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File: Complicated Grief Report Resource
complicated grief published as a public service by the hospice support fund a program of new hope foundation p o box 1839 merrifield va 22116 8039 m8245cg grief is normal ...

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                             COMPLICATED GRIEF
                                    Published as a public service by 
                                   The Hospice Support Fund 
                                  a program of New Hope Foundation
                                             P.O. Box 1839
                                      Merrifield, VA 22116-8039
        M8245CG
            Grief  is  normal.  Grief  is  a  common,  natural 
            response one experiences after a significant and           Most  people  assume  the  grieving  person  will 
            permanent loss. Grief is usually caused by death          have feelings of loss and sadness soon after the 
            of the loved one, but may be caused by the death          death or separation, which lessen over time as 
            of a pet, the end of a relationship (i.e. divorce), or    the  person  moves through the stages of grief. 
            the loss of property.1 Over time, grief lessens in        In fact, most people do not experience grief in 
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            intensity and the grieving individual returns to a        this way.  For many people, grief is never really 
            normal or near normal level of functioning.               over. Instead, the grieving person finds herself in 
                                                                      one of four categories: resilience, chronic grief, 
            Complicated grief, on the other hand, is abnormal.        depressed  improved,  and  chronic  depression.5 
            It is a state of intense, unrelenting, and disabling      People who grieve in one of these four normal 
            sorrow. Complicated grief is a distinct psychiatric       ways regain a reasonable level of functioning; 
            syndrome requiring specific treatment.                     people with complicated grief do not.
            What is “normal” grief?                                   Resilience
            While  everyone  agrees  grief  is  normal,  few          People  who  experience  the  resilience  grief 
            people agree on a precise definition of “normal”           pattern show very few signs of grief, sadness, 
            grief. Grief is a complex reaction that includes          or loss. Instead, they show a relatively low level 
            emotional, physical, cognitive, and psychological         of chronic distress or simply no outward signs 
            components.                                               of grief whatsoever. This pattern was previously 
                                                                      considered abnormal. People with this grieving 
            One of the oldest and well-known models of grief          style were encouraged to “let out their emotions” 
            is  the  five-stage  model  proposed by Elizabeth          and “stop trying to be strong.” 
            Kübler-Ross.  She  said  a  grieving  individual 
            will  normally  progress  through  denial,  anger,        Careful  research  of  the  resilience  pattern  has 
            bargaining, and depression and then ultimately            revealed it is not abnormal at all. In fact, 46% of 
                                             2                                                                           4,6,7 
            come  to  accept  the  loss.   Newer  research            people experience grief in a resilience pattern.
            suggests many people do not experience grief              Moreover, people in this category have positive 
            in a sequential order and may also experience             coping styles and healthy adjustment to the loss. 
            symptoms  such  as  emotional  numbness,                  They have few or no symptoms of depression 
                                     3
            yearning, and despair.                                    at six or 18 months after the loss.6 Not only is 
                                                                      resilience the most common grief pattern, but it 
            Perhaps because of this multistage progression,           appears to cause the least number of functional 
            grief has been viewed as something from which             and psychological problems. Resilient grievers 
            one “recovers.” Grief is a process, not a state. It       experience  and  express  positive  emotions  and 
            progresses in fits and starts and may ebb and flow.         remember their lost love one fondly. Individuals 
            It is generally felt in waves of intense sadness,         in this group may experience occasional pangs 
            loss, and separation. One does not simply “get            of loss and continued yearning, but still function 
            over” the loss of a loved one, just as one does           at their normal level.8
            not get over graduation or a wedding. The loss             
            of a loved one is a major life event that will be         Chronic Grief 
            remembered  and  contemplated.  It  will  cause 
            emotions that may be unpleasant, painful, and             A small percentage of people experiencing grief 
            powerful. One hopes the waves of emotion even             will manifest a chronic grief pattern. People in 
                                         4
       2    out into ripples over time.                               this  category will experience significant pangs 
        of loss and sadness and sustained yearning for          four patterns are distinct from complicated grief.
        the  lost  individual.  Chronic  grief  occurs  most 
        commonly in widows/widowers who were quite              Complicated Grief: Features and Symptoms
        dependent  on  their  deceased  spouse.  Chronic 
        grief  eventually  resolves  within  four  years  on    Approximately 7% of those who experience grief 
                                                                                                  9
        average  as  the  person  integrates  the  loss  into   will develop complicated grief.  The rate is even 
        normal living.8                                          higher among those who have suffered the loss 
                                                                 of a life partner or child, especially to a violent 
        Depressed Improved                                       death.  Complicated  grief  is  most  common  in 
                                                                 women over the age of 60.9
        One in ten individuals who have lost a spouse 
        exhibit a depressed improved pattern grieving.6          Complicated  grief  is  an  unusually  severe  and 
        This  pattern  occurs  most  often  when  the            prolonged form of grief that impairs the sufferer’s 
                                                                                     10
        deceased suffered a long health problem prior to         ability to function.  In most cases, people with 
        death or the couple had an unhappy relationship.        complicated  grief  will  experience  persistent, 
        The depressed phase of the depressed improved           intense  yearning  and  sadness  accompanied 
        pattern occurs before the loss and the improved         by  frequent  thoughts  of  the  deceased  and  an 
        phase  begins  upon  death.  The  grieving              inability to accept the person is gone. Sufferers 
        individual is able to focus on positive memories        tend to ruminate on the factors surrounding the 
        of the deceased, finds meaning in the loss of the        death itself. For example, sufferers may be angry 
        deceased, and visualizes/experiences the benefits        with those they deem responsible for the death or 
        of  living  without  the  deceased.  The  loss  of  a   guilty that they did not do more to prevent death 
                                                                                                      10
        loved one is the loss of a chronic stressor. Thus,      or prolong the life of the deceased.  
