Complicated grief disorder

In psychiatry, complicated grief disorder (CGD) is a proposed disorder for those who are significantly and functionally impaired by prolonged grief symptoms for at least twelve months after the bereavement.[1] It is distinguished from non-impairing grief[2] and other disorders (such as major depressive disorder[3][4][5][6][7][8] and posttraumatic stress disorder).[4][5][6][9][10] This disorder has been reviewed by the DSM-5 work groups, who have decided that it be called Persistent complex bereavement disorder and placed it in the chapter on Conