Abnormal Grief Research Articles

Living with loss: a cognitive approach to prolonged grief disorder - incorporating complicated, enduring and traumatic grief - ADDENDUM.

The subject of prolonged, complicated and traumatic grief has become more topical as a consequence of the Covid-19 pandemic. CBT practitioners have been asked to provide effective therapeutic responses for clients with enduring distressing grief reactions. These enduring grief conditions have now been categorised as Prolonged Grief Disorder in the two main mental health classification systems: in the ICD -11 in November 2020 and as a revision to the DSM-5 in 2021. In this paper we draw on our research and clinical experience in applying cognitive therapy for PTSD (CT-PTSD) to traumatic bereavement to derive lessons for the treatment of prolonged grief. During the pandemic the authors of this paper delivered several workshops on prolonged grief disorder (PGD) during which clinicians raised several thought-provoking questions; how do we differentiate between normal and abnormal or pathological grief; how do we categorise pathological grief; how effective are existing therapies and is there a role for CBT; and how do our experiences with Cognitive Therapy for PTSD help with conceptualisation and treatment of PGD. The purpose of this paper is to answer these important questions and in so doing, consider the historical and theoretical concepts relating to complex and traumatic grief, factors that differentiate normal grief from abnormal grief, maintenance factors for PGD and implications for CBT treatments.

Examining the Basic Assumption of Psychoanalytic Theory Regarding Normal and Abnormal Grief: Roles of Unfinished Businesses and Bereavement Related Guilt.

To date, several theoretical models have been proposed to explain how the expected and natural grief processes turns into psychiatric disorders. Nevertheless, there is a paucity of empirical research examining the basic assumption of psychoanalytic theory regarding pre-death conflict and bereavement related guilt. Accordingly, the current study aimed to investigate the mediator role of bereavement related guilt in the relationship between the pre-death conflict and maladaptive grief process. The sample consisted of 447 bereaved adults who lost a loved one due to death in the last 5years. The Unfinished Business in Bereavement (UBBS), Bereavement Guilt Scale (BGS), Beck Depression Inventory (BDI), and Prolonged Grief Disorder Scale (PG-13) scales were administered. The results indicated that the UBBS scores were positively correlated with both BDI and PG-13 scores, and BGS scores mediated these relationships. Obtained findings were discussed in relation to psychoanalytic theory and existing studies in the grief literature.

Prolonged grief disorder in refugees from Syria: qualitative analysis of culturally relevant symptoms and implications for ICD-11

ABSTRACT Prolonged Grief Disorder (PGD) is a new mental disorder recognised by the ICD-11. However, the cultural norms for grief in refugees or humanitarian migrants from Syria have not yet been established. Here we conduct an exploratory qualitative study of 10 key informant interviews with refugees from Syria with two main aims: (1) to identify common symptoms of normal or abnormal grief in refugees from Syria (2) to identify barriers to the acceptability of the new prolonged grief disorder. Three levels of qualitative analysis informed a new model of grief in Syrian refugees. Important culturally relevant symptoms such as “emotional outburst” and “weariness” emerged. The theme of “refugee experience” including sub-themes such as loss of homeland, lack of social network and ambiguous loss, emerged as potential predictors of grief severity. Finally, the level of culture and society revealed key barriers to the acceptability of the PGD diagnosis including stigma.

The Preparedness of Emergency Care Providers to Deal with Death, Dying and Bereavement in the Pre-Hospital Setting in Dubai

Introduction This study sought to investigate how prepared emergency care providers are to deal with death, dying and bereavement in the pre-hospital setting in Dubai, and to make recommendations related to such events. Methods A quantitative descriptive prospective design was utilised. Data was collected using an online self-report questionnaire sent to all operational emergency care providers in the Dubai Corporation of Ambulance Services. The data was analysed using the IBM Statistical Package for Social Sciences version 25.0. Results Nearly 65% of participants (n=316) reported that they had not received any formal education or training on death, dying and bereavement. Those that did, reported that the training was conducted mainly by nursing (25.9%; n=124) and paramedic (13.6%; n=65) instructors. One-quarter of participants (25.4%; n=126) reported experiencing intrusive symptoms such as sleep loss, nightmares and missing work as a result of a work-related death or dying incident, but only 4.1% (n=20) had received professional counselling. Conclusion This study found that emergency care providers are underprepared to deal with death, dying and bereavement. A comprehensive death education program encompassing the unique challenges that emergency and pre-hospital setting presents should be implemented to reduce emotional anxiety and help emergency care providers cope better with death, and decrease abnormal grief reactions of the bereft. Abnormal grief reactions can include restlessness, searching for the lost person and disrupted autonomic nervous system functions.

The recommendation for management of the bereavements among the family members died with novel coronavirus pneumonia

The death of a family member died with the novel coronavirus pneumonia is a special traumatic stress to the other family members and they will bear unbelievable distress and dramatic sorrow. The grief responses can be divided into normal grief responses and abnormal grief responses. The latter are much stronger, more severe, last longer and the responses can be delayed or inhibited or distorted. The management of abnormal grief responses includes counseling, supportive group, psychotherapy and medications. Key words: Novel coronavirus pneumonia; Bereavement; Grief; Psychological support

Clinical Utility and Global Applicability of Prolonged Grief Disorder in the ICD-11 from the Perspective of Chinese and German-Speaking Health Care Professionals

Background: Prolonged grief disorder (PGD) is included in the ICD-11 (11th edition of the International Classification of Diseases). The new PGD criteria reflect the requirements and recommendations of the World Health Organization for improved clinical utility and international applicability. Even though the ICD classification system is globally used, no research has investigated how healthcare professionals (HP) in non-Western countries may adopt this change for their own practice. Objective: The present study explored the extent to which the new PGD criteria were accepted and perceived to meet the standards for clinical utility and international applicability among Chinese and German-speaking HP. Methods: Individual semistructured interviews were conducted in person, by phone, or online (e.g., via Skype), with 24 Chinese (n = 10) and German-speaking (n = 14) HP working with bereaved populations in China and Switzerland, and analyzed using a qualitative framework analysis. Questions included “what items are currently missing from the PGD criteria?”. Results: Across all HP, the majority supported the inclusion of PGD and were generally aligned with the current criteria. HP found that the criteria distinguished between normal and abnormal grief and considered the criteria easy to use if their modifications were considered. Merits included, among others, improved clinical decision making, research promotion, and social acknowledgment. Main concerns included misdiagnosis, pathologization, and a lack of specificity of criteria. The importance of international applicability was emphasized across Chinese and German-speaking HP. Different grief-specific symptoms were identified by German-speaking and Chinese HP. Conclusions: These findings provide evidence for the clinical utility and international applicability of ICD-11 PGD criteria among German-speaking and Chinese HP, as well as cultural similarities and differences in the barriers to implementation of these criteria.

Health professionals' experiences of grief associated with the death of pediatric patients: a systematic review.

The objective of this review was to synthesize the experiences of health professionals who have experienced grief as a result of a pediatric patient dying. There has been some research into health professionals' grief experiences associated with the death of pediatric patients, but there has not been a review that synthesizes the findings of these experiences. Other related reviews have focused on prenatal, perinatal or adult deaths or the coping strategies employed by health professionals. This review highlights the complexities of experiences faced by pediatric health professionals. Qualitative studies involving pediatric health professionals working in any healthcare setting who had experienced grief from the death of a patient were considered for inclusion. Studies were conducted in any country, at any time and published in English. The search was conducted in PubMed, CINAHL, Embase, PsycINFO, Scopus and ProQuest Dissertations and Theses. The search was completed in January 2019. The review followed principles of meta-aggregation in line with the JBI approach. Methodological quality assessment was based on representation of participants' voices and congruence between research methodology and both research question and analysis of data. Meta-aggregation led to three synthesized findings from 12 qualitative studies that met the inclusion and methodological quality criteria. Studies predominantly included nurses working in a hospital, with sample sizes ranging from six to 25 participants. The synthesized findings were physical, behavioral, psychological or spiritual symptoms; compounding grief; and alleviating grief. Physical, behavioral, psychological, or spiritual symptoms highlighted the various characteristics of grief experiences by health professionals. Compounding grief was the largest synthesized finding and incorporated the various factors that contributed to a poorer experience of grief. Alleviating grief showed the limited identified factors that improved the experience of grief. Methodological quality led to synthesized findings receiving a ConQual rating of low or moderate. The synthesized findings from this review highlight the varied reported experiences of grief in health professionals. The methodological quality and reporting of studies, however, led to decreased confidence in the synthesized findings and recommendations arising from this review. Healthcare professionals should be aware of the potential for experiencing grief when a patient dies and the compounding and alleviating factors associated with this. Further research could expand participant and language limitations, and improve methodological quality and reporting.

