Complicated Grief: Literature Review and a Case Study

Abstract

The current article covered a brief literature review on grief, the factors affecting the grief process leading to complicated grief reactions and depressive symptoms and focused on the psychotherapy process of an individual with complicated grief reactions. Complicated grief reactions is a current topic in research and psychotherapy that led American Psychiatric Association (APA) to include a diagnostic criteria named “Persistent Complex Bereavement Disorder” (PCBD) under the heading of “Conditions for Further Study”. As the term “complicated grief” (CG) rather than PCBD was widely used in the current literature, this term was used in this article. CG encompasses symptoms such as separation distress (e.g., craving, yearning, intense feelings of loneliness, desiring to die in order to reunion, preoccupation with thoughts of the deceased) and other cognitive, emotional, and behavioral symptoms (e.g., confusion, disbelief, avoidance, anger, numbness, difficulty moving on with life). In the literature, many precipating factors for complicated grief reactions were reported. These factors involve the type of death, personal well-being, the relationship with the deceased, personality characteristics, coping style, schemas and beliefs, and social support. These factors that result in complicated grief reactions may be helpful in understanding complicated grief and its treatment. In this article, after the literature review on complicated grief, a treatment model and its application in the psychotherapy process of N. was mentioned. According to this cognitive model that was suggested by Boelen and his collegues (2006), core processes such as poor integration of the separation with existing autobiographical knowledge, negative global beliefs and misinterpretations and anxious and depressive avoidance strategies moderate the relationship between some background variables (e.g., individual vulnerabilty factors, characteristics of the loss event, characteristics of the loss sequelae) and the clinical outcomes (e.g., separation distress, traumatic distress). Boelen and his collegues (2006) state that the treatment of complicated grief should have three targets: 1) loss needs to be conceptually processed and integrated within the autobiographical memory 2) dysfunctional beliefs and misinterpretations need to be identified and replaced with functional ones 3) anxious and depressive avoidance strategies need to be replaced with helpful strategies promoting adjustment. The model does not restrict cognitive behavioral techniques. In order to reach these goals, Boelen and his collegues (2006) suggest using techniques such as psychoeducation, exposure, Socratic questioning and cognitive restructuring. Therefore the psychotherapy process involved a collaborative therapeutic relationship and cognitive behavioral techniques while focusing on the integration of loss in memory, dysfunctional beliefs and avoidance strategies in order to replace them with more adaptive ones.

Keywords

• Complicated Grief,Grief,Psychotherapy,Cognitive Model

Komplike Yas: Derleme ve Vaka Çalışması

Abstract

Yas süreci ve depresyon, Freud’un (1915/2000) Yas ve Melankoli üzerine makalesinden bu yana, birbiri ile ilişkili olarak değerlendirilmiş ve iki süreci ayrıştıran özellikler, kuramcılar ve klinisyenler tarafından ilgi odağı olmuştur. Son dönemde, komplike yas kavramı, araştırmalar temelinde, kendine özgü bazı belirtileri kapsayacak şekilde tanımlanmıştır. Literatürdeki yaygın ismi ile komplike yas, süreğen kompleks yas bozukluğu olarak DSM-V tanı kitabına dahil edilmiştir. Bu tanının DSM-V’e dahil edilmesi, gelecekteki çalışmaları arttırmak ve onlara yön vermek amacı taşımaktadır. Bu makalede, literatürdeki araştırmalara paralel olarak “komplike yas” kavramı kullanılmış; kaybın inkarı, ölen kişiye dair sürekli zihinsel meşguliyet, yoğun hasret ve kaybedilenle bir araya gelmek amacıyla intihar düşünceleri gibi belirtileri niteleyen bu kavramın, normal yas sürecinden farkına, komplike yasa yol açabilecek bazı faktörlere, komplike yasın bilişsel kavramsallaştırması ile bu temelde ilerleyen bir vaka çalışmasına yer verilmiştir.

