Complicated Grief #254

Background

The majority of individuals experience normal grief after the death of a loved one (see Fast Fact #32). However, about 10–20% of bereaved individuals experience a persistent, debilitating phenomenon referred to as complicated grief (CG). ¹ Complicated grief has also been referred to as prolonged, traumatic, or pathologic grief. ²

Risk Factors

CG is principally considered an attachment disorder. ¹ Insecure attachment styles (excessive dependency, compulsive caregiving, defensive separation) are correlated with CG. Additionally, supportive marital relationships (characterized as security-enhancing, confiding, and emotionally supportive) are correlated with CG after the loss of a spouse, suggesting that the loss of a spouse who provides emotional stability and security may lead to an exacerbated grief reaction. ³ Other risk factors include weak parental bonding in childhood, childhood abuse and neglect, female gender, low perceived social support, and low preparation for the loss.^1,4

Impact on Health

CG is associated with mental and physical health problems, including depression, hypertension, work and social impairment, and reduced quality of life. Additionally, CG increases an individual's risk of suicide and suicidal behavior. ⁶

Diagnosis

CG shares characteristics with major depressive disorder (e.g., suicidal ideation and preoccupation with worthlessness) and post-traumatic stress disorder (e.g., re-experiencing intrusive thoughts of the deceased, and avoidance of reminders of the deceased and emotional numbness). However, these are separate entities differentiated by precipitating events, risk factors, course of illness, and response to intervention. ² The precise diagnostic criteria for CG are currently being debated. ⁴ Commonly agreed upon characteristics include:

• yearning, pining, or longing for the deceased

Symptoms must cause marked dysfunction in social, occupational, or other important domains. The duration of symptoms required to meet criteria for CG has not been defined, and varies between 6 and 12 months after the death.^1,4

Screening

The following Brief Grief Questionnaire is a 5-item screening tool scored on a 0–2 Likert scale (“not at all,” “somewhat,” and “a lot”), which has been used to screen for CG.

1. How much of the time are you having trouble accepting the death of a loved one?

Expert recommendation is that individuals with scores of ≥5 should undergo a diagnostic evaluation by a mental health professional. ⁵

Treatment

A recent meta-analysis of the treatment of CG showed efficacy of interventions including cognitive-behavioral and group therapy in alleviating symptoms, with a duration of benefit from 3–6 months. Limitations of the meta-analysis include underrepresentation of men (average 71% female), the small number of studies included (n=5), and the small number of participants (n=485, 109 lost to follow-up). ⁶ There have been no randomized controlled trials evaluating the pharmacologic treatment of CG, and there is currently no defined role for drug therapy. A randomized trial is currently underway to evaluate the effect of a selective serotonin reuptake inhibitor on CG. Many hospice agencies provide bereavement services, even if the bereaved's loved one was not a patient of the hospice agency.

Bottom Line

Most bereaved individuals experience normal grief. A minority will experience long-term, persistent, disruptive symptoms that impair functioning and increase the risk for negative mental and physical health states. Individuals suffering from CG benefit from referral to a trained mental health provider who can administer therapy specific to CG.