Bereavement support and prolonged grief disorder among carers of people with motor neurone disease

Family carers of people with motor neurone disease (MND) face many difficulties before and after bereavement; their support needs are not routinely assessed and little attention is paid to recognising abnormal grief responses. The authors‘ survey (n=56) sought the views of those involved in the care of this population in England (Motor Neurone Disease Association regional care development advisers, staff working in motor neurone disease care and research centres and other health professionals) on bereavement support and prolonged grief disorder in family carers. Results revealed that more than two-thirds of respondents felt unable to predict future cases of prolonged grief disorder (PGD) and that an alert tool to help identify at-risk carers of people with MND would be welcomed. The implications for future research and development of support are also discussed within this article.

Abnormal Grief: Should We Consider a More Patient-Centered Approach?

Grief, the psychological reaction to the loss of a significant other, varies complexly in its cause, experience, evolution, and prognosis. Although most bereaved individuals experience a normal grieving process, some develop complicated grief (CG) or major depressive disorder (MDD). The DSM-5, which controversially altered the nosology, recognizes grief-related major depression (GRMD) as a diagnostic subtype if a patient meets MDD criteria two weeks post bereavement. The (DSM-5) tries to distinguish between grief and MDD, but remains a symptom-based, centered approach to grief that is not patient centered. This article reviews grief in its normal and abnormal dimensions. Using an illustrative clinical case in which interpersonal psychotherapy (IPT) was employed, we discuss the need for a more patient-centered approach to treating abnormal grief, considering the patient's personal history, perceptions, experiences of bereavement, and interpersonal environment. Clinical studies need to better identify subgroups of individuals susceptible to abnormal grief and to evaluate their response to early interventions.

Initial management of bereaved relatives following trauma

Emergency department (ED) staff confront death more frequently than any other specialty except oncology. These deaths are often traumatic, sudden, unexpected and occur in a younger age group. As a consequence, bereaved survivors have a greater risk of an abnormal grief reaction. [ Walters DT, Tupin JP (1991) Family grief in the emergency department. Emergency Medicine Clinics of North America 9(1): 189–206.] Whilst the severity or timing of traumatic injuries may preclude medical attempts to influence patient survival, the approach of the same resuscitation team to the bereaved before death, during resuscitation and after death may have profound influences on subsequent grief in the bereaved. Despite this, it can be argued that Emergency Medicine within the UK has given little thought and time for reflection upon how we treat the bereaved. That the care of the dying and the bereaved within the ED matters is greatly reinforced by the Scottish Government’s 2010 Consultation document on bereavement that states: ‘There is … evidence that the way [the] bereaved experience events around the time of death will influence their grief. Where health services get it right … bereaved people are supported to accept the death … Conversely if the health services get it wrong, then bereaved people may experience additional distress, and that distress will interfere with their successful transition through the grieving process’.