Keywords

• Komplike yas, yas, psikoterapi, bilişsel model

References

1. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders
2. (5th ed.).Washington, DC: American Psychiatric Association. Adler, N., Boyce, T., Chesney, M. A., Cohen, S., Folkman, S., Kahn, R. L., Syme, S. L. (1994).
3. Socioeconomic status and health: the challenge of the gradient. American Journal of ogy, 49, 15-24. Beder, J. (2004). Voices of Bereavement: A Casebook for Grief Counselors. Brunner & ledge: Great Britain.
4. Boelen, P. A. & Van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: A confirmatory factor analysis study. American Journal of 2177.
5. Boelen, P. A., Van den Hout, M. & Bout, J. (2006). A cognitive- behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13 (2), 09-128.
6. Boelen, P. A. & Van den Bout, J. (2010). Anxious and depressive avoidance and symptoms of prolonged grief, depression, and post-traumatic stress disorder. Psychologica Belgica, 50, 1, 49-67.
7. Boelen, P. A. & Klugkist, I. (2011). Cognitive behavioral variables mediate the associatives of neuroticism and attachment insecurity with prolonged grief disorder severity. Anxiety, and Coping, 24 (3), 291-307.
8. Boelen, P. A., Keijser, J., Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., Carr, D., Nesse, R. M. (2011). Factors associated with outcome of cognitive–behavioural therapy for cated grief: A preliminary study. Clinical Psychology and Psychotherapy, 18, 284- 291.

