical cases while identifying more than 90% of clinical cases. The authors conclude that significant modification is needed to improve case identification by DSM-5 persistent complex bereavement disorder diagnostic criteria. Complicated grief criteria are superior in accurately identifying clinically impairing grief.

Bereavement and Anxiety

Bereavement, one of life’s most difficult experiences, usually triggers acute grief with yearning and longing for the deceased person that is often intense and preoccupying, along with frequent thoughts and memories of the person who died and relatively little interest in anything unrelated to the deceased loved one. Anxiety is a very common feature of grief that is often neglected. Anxiety is a natural response of the attachment system to separation from a loved one, seen in adults as well as children. Confrontation with one’s own death is also a natural trigger of anxiety, though we usually protect ourselves from mortality salience using terror management strategies related to cultural values and self-esteem. In addition, loss of a loved one can trigger the onset of a DSM-IV anxiety disorder that, when present, can derail the mourning process and prolong acute grief. Bereavement-related anxiety disorders need to be recognized and treated.

Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients

BACKGROUND Persistent complex bereavement disorder (PCBD) is a protracted form of grief included in DSM Section 3 indicating a need for more research. Two other criteria sets [prolonged grief disorder (PGD) and complicated grief (CG) disorder] are also currently in use by researchers. This study evaluates rates of diagnosis of each proposed criteria set in a clinical sample of bereaved individuals participating in clinical research. METHOD Two groups in which persistent grief was judged to be present or absent completed an assessment instrument that included items needed to diagnose PCBD as well as PGD and CG. One group included grief treatment-seeking participants in our multicenter National Institute of Mental Health (NIMH)-sponsored study who scored ⩾30 on the Inventory of Complicated Grief (ICG) and the other comprised bereaved adults enrolled in clinical research studies who scored <20 on the ICG. Rates of diagnosis were determined for proposed PCBD, PGD and CG criteria. RESULTS PCBD criteria diagnosed 70 [95% confidence interval (CI) 64.2-75.8] % of the grief treatment-seeking group, PGD criteria identified 59.6 (95% CI 53.4-65.8) % of these individuals and CG criteria identified 99.6 (95% CI 98.8-100.0) %. None of the three proposed criteria identified any cases in the bereaved comparison group. CONCLUSIONS Both proposed DSM-5 criteria for PCBD and criteria for PGD appear to be too restrictive as they failed to identify substantial numbers of treatment-seeking individuals with clinically significant levels of grief-related distress and impairment. Use of CG criteria or a similar algorithm appears to be warranted.

PERILOSS DISSOCIATION, SYMPTOM SEVERITY, AND TREATMENT RESPONSE IN COMPLICATED GRIEF

Complicated grief (CG) is a bereavement‐specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e. periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD‐adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop‐out rate.

Complicated grief after suicide bereavement and other causes of death

ABSTRACT The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.

Catecholamine predictors of complicated grief treatment outcomes.

Could sympathetic hyperarousal limit treatment success in complicated grief? The present study investigated persons with complicated grief, a chronic condition with distinct symptoms including persistent intense yearning and longing for the person who died, avoidance of reminders that the person is gone, deep relentless sadness, self-blame, bitterness, or anger in connection with the death, and an inability to gain satisfaction or joy through engaging in meaningful activities or relationships with significant others. Length of bereavement did not correlate with complicated grief scores. Catecholamines (i.e., epinephrine, norepinephrine, dopamine) in plasma were assessed pre- and post-psychotherapeutic treatment. Participants with the highest levels of epinephrine at pre-treatment had the highest levels of complicated grief symptoms at post-treatment, accounting for baseline levels of symptoms. This predictive relationship was not seen for depressive symptoms. The present study supports the hypothesis that catecholamine levels are affected by bereavement, and in turn, can affect the ability of those with complicated grief to benefit from psychotherapy.

Yearning and Its Measurement in Complicated Grief

ABSTRACT Persistent intense yearning for the deceased is a core clinical feature of complicated grief (CG) that distinguishes it from other mental disorders that develop following loss. The Yearning in Situations of Loss Scale (YSL) is a recently developed assessment of yearning. To assess the psychometric properties of the YSL in those with CG, we administered the YSL, Inventory of Complicated Grief, and Quick Inventory of Depression Symptomatology to 303 treatment-seeking bereaved adults with CG. Our results suggest the YSL is a reliable assessment with acceptable convergent and discriminant validity as a measure of yearning in those with CG.