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SUDC Insights

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SUDC Insights is the official blog of the SUDC Foundation which shares and discusses issues important to the understanding and the ultimate prevention of SUDC. If you have questions or issues you would like to see addressed in SUDC Insights, please let us know at sudcinsights@sudc.org.

What is Complicated Grief?

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Grief is a natural part of life. The often painful and difficult grieving process can be overcome by individuals experiencing it using personalized methods, on their own time, and with minimum complications. There are individuals that can also experience what is referred to as a comorbidity with their grief, such as Major Depressive Disorder (MDD) or Post Traumatic Stress Disorder (PTSD).

Others may experience a different type of grief entirely; complicated grief (CG). Referenced in the DSM V for additional study under “Other Specified Trauma- and Stress-Related Disorder, 5. Persistent Complex Bereavement Disorder," and sometimes also called Traumatic Grief or Prolonged Grief. This type of grief affects about 2-3 percent of the population. It leaves those in mourning with a distressing preoccupation concerning their loved one, often with an intensity that can interfere with daily living. This differs from MDD and PTSD in that symptoms are primarily focused on the individual who has passed, though both can be comorbid.  
 
Grief is a normal process most of us have, or will experience in life. It is natural to experience changes in emotions, thoughts, behaviors, and even some physiological changes during these times. For some, managing these changes and new life experiences can be just as natural as any other ebb and flow of life, but for others, they can experience “getting stuck.” It is important to note that there is no one right or wrong way to grieve; everyone grieves differently. Everyone experiences trauma differently as well, so where these may or may not intersect can be important.   

Experiencing trauma does not necessitate developing PTSD. What will make the traumatic event different from one person to another is its ability to violate any sense of safety and security that individual ever knew. What differentiates PTSD from CG is the focus of symptoms, and also the lack of, or presence of other symptoms. While there may be avoidance, restless nights, ruminating thoughts, and recurrent images in both, in CG they’re focused on the lost individual while in PTSD they’re focused on the traumatic event itself, or its aftermath. PTSD can be present with CG when the events surrounding death are traumatic (i.e. sudden, violent, witnessed). Then there are symptoms focused on the traumatic events, rather than solely on the deceased individual.
 
This differential diagnosis is also commonly true of MDD. Many of the effective symptom characteristics in CG parody those of MDD, such as depressed mood, guilt, difficulty concentrating, having preoccupying thoughts, avoidance, and suicidality. However, just as in PTSD the difference is where the focus of those symptoms lie. In a major depressive episode, feelings and symptoms are focused on a depressed perception of the self, whereas in grief of any kind, feelings and symptoms are focused on the person lost. For example: 

Guilt Grief: “She was so great to me; I really should have taken her to that concert.”   

Guilt Depression: “I never did enough for her because I was never good enough for her. I should have never entered her life or anyone else's. I can never do enough, I’m worthless.”   

It is not uncommon for a bereaved individual to express a will to “join” their loved one. Contrarily to someone suffering MDD, who may express wanting to end their life due to personal feelings of worthlessness and an inability to cope with the unbearable pain of the depression itself. (Suicidal ideations should always be taken seriously and monitored in some fashion; to learn more about risks and warnings click here).  
 
While normal grief entails various stages and phases, one of those many times being acute; someone with CG never left the acute grieving phase and is stuck there. CG is typically assessed when the bereaved loses someone close and continues to experience significant grief-related symptoms such as reactive distress to the death, or continued social and personal identity disruptions related to the deceased beyond one year (6 months for children).  

Some practitioners may advise or start treatment for CG as early as six months after a death, as needs concerning individuals, cultures, and circumstances may vary. Unsurprisingly, counseling is the recommended first-line treatment. Although there’s no cure-all, numerous scientific studies have shown the use of antidepressant medications in conjunction with psychotherapy to provide better outcomes.  
 
Nothing is one size fits all, and neither is the specific modality of counseling someone may benefit from. Depending on the methods used, counseling can range anywhere from a recommended 10-20 sessions (possibly more or less). The use of cognitive-behavioral therapy (CBT) in conjunction with other psychotherapeutic approaches is common in “Complicated Grief Treatment” which combines self-restorative focused interpersonal psychotherapy (IPT) strategies with loss-focused CBT techniques. CBT can help individuals develop better personal coping strategies after a loss has triggered or enhanced cognitive distortions which contribute to emotional dysregulation. In addition to IPT, there is a range of psychoanalytic approaches that can be used to help clients break down their inner defenses to gain insights into themselves and their relationships, and their past and future. 

Contrary to normal grief, complicated grief is unlikely to resolve itself and can ultimately reduce an individual's quality of life over time due to an increased risk of harmful health behaviors and impairments in social functioning.  Having or creating a strong support system and communicating personal needs is the most important thing one can do no matter where they are in their grief. Remember, it’s never too early to ask for help. If you or someone you know have suffered the sudden unexpected or unexplained death of a child (1-18years) please contact the SUDC Foundation at 800-620-SUDC, sudc.org or info@sudc.org to learn about our comprehensive no-cost services available to families. 
 

References: 

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5. Arlington, VA. 
Ehlers, A. (2006). Understanding and Treating Complicated Grief: What Can We Learn from Posttraumatic Stress Disorder? Clinical Psychology: Science and Practice, 13(2), 135–140. doi: 10.1111/j.1468-2850.2006.00015.x 

O’Connor, M., Lasgaard, M., Shevlin, M., & Guldin, M.-B. (2010). A confirmatory factor analysis of combined models of the Harvard Trauma Questionnaire and the Inventory of Complicated Grief-Revised: Are we measuring complicated grief or posttraumatic stress? Journal of Anxiety Disorders, 24(7), 672–679. doi: 10.1016/j.janxdis.2010.04.009 

Regehr, C., & Sussman, T. (2004). Intersections Between Grief and Trauma: Toward an Empirically Based Model for Treating Traumatic Grief. Brief Treatment and Crisis Intervention, 4(3), 289–309. doi: 10.1093/brief-treatment/mhh025 

Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of Complicated Grief. Jama, 293(21), 2601. doi: 10.1001/jama.293.21.2601 

Shear, M. K. (2015). Complicated Grief. New England Journal of Medicine, 372(2), 153–160. doi: 10.1056/nejmcp1315618 
 


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