Letters to the Editor
Recognizing Complicated Grief in Clinical Practice
Dear Editor:
Losing a significant person through death is a common experience. Recently, we conducted a study that examined the prevalence of death losses and complicated grief among psychiatric outpatients at 2 hospital clinics (1). We found that 55% of patients reported a death loss; of this group, 60% met criteria for complicated grief. These figures suggest that as many as one-third of the patients seen at outpatient clinics may meet criteria for complicated grief.
Although not recognized as a distinct disorder in the DSM-IV-TR (2), there is reasonable consensus in the field about what constitutes complicated grief. A person experiencing complicated grief often reports preoccupation with, yearning for, and searching for the deceased. Intrusive images, ideas, memories, or recurrent dreams or nightmares associated with the lost person are also frequently reported. Active avoidance of thoughts, communications, or actions associated with the loss are common. Despite the unpleasant nature of these symptoms, patients often seem reluctant to give them up.
The symptoms’ debilitating effect often interferes with daily functioning—also a criterion for other disorders, most notably major depression. Despite their frequent comorbidity, we have demonstrated that complicated grief and depression can be clearly distinguished (3).
Clinicians must also be aware of the time since the loss. To avoid pathologizing a normal, acute bereavement response, experts suggest that symptoms must persist for several months after the loss before a diagnosis of complicated grief is considered.
Medical and psychiatric training often devote little time to the recognition of complicated grief. This may lead to its lack of detection. Identifying complicated grief is also made difficult by the fact that patients may not be aware of the causal connection between a significant loss and present difficulties. Therefore, clinicians must consider the etiology of symptoms as well as their phenomenology. This task can be assisted by familiarity with the factors placing individuals at risk for complicated grief and with the indications that the syndrome may be present.
Consistently reported risk factors include loss through suicide; loss of a child or partner; sudden, unexpected, or untimely deaths; lack of social support; and a problematic relationship with the deceased. One of the clearest indicators of complicated grief is the patient’s inability to speak about the loss with composure, even though a long time may have elapsed since the loss. Another indicator concerns anniversary reactions. The clinician may discover that the patient’s symptoms occur at specific dates or times of the year. Alternatively, despite the apparent importance of a loss, there may be a total absence of distress. The affect of the patient may change dramatically when the loss is further explored.
Several resources can help those who are having difficulty adjusting to a death loss. Referral is based on the severity of the individual’s maladjustment. For those with mild-to-moderate difficulties, community peer-support groups or counselling may be appropriate. For those with more severe difficulties, specialized psychiatric care may be required. Antidepressant medications have shown a modest effect on complicated grief symptoms (4), and group psychotherapy has been found to be highly effective (5).
References
1. Piper WE, Ogrodniczuk JS, Azim HF, Weideman R. Prevalence of loss and complicated grief among psychiatric outpatients. Psychiatr Serv 2001;52:1069–74.
2. American Psychiatric Association. Diagnostic and statistical manual for mental disorders. 4th ed. Text revision. Washington (DC): American Psychiatric Association; 2000.
3. Ogrodniczuk JS, Piper WE, Joyce AS, Weideman R, McCallum M, Azim HF, and others. Differentiating symptoms of complicated grief and depression among psychiatric outpatients. Can J Psychiatry 2003;48:19–25.
4. Zygment M, Prigerson HG, Houck PR, Miller MD, Shear MK, Jacobs S, and others. A post hoc comparison of paroxetene and nortriptyline for symptoms of traumatic grief. J Clin Psychiatry 1998;59:241–5.
5. Piper WE, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk JS. Patient personality and time-limited group psychotherapy for complicated grief. Int J Group Psychother 2001;51:525–52.
John S Ogrodniczuk, PhD
William E Piper, PhD
Vancouver, British Columbia
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