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The Psychopathological Characteristics of Prolonged Grief

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The Psychopathological Characteristics of Prolonged Grief Modern psychopathologies or old diagnoses? The psychopathological characteristics of prolonged grief M.G. Nanni1, S. Tosato2, L. Grassi1, M. Ruggeri2, H.G. Prigerson3 1 Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Italy and University Hospital Psychiatry Unit, Program in Psycho-Oncology and Psychiatry in Palliative Care, S. Anna University Hospital and Local Health Agencies, Ferrara, Italy; 2 Section of Psychiatry, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy; 3 Joan and Sanford I, Weill Department of Medicine, Weill Cornell Medical College, Cornell University, New York, USA, and Center for Research on End of Life Care, Weill Cornell Medical College, Cornell University, New York, USA Summary treatment. PG has been recognised as a predictor of negative Grief is a normal human response to the death of a loved one outcomes, such as substantial impairment in work and social that may vary among individuals and in the way it manifests functioning, reduction of quality of life, risk for mental disor- itself across cultures. Whereas the majority of bereaved people ders and suicidality, and physical health problems. This article adjust adequately to the loss, a small but noteworthy proportion discusses the main clinical features of PG, the determinants as- of individuals may experience a prolongation of the symptoms sociated with the severity of PG symptoms, the risk factors that of acute grief well beyond the period when these have com- may predispose an individual to develop PG and the efficacy of monly abated. This syndrome, characterised by prolonged psy- different preventive and treatment approaches, including psy- chological distress in relation to bereavement, has been termed chopharmacological and psychotherapeutic interventions. prolonged grief (PG) and shows distinct psychopathological features compared with other stress-related mental disorders. Key words Accurately diagnosing PG in the context of difficult bereave- Bereavement • Grief • Complicated grief • Traumatic grief • Prolonged ment is an ongoing challenge to clinicians and researchers and grief disorder • Prolonged grief diagnostic criteria • Prolonged grief risk many have called for improving the identification of PG and its factors • Prolonged grief treatment Introduction experts agree that progress usually becomes apparent by 6 months. Even if possible intense symptoms may re- Over the last 20 years, several studies have focused on emerge periodically, most people are able to adjust to 1 2 complications of grief and bereavement . Assuming that the loss by this time 7-10. Unfortunately, a small subset of bereavement is a normal human experience and that grief bereaved individuals never fully integrates the loss into is the physiological reaction to the loss of a loved one, their life, and continue to experience severe disruption in many researchers have attempted to identify the stages daily life even many years after the loss. of grieving process as well as the order in which they The labels given to this condition have changed over the may arise. Historically, Kübler Ross described grief as a years, including pathological grief, traumatic grief, com- succession of five steps according to a relatively linear plicated grief and, more recently, prolonged grief 10. We “recovery” trajectory over time (the so-called five-stage decided to use the term “prolonged grief” (PG) for two 3 model) . Recently, it has been showed that bereaved peo- reasons. First, it better expresses the nature of the disorder, ple, in correlation with different individual and contex- characterised by the abnormal persistence of severe disa- tual features, may experience a range of symptoms during bling symptoms related to the bereavement 11. Second, it the whole process, and not necessarily in a sequential or- is most likely that the revision of the International Clas- der 4. Empirical data have indeed supported the existence sification of Disease (ICD-11), which is currently planned of distinct patterns of grieving, allowing recognition and for approval by the World Health Assembly, will intro- study of different trajectories of the process 5 6. duce a new diagnosis to recognise this clinical condition, Evidence has demonstrated that most bereaved individu- using the label of Prolonged Grief Disorder (PGD) 12. als finally succeed in coming to terms with the loss of However, the identification of this syndrome in the cur- their loved one and integrate this experience in their rent psychiatric diagnostic systems has been much de- lives 1 4 5. The time period during which this process is bated recently. Factor analytic studies have identified and completed has not been definitely established, but most isolated the specific PGD symptoms, indicating that it is Correspondence Maria Giulia Nanni, Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, corso Giovecca 203, 44121 Ferrara, Italy • E-mail: [email protected] Journal of Psychopathology 2015;21:341-347 341 M.G. Nanni et al. distinct from other psychiatric disorders, such as anxiety, tifying bereaved individuals who suffer from the syn- depression, post-traumatic stress disorder and adult sepa- drome and provide them with appropriate, timely and ration anxiety 13-16. Based on these data, consensus criteria effective treatments. for PGD have been formulated 10. Nevertheless, the Diag- nostic and Statistical Manual of Mental Disorders, 5th Edi- The phenomenology of prolonged grief tion (DSM-5), failed to include this diagnosis, relegating the complications of grief to the section “other specified According to the model proposed by Prigerson et al. 13, trauma and stressor-related disorders”, under the label of PG includes two core clusters of symptoms: the first is Persistent Complex Bereavement Disorder (PCBD), with related to separation distress (e.g. intensive yearning, the explicit criteria listed under conditions requiring fur- strong desire of the beloved, constant state of concern ther study 17. The DSM-5 reluctance to recognise PGD as linked to the memory of the loved one), and the second a full diagnosis is probably due to different reasons, such is related to traumatic distress (e.g. recurrent and intru- as the risk to pathologise normal grief responses, the risk sive thoughts about the absence of the deceased, sense of to underestimate the influence of cultural and contextual disbelief regarding the death, being angry or emotionally variables on the variation of the manifestations of grief numb, tendency to avoidance of memories associated and the risk to place much emphasis on traumatic stress, with the pain of loss) 10. Bereaved people who suffer from which may result in misdiagnosing or not diagnosing in- PG typically have difficulty in accepting the reality of the dividuals suffering from other common and severe men- death and in adapting to life without the deceased. They tal disorders 12 18 19. find themselves in a repetitive loop of intense yearning Contrary to DSM-5, the ICD-11 will likely include, with- and longing, being unable to move forward in life. PG in the proposed new group of “Disorders specifically symptoms last over 6 months, can sometimes persist for associated with stress”, a separate diagnosis of PGD, as years and negatively influence functioning and quality of a condition characterised by a distinct psychopathol- life 14. PG symptoms also include anger, guilt, or blame ogy 12. The ICD Working Group has exposed different regarding the death, lowered self-worth, inability to form elements favouring the inclusion of this new diagnosis. new bonds or relationship with others and strong denial First, studies have shown that the core symptoms of PG of the loss, which is accompanied by feelings of mistrust, are distinguishable from symptoms of uncomplicated bitterness and identity confusion 10 29. Overall, a signifi- grief 13 20 and are associated with significant conse- cant preoccupation with the deceased is developed, with quences. In fact, PG can predict long-term functioning ruminations about circumstances or consequences of the impairments, reduction of quality of life, risk for men- loss, intense physical or emotional reactivity to remind- tal disorders and suicidality, as well as physical health ers, avoidance of reminders, or compulsive proximity problems (e.g. hypertension, cardiovascular disorders, seeking (e.g., keeping reminders of the died person). This immunological dysfunctions) 9 14. Second, the risk of condition can lead bereaved individuals to be chronically medicalisation of some non-pathological reactions of disengaged from others and from the world, to believe grief seems very limited: epidemiological data show that that life is empty and meaningless without the deceased a PG diagnosis only applies to a minority (about 10% and that their intense pain will never end. For this reason, following normal circumstances of loss) of bereaved suicidal thoughts may occur and are usually related to the people who experience persistent impairment 10 21, with hope of being reunited with the deceased loved one 8 30. higher rates following disasters, violent deaths, or the Some years ago, a panel of experts on bereavement ap- death of a child 22-24. Moreover, population rates of PG proved a consensus list of shared symptoms, outlining the are estimated between 2.4% and 4.8% 25 26. Finally, di- clinical features of PG. They proposed empirically
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