9. Bonanno, G. A., Wortman, C. B. , Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., Carr, D., Nesse, R. M. (2002). Resilience to loss and chronic grief: A prospective study from to 18 months post-loss. Journal of Personality and Social Psychology, 83, 1150
10. Bowlby, J. (1982). Attachment and loss: Vol. 3. Loss, sadness, and depression. NewYork: Basic Books.
11. Burton, C. L., Yan, O., Pat-Horenczky, R., Chan, I. S., Ho, S., Bonanno, G. A. (2012). Coping flexibility and complicated grief: A comparison of American and Chinese samples. sion & Anxiety, 29 (1), 16-22.
12. Casarett, D., Kutner, J. S., Abrahm, J. (2001). Life after death: A practical approach to grief and bereavement. Annals of Internal Medicine, 134, 208-215.
13. Chiu, Y., Yin, S., Hsieh, H. Y., Wu, W. C., Chuang, H. Y., Huang, C. T. (2010). Bereaved females are more likely to suffer from mood problems even if they do not meet the criteria for prolonged grief . Psycho-Oncology, 20, 1061–1068.
14. Craig, L. (2010). Prolonged grief disorder. Oncology Nursing Forum, 37 (4), 401-405.
15. Cowhock, F., Ellestad, B., Meador, K. G., Koenig, H. G., Hoosen, E. G., Swamy, G. K. (2011).
16. Religiosity is an important part of coping with grief in pregnancy after a traumatic secondtrimester loss. Journal of Religion & Health, 50 (4), 901-910. Currier, J. M., Holland, J. M. & Neimeyer, R.A. (2009). Assumptive worldviews and problematic reactions to bereavement. Journal of Loss and Trauma, 14, 181-195.
17. Dell’Osso, L., Carmassi, C., Corsi, M., Pergentini, I., Socci, C., Maremmani, A., Perugi, G. (2011).
18. Adult separation anxiety in patients with complicated grief versus healthy control subjects: relationships with lifetime depressive and hypomanic symptoms. Annals of atry, 10:29, 1-6.
19. Freud, S. (2000). Yas ve Melankoli. Metapsikoloji (s.179-191) Çev. Yardımlı, A. Birinci Basım.
20. İdea Yayınevi: İstanbul. (Özgün eser 1915 tarihlidir).
21. Gamino, L. A., Sewell, K. W., & Easterling, L. (2000). Scott and White grief study Phase 2: Toward an adaptive model of grief. Death Studies, 24, 633-660.
22. Ghesquiere, A., Haidar, Y. M. M., Shear, M. K. (2011). Risks for complicated grief in family caregivers. Journal of Social Work in End-of-Life & Palliative Care, 7, 216-240.
23. Gona, K. & K’Delant, P. (2011). The effects of temperament, character, and defense mechanisms of grief severity among the elderly. Journal of Affective Disorders, 128, 1-2, 128-134.
24. Harvard Mental Health Letter (HMHL) (2011). Coping with complicated grief. Harvard Mental
25. Health Publications, 6. Hollis, James (2004). Ruhun Kaygan Kumları. Çev. Toksoy, S., Erendağ, Ç. Birinci Basım.
26. Sistem Yayıncılık: İstanbul. Horowitz, M. J., Siegel, B., Holen A., Bonanno, G. A., Milbrath, C., Stinson, C. H. (1997).
27. Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154, Kelley, M. M., Chan, K. T. (2012). Assessing the role of attachment to God, meaning, andreligious coping as mediators in the grief experience. Death Studies, 36, 199-227.
28. Kessler, R. C., Kendler, K. S., Heath, A., Neale, M. C., Eaves, L. J. (1992). Social support, depressed mood, and adjustment to stress: a genetic epidemiologic investigation. Journal of
29. Personality and Social Psychology, 62- 257-272. Kübler-Ross (1969). On Death and Dying. MacMillan: New York.
30. Kristensen, P., Weisaeth, L. & Heir, T. (2012). Bereavement and mental health after sudden and violent losses: A Review. Psychiatry, 75 (1), 76-97.
31. Le Guin, U. (1999). Yerdeniz Büyücüsü. İstanbul: Metis Edebiyat.
32. Lindemann (1963). Symptomatology and management of acute grief. Pastoral Psychology, 14 (6), 8-18.
33. Lobb, E. A., Kristjanson, L., Samar, M., Leanne, M., Georgia, K. B., Halkett, A. D. (2010).
34. Predictors of complicated grief: A systematic review of empirical studies. Death Studies, 34, 698. Love, A. W. (2007). Progress in understanding grief, complicated grief, and caring for the bereaved. Contemporary Nurse, 27 (1), 73-83.
35. Maccallum, F. & Bryant, R. A. (2011). Imagining the future in complicated grief. Depression and Anxiety, 28, 658-665.
36. Maercker, A., Bonnanno, G. A., Znoj, H. & Horowitz, M. J. (1998). Prediction of complicated grief by positive and negative themes in narratives. Journal of Clinical Psychology, 54 (8), 1136.
37. Maercker, A. & Lalor, J. (2012). Diagnostic and clinical considerations in prolonged griefdisorder.