        death releases the grieving person from a difficult      Like those with post-traumatic stress disorder, 
        relationship or from caregiving duties associated       people  with  complicated  grief  tend  to  avoid 
        with caring for a chronically ill loved one.            situations  that  may  evoke  feelings  of  grief  or 
                                                                reminders of loss. On the other hand, this same 
        Chronic Depression                                      person may spend inordinate amounts of time 
                                                                viewing photos, mementos, or belongings of the 
        People who experience the chronic depression            deceased.
        pathway  of  grief  share  an  important  feature 
        with the depressed improved individual, namely          In  some  cases,  the  person  with  complicated 
        experience depression before the loved one dies.        grief has a diminished sense of self, meaning the 
        Unlike people in the third group, the depression        sufferer cannot imagine a life without the lost 
        of chronically depressed grievers does not begin        loved one, causing the sufferer to withdraw from 
        to resolve with the loved one’s death. Instead,         work, family,  and  social  ties. As  a  result,  the 
        the depression remains or worsens. The ongoing          sufferer’s support system is strained, frustrating 
        depression may last for four years or more after        family  members and friends,  causing  them  to 
        the loss and may reflect a long-standing mood            further  distance  themselves  from  the  grieving 
                                            2
        disorder rather than simple grief.                      person. Thus, the sufferer’s sense of isolation is 
                                                                perpetuated.
        In summary, resilience, chronic grief, depressed 
        improved, and chronic depression are considered         The most common features of complicated grief 
        normal pathways or patterns of grief. Those who         are yearning for the deceased and feeling upset by 
        experience one of these four patterns of grief          memories of the deceased. In a survey of nearly 
        may experience mild functional difficulty, yet all       300 patients with complicated grief, researchers 
                                                                                                                       3
                 identified the most common symptoms, in order                                        Diagnostic  and  Statistical  Manual  (DSM)  to 
                                                         11
                 of decreasing frequency:                                                            diagnose  mental  health  conditions,  diseases, 
                            • Yearning for the deceased (88% of those                                and syndromes. Currently, there is no entry for 
                               surveyed)                                                             complicated  grief  in  the  latest  edition  of  the 
                            •  Feeling upset by memories of the                                      DSM, the DSM-5. 
                               deceased (82%)
                            •  Loneliness (81%)                                                      Complicated grief is called Persistent Complex 
                            •  Feeling life is empty (80%)                                           Bereavement  Disorder  in  the  DSM-5  and  is 
                            •  Disbelief (76%)                                                       discussed  in  appendix  of  the  manual  entitled 
                                                                                                                                                            12
                            •  Inability to accept the death (70%)                                   “Conditions  for  Further  Study.”   It  is  quite 
                                                                                                     possible the next edition of the DSM will include 
                 Complicated Grief: Diagnosis                                                        full diagnostic criteria for this disorder, but the 
                                                                                                     next update is not anticipated until at least 2025. 
                 Ordinarily, psychiatrists and psychologists in the                                  Here is the description of Persistent Complex 
                 United States use diagnostic criteria laid out in                                   Bereavement  Disorder  in  the  appendix  of  the 
                 the American Psychiatric Association’s                                              DSM.
                                                                                                                                                                12
                                 Provisional DSM-5 Criteria for Persistent Complex Bereavement Disorder
                 The individual experienced the death of someone with whom he or she had a close relationship.
                 Since the death, at least 1 of the following symptoms is experienced on more days than not and to a 
                 clinically significant degree has persisted for at least 12 months after the death in the case of bereaved 
                 adults and 6 months for bereaved children:
                            •          Persistent yearning or longing for the deceased. In young children, yearning may
                    expressed in play and behavior, including behaviors that reflect being separated from,
                    and also reuniting with, a care-giver or other attachment figure.
                            •          Intense sorrow and emotional pain in response to the death.
                            •          Preoccupation with the deceased.
                            •          Preoccupation with the circumstances of the death. In children this preoccupation with
                    the deceased may be expressed through the themes of play and behavior and may extend
                                       to preoccupation with possible death of others close to them.
                 Since the death, at least 6 of the following symptoms are experienced on more days than not and to a 
                 clinically significant degree, and they have persisted for at least 12 months after the death in the case 
                 of bereaved adults and 6 months for bereaved children:
                            •          Reactive distress to death:
                    • Marked difficulty accepting the death. In children, this is dependent on the
                        child’s capacity to comprehend the meaning and permanence of death.
                    • Experiencing disbelief or emotional numbness over the loss.
                    • Difficulty with positive reminiscing about the deceased.
                    • Bitterness or anger related to the loss.
                    • Maladaptive appraisals about oneself in relation to the deceased or the death 
                           (eg, self-blame).
                    • Excessive avoidance  of reminders of the loss (eg, avoidance of individuals,  
                          places, or situations associated with the deceased; in children, this may include
                        avoidance of thoughts and feelings regarding the deceased. 
         4
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