Help is at hand for people bereaved by suicide and other traumatic death

Bereavement following suicide is traumatic. Guilt, shame, stigma and feelings of rejection and isolation set it apart from the sadness following other kinds of death and may make it difficult for the bereaved person to obtain help (Harwood et al, 2002; Hawton & Simkin, 2003; Beautrais, 2004). the necessary official processes surrounding death by suicide, like the police and coroner's investigations, can add to the trauma (Biddle, 2003). This may be compounded by inaccurate or insensitive media reporting. Bereaved individuals are at risk of increased morbidity from abnormal grief reactions (Mitchell et al, 2005) and suicide (Qin et al, 2002), and they often need considerable support (de Groot et al, 2006; 2007).

Death and Life in Residency

Back to table of contents Previous article Next article Residents' ForumFull AccessDeath and Life in ResidencyNatalie Gluck, Natalie GluckSearch for more papers by this author, M.D.Published Online:5 Aug 2005https://doi.org/10.1176/pn.40.15.00400032A couple of weeks into my third year of residency, just as I was beginning to acquaint myself with a large and daunting caseload of outpatients, my father died. Without warning, I went from navigating another day in the clinic to making travel plans and funeral arrangements. My life as a resident would have to be put on hold.When I received the devastating phone call on that balmy afternoon, my immediate response—thanks to a ready reserve of ego defenses—was to agonize over my patients. How would a sudden, unexplained departure affect a group of people already traumatized by the recent changeover of doctors? How could I gracefully maneuver through all of the phone calls without sounding panicked or betraying my veil of neutrality? I was stuck in a quagmire of technical questions, the answers to which were not easily found in a Glen Gabbard textbook.As a resident in a program that clings doggedly to modern psychiatry's psychoanalytic roots, I have been served ample portions of dynamic theory. But in all our lectures on process in psychotherapy, not a single one had addressed the transference and countertransference implications of a therapist's crisis. I thought a lot about this during that period of suspended reality known as shiva, the first seven days of mourning in the Jewish tradition, and questioned whether I could treat people in pain while I myself was suffering. I grappled with issues of self-revelation, wondering how I would explore my patients' fantasies of where a “family emergency” had taken me. My own fantasies led me to fear the worst— that my patients would flee treatment, stop their medication, or decompensate.I returned to work, emotionally at half-mast and with no clear idea of how I would manage. But I quickly found that, consciously at least, it was possible to keep my father's death out of the room. Many of my higher-functioning patients expressed relief at my return but did not linger on the issue, and we were quickly able to pick up where we had left off. For those in a more supportive therapy, I offered a direct explanation for my absence, accepted their condolences, and moved on.Outside of the therapeutic interaction, however, I noticed a kind of self-consciousness about being a person in mourning, unsure of what others expected of me. I worried that supervisors would restrain their questions in an effort to avoid the dangerous territory where supervision becomes individual therapy. I worried that my colleagues might interpret a bright affect as pathologic. I even scanned the DSM-IV criteria for abnormal grief reaction for fear of confirming their suspicions.I'd often respond to inquiries with intellectualized defenses, including quoting the stages of grief described by Elizabeth Kubler-Ross, who, ironically, died a few weeks after my father. There were questions of whether I was in therapy (twice weekly, thank you very much) or had considered joining a bereavement group (I had, but couldn't find one where phrases like“ identification with the lost object” were appreciated). After a while, I developed a sort of haughtiness, as if the death of a parent somehow adds to your life's curriculum vitae. Yep, now I can say that I get loss.As I enter my final year of training and approach the first anniversary of my father's death, there are many things for which I am grateful. I am grateful for my fellow residents, who have showered me with kindness and support, offering everything from taking extra call to permitting a space for bereavement in process group. I am grateful for the supervisors who acknowledged my sorrow, but respected the work enough to keep me from drowning in it. I am grateful that patients are more resilient than I gave them credit for and that my sudden departure weaved its way into their therapies in subtle but meaningful ways.Through the tribulations of residency, I've battled self-doubt and uncertainty. But even as I weather sadness and anger, I realize that most of my patients are doing well, and a few have even gotten better. And like my father—himself a physician who devoted much of his life to the practice of medicine—I continue to derive satisfaction from my work.My dad would have been proud. ▪Natalie Gluck, M.D., is a PGY-4 resident at the New York University School of Medicine. ISSUES NewArchived