38. Dialogues in Clinical Neuroscience, 14 (2), 167-175. Mathew, L. T. & Marwit, S. J. (2004). Complicated grief and the trend toward cognitive behav- ioral therapy. Death Studies, 28, 849-863.
39. Melhem, N. M., Day, N., Shear, K., Day, R., Reynolds III, C., Brent, D. (2003). Predictors of complicated grief among adolescents exposed to a peer’s suicide. Journal of Loss and , 21-34.
40. Metzger, P. & Gray, M. (2008). End-of-Life communication and adjustment: Pre-loss nication as a predictor of bereavement-related outcomes. Death Studies, 32, 301- 325.
41. Nakao, M., Kashiwagi, M., Yano, E. (2005). Alexithymia and grief reactions in bereaved Japanese women. Death Studies, 29, 423-433.
42. Neimeyer, R. A. (2006). Complicated grief and reconstruction of meaning: Conceptual and empirical contributions to a cognitive-constructivist model. Clinical Psychology: Science and Practice, 13, 141-145.
43. Newson, R. S., Boelen, P. A. & Hek, K. (2011). The prevalance and characteristics of cated grief in older adults. Journal of Affective Disorders, 132, 1-2, 231-238.
44. Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., Weideman, R., McCallum, M., Azim, H. F., Rosie, J. S. (2003). Differentiating symptoms of complicated grief and depression amongpsychiatric outpatients. The Canadian Journal of Psychiatry, 48 (2), 87-93.
45. Parkes C. M. (1998). Traditional models and theories of grief. Bereavemnt Care, 17 (2), 21-23.
46. Parkes, C. M. (2002). Grief: lessons from the past, visions for the future. Death Studies, 26, 367
47. Prigerson, H. G., Horowitz, M.J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, ciejewski, P. K. (2009). Prolonged grief disorders: Psychometric validation of proposed for DSM-V and ICD-11. Plos Med, 6 (8).
48. Raphael, B. & Dobson, M. Bereavement. In Loss and trauma: General and close relationship perspectives, ed. By. Harvey, J. H. & Miller, E. D. (2000). Brunner & Routledge: UK
49. Robinson & Marwit, S.J. (2006). An investigation of the relationship of personality, coping, and grief intensity among bereaved mothers. Death Studies, 30, 677-696.
50. Schnider, K. R & Elhai, J. D. (2007). Coping style use predicts posttraumatic stress and compli- cated grief symptom severity among college students reporting a traumatic loss. Journal of
51. Counseling Psychology, 54 (3), 344-350. Shear, K. & Shair, H. (2005). Research reiew: Attachment, loss, and complicated grief. opmental Psychobiology, 47, 253-267.
52. Shear, M. K.., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N…Kesaviah, A. (2011).
53. Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28, 117. Shear, M. K. (2012). Getting straight about grief. Depression and Anxiety, 29: 461-464.
54. Stroebe M, Schut H, Stroebe W (2007). Health outcomes of bereavement. Lancet 370: 1960
55. Stroebe, M., Boelen, P. A., Van den Hout, M., Stroebe W., Salemlnk, E., Van den Bout J. (2007).
56. Ruminative coping as avoidance: A reinterpretation of its function in adjustment o bereavement. Eur Arch Psychiatry Clin Neurosci, 257, 462–472. Strupp, H. (1988). What is therapeutic change? Journal of Cognitive Psychotherapy, 2 (2), 75
57. Sung, S. C., Dryman,, M. T., Marks, E., Shear, M. K., Ghesquiere, A., Fava, M., Simon, N. M. (2011). Complicated grief among individuals with major depression: Prevalence, comorbidity, and associated features. Journal of Affective Disorders, 134, 1-3, 453-458.
58. Tomarken, A., Holland, J., Schacher, S., Vanderwerker, L., Zuckerman, E., Nelson, C…Prigerson, H. (2008). Factors of complicated grief pre-death in caregivers of cancer patients. Psycho-Oncology, 17, 105-111.
59. Tomarken, A., Roth, A., Holland, J., Ganz, O., Schachter, S., Kose, G….Nelson, C.J. (2012).
60. Examining the role of trauma, personality, and meaning in young prolonged grievers. Psycho-Oncology, 21, 771-777. Worden, J. W. (1996). Children and Grief: When A Parent Dies. New York: Guilford Press.
61. Worden, J. W. (2004). Grief Counseling and Grief Therapy: A Handbook for the Mental Healh
62. Practitioner. Brunner & Rutledge: New York. Third Edition. Worden, J. W. (2009). Grief Counseling and Grief Therapy: A Handbook for the Mental Healh
63. Practitioner. Brunner & Rutledge: New York. Fourth Edition. Wright, J. H. & Davis, D. (1994). The therapeutic relationship in cognitive-behavioral therapy:
64. Patient perceptions and therapist responses. Cognitive and Behavioral Practice, 1, 25-45. Zisook, S., Corruble, E., Duan, N., Igiewicz, A., Karam, M. D., Lanuoette, N….Young, I. T. (2012). The bereavement exclusion and DSM-5. Depression and Anxiety, 29, 425-443.