Complicated Grief

content provided by the Faculty of the Harvard Medical School

Complicated grief

Looking for help when mourning persists and intensifies.

Except for those who die too young, grief is an unavoidable and normal experience. But it can take intense and disturbing forms that surprise a bereaved person, including forms that in other circumstances would be called a psychiatric disorder. In some cases, psychiatric treatment may help.

Bereaved persons may suffer not only sadness but anger and suspicions about the motives of prospective helpers. They may ruminate obsessionally about the events leading up to the death and blame themselves or others for it. Up to 50% of widows and widowers have symptoms typical of major depression in the first few months. They may also have hallucinatory experiences - imagining that the dead are still alive, feeling their presence, hearing them call out. The writer Joan Didion, in a memoir, called her period of mourning for her husband "the year of magical thinking."

These symptoms, upsetting as they may be, are usually normal responses to the loss. They call for comforting and sometimes explanation, but not treatment. But if the symptoms linger and become increasingly debilitating, the condition turns into what is now being called unresolved, protracted, traumatic, or complicated grief. It has features of both depression and post-traumatic stress disorder (PTSD). And there is some evidence that a distinct type of treatment may bring relief.

The most characteristic symptoms are intrusive thoughts and images of the deceased person and a painful yearning for his or her presence. Other complications are denial of the death, imagining that the dead person is alive, desperate loneliness and helplessness, anger and bitterness, thoughts of suicide, and wanting to die. It is not simply depression, because of the yearning and hallucinatory symptoms. And it is not simply a post-traumatic reaction either - not only because bereavement is in the range of normal human experience, but also because a grieving person is responding not so much to the event of death as to the loss of a human connection.

Risk factors

The risk of developing complicated grief depends on both the immediate circumstances of the death and the background against which it occurs. PTSD is more likely to follow a traumatic experience if the person who undergoes it regards his reactions as a sign of weakness, believes that others are not responding helpfully or sympathetically, fears that he will lose his sanity if he thinks too much about the experience, or ruminates about how he or someone else could have prevented it from happening. These are also risk factors for complicated grief, and the disorder is more likely to occur after a death that is traumatic - premature, sudden, violent, or unexpected.

But studies have shown that experiences not typically regarded as traumatic - work problems, family conflict, chronic illness - can lead to symptoms that resemble PTSD. In the same way, even normal bereavement can produce complicated grief.

Whether that happens depends on how a person copes, not just with trauma, but with loss. We are all vulnerable to unfulfilled hopes, broken romances, illness, and injury. For anyone who could not respond to earlier losses without losing emotional equilibrium, complicated grief becomes a greater danger. So a person with a history of depression, anxiety disorders, or a personality disorder is more likely to suffer complicated grief after bereavement, as well as PTSD after a traumatic experience.

Grief work and separation

Grieving is especially difficult and painful for a survivor who has had a close but uneasy relationship with the deceased person. That idea is the basis of the two most widely known theories about grieving and its potential complications - Sigmund Freud's and John Bowlby's.

According to Freud, at first the libido or emotional energy of a bereaved person is directed at images and thoughts of the deceased, an external person who has been lost. Getting over the death is "grief work," accomplished when this energy is finally turned to engage the world again.

Sometimes a mourner feels hatred, anger, or resentment as well as affection for the lost person. According to psychodynamic theory, the survivor may internalize the image of the deceased and identify with the image, turning anger and hatred against himself or herself. Survivors who have difficulty coming to terms with ambivalent feelings about the deceased may experience self-punishing feelings, such as guilt and worthlessness. These feelings are also typical of depression.

Bowlby's theory of attachment provides a variation on the theme of completing grief work. According to Bowlby, infants and young children are attached to a parent or other caregiver who provides a safe haven and a base from which to explore the world. Eventually they must separate, but separation is stressful and may be resisted on both sides. The quality of attachment influences how successfully we achieve separation from caregivers in childhood and how well we cope with adult losses, especially bereavement.

The process of separation is complicated when a child has been insecurely or anxiously attached to caregivers - unsure whether they will be there when needed, emotionally or otherwise. Insecure early attachment can lead to insecurity in later relationships and corresponding complications in the process of grieving.

Treatment

Treatment of complicated grief often relies on the idea, central to both psychoanalytic and attachment theories, that grieving is an experience to be worked through. Some people are thought to be stuck and unable to free themselves because of problems arising from emotional instability, previous losses, or difficulties in their relationship with the person who has died. A psychodynamic therapist may try to help by identifying past losses that were never fully mourned and discussing their connections with the present loss. The therapist may also gently point out feelings about the deceased that the survivor may be defending against, helping the mourner come to terms with ambivalence. Cognitive therapists help them reinterpret the loss, partly by re-experiencing it in imagination. Interpersonal therapists help them develop new social relationships and activities.

A promising treatment called traumatic grief therapy uses cognitive behavioral methods for traumatic symptoms and stress relief, along with interpersonal techniques to encourage re-engagement with the world. Patients tell the story of the death repeatedly and listen to tapes of the recitation - imaginal exposure. They learn to confront thoughts and situations they may have been avoiding - in vivo exposure. They evoke memories of the deceased, especially happy memories, and hold imaginary conversations with him or her under a therapist's guidance, exploring regrets or resentment. They are encouraged to think about how to enjoy other activities rather than dwell on the loss.

In one study, traumatic grief therapy was found to be especially effective for people mourning a violent death; more than half of them improved, compared with 13% in standard interpersonal therapy.

Complicated grief is not one of the disorders in the American Psychiatric Association official diagnostic manual. But reactions to loss have been included since the diagnosis of PTSD was adopted, and it's understood that certain kinds of bereavement - unexpected and violent - can be traumatic in themselves. A diagnosis of complicated grief may be added in the next edition of the manual, or normal bereavement may be labelled a potentially traumatic experience. Some think a standard diagnosis is needed to improve research on the symptoms of complicated grief. Others regard that as simply another variation on PTSD, which they suspect is already diagnosed too often. What matters is not whether another diagnostic category is introduced, but how to identify and help the minority of bereaved people who need more than the usual comfort and support. Thinking about complicated grief is worthwhile in order to fulfill that purpose.

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Last updated:	October 1, 2006