Death, Grief, and the Home Health Worker: A Systems Approach

As the burden of long-term care shifts from nursing homes to home-based care, home health workers are increasingly likely to serve an older clientele susceptible to chronic disease and death. A significant occupational stressor in such cases is a lack of knowledge about what constitutes professionally appropriate interaction with dying patients and their families. Utilizing social systems theory and findings from the sociology of death and dying, this article provides information helpful to workers dealing with such cases. There is discussion of the stages of grief for the dying patient and for survivors, the difference between normal and abnormal grief, how to lessen the symptoms of grief, the art of condolence, and the special topic of children and grief. The article concludes with six recommended strategies for workers to cope with the problems of death, dying, and grief within the real-life social system in which they work and live.

Abnormal Grief Reaction is a Mental Disorder from the Legal Perspective

Abnormal Grief Reaction is a Mental Disorder from the Legal Perspective

An unsuccessful resuscitation: The families' and doctors' experiences of the unexpected death of a patient

Background: The objective was to elicit families' experience of the death of a family member at the Elsies River Community Health Centre, their feelings towards the staff involved in the resuscitation and their opinions about how things could be improved. The study also elicited the doctors' experiences of communicating with the families of patients who had died in the emergency unit. Methods: This was a qualitative study, using free attitude interviews for family members and focus group discussions for doctors. Twelve family members whose loved ones had died in the emergency room and 15 doctors who worked in the emergency room were included. Results: Key themes were identified, relating to issues in the pre-resuscitation period, the resuscitation, breaking the bad news, after breaking the bad news and post-event sequelae. In the pre-resuscitation period, there were problems in admitting, identifying and responding to acutely ill patients. During the resuscitation, the families and staff disagreed about witnessing the resuscitation. Breaking the bad news was often difficult for the doctors and hindered by the physical environment. Afterwards, there were mixed feelings about the quality of emotional support, the use of medication and bereavement counselling. All agreed that viewing the body was helpful and funeral arrangements were not a problem. There was no effective follow-up of the families and the doctors also experienced increased stress following unsuccessful resuscitations. Conclusion: The study found that the role of security staff should be clarified and a better triage system established to enable critically ill patients to be seen promptly. Families should be given the option of viewing the resuscitation and always be kept informed of progress. Doctors need better training in communication skills and breaking bad news, which should be done in a private area. Families should also be given the opportunity to view the body. Families should be assisted with contacting the undertaker and a follow-up visit should be organised after the initial shock, when further questions can be asked and abnormal grief reactions identified. Bereavement counselling should be available and community-based resources should be identified in this regard. Debriefing should also be available for staff involved in unsuccessful resuscitations. SA Fam Pract 2004;46(8): 20-25

Working with grieving adults

Despite the dearth of recent psychiatric literature on the subject of grief, mental health professionals continue to see patients suffering from complex responses to grief. This article reviews psychological theories about normal and abnormal grief, drawing particularly on the work of Freud, Klein, Bowlby and Parkes. It describes the principles of grief work, using as illustration clinical examples of adults grieving as a result of bereavement. These principles also apply to work with adults grieving other forms of loss (e.g. breakdown of a love relationship, loss of employment or loss of physical health).

The Value of Maintenance Interpersonal Psychotherapy (IPT) in Older Adults With Different IPT Foci

Objective/METHODS The authors examined recurrence rates of major depression in elderly subjects with different foci of interpersonal psychotherapy (IPT), who were treated for up to 3 years with either monthly maintenance IPT and pill placebo or with monthly clinical management and pill placebo. RESULTS Among subjects with an IPT focus on role conflict, a greater proportion of those treated with maintenance-IPT survived for 3 years without recurrence than those treated with placebo/clinical management. Median time to recurrence was 68.9 weeks in IPT-treated patients versus 16.3 weeks for patients in clinical management. Subjects with an IPT focus on abnormal grief or role transition demonstrated no effect differential for maintenance IPT and pill-placebo on recurrence prevention over supportive clinical management and pill-placebo. CONCLUSION If replicated in a larger sample, these findings have important implications for ongoing case-management decisions. The authors examined recurrence rates of major depression in elderly subjects with different foci of interpersonal psychotherapy (IPT), who were treated for up to 3 years with either monthly maintenance IPT and pill placebo or with monthly clinical management and pill placebo. Among subjects with an IPT focus on role conflict, a greater proportion of those treated with maintenance-IPT survived for 3 years without recurrence than those treated with placebo/clinical management. Median time to recurrence was 68.9 weeks in IPT-treated patients versus 16.3 weeks for patients in clinical management. Subjects with an IPT focus on abnormal grief or role transition demonstrated no effect differential for maintenance IPT and pill-placebo on recurrence prevention over supportive clinical management and pill-placebo. If replicated in a larger sample, these findings have important implications for ongoing case-management decisions.

The Value of Maintenance Interpersonal Psychotherapy (IPT) in Older Adults With Different IPT Foci

The authors examined recurrence rates of major depression in elderly subjects with different foci of interpersonal psychotherapy (IPT), who were treated for up to 3 years with either monthly maintenance IPT and pill placebo or with monthly clinical management and pill placebo. Among subjects with an IPT focus on role conflict, a greater proportion of those treated with maintenance-IPT survived for 3 years without recurrence than those treated with placebo/clinical management. Median time to recurrence was 68.9 weeks in IPT-treated patients versus 16.3 weeks for patients in clinical management. Subjects with an IPT focus on abnormal grief or role transition demonstrated no effect differential for maintenance IPT and pill-placebo on recurrence prevention over supportive clinical management and pill-placebo. If replicated in a larger sample, these findings have important implications for ongoing case-management decisions.

Perceptions of catholic priests toward help‐seeking behavior of parishioners

Abstract Randomly sampled Catholic priests functioning in parishes throughout the United States were surveyed to determine who they believed should assist people in 13 moral, emotional, familial, and personal problem‐situations. To each problem situation, respondents were asked to choose one of the following four options: (1) a priest; (2) a priest with advanced mental health training in clinical social work, counseling, psychology or psychiatry; (3) a lay mental health professional; or (4) these specific situations should be handled by the person alone and without skilled help. The findings indicate that priest‐respondents believed that moral problems such as marrying a non‐Catholic (92.0%) and conflict over birth control (78.9%) should be handled by priests, whereas severe emotional problems (74.9%), spousal abuse (62.8%), personal alcohol abuse (59.3%), abnormal grief reactions (54.8%), and teenagers using drugs (52.3%) should be referred to lay professionals. “Hearing the voice of God” and “seeing Jesus” were situations perceived to be within the competence of priests, especially those with advanced clinical training. Years of pastoral experience and advanced clinical training seem to have an effect on few of these decisions. Implications for social work are discussed, particularly in light of policy initiatives for faith‐based service provision.

Perceptions of Catholic Priests Toward Help-Seeking Behavior of Parishioners

Abstract Randomly sampled Catholic priests functioning in parishes throughout the United States were surveyed to determine who they believed should assist people in 13 moral, emotional, familial, and personal problem‐situations. To each problem situation, respondents were asked to choose one of the following four options: (1) a priest; (2) a priest with advanced mental health training in clinical social work, counseling, psychology or psychiatry; (3) a lay mental health professional; or (4) these specific situations should be handled by the person alone and without skilled help. The findings indicate that priest‐respondents believed that moral problems such as marrying a non‐Catholic (92.0%) and conflict over birth control (78.9%) should be handled by priests, whereas severe emotional problems (74.9%), spousal abuse (62.8%), personal alcohol abuse (59.3%), abnormal grief reactions (54.8%), and teenagers using drugs (52.3%) should be referred to lay professionals. “Hearing the voice of God” and “seeing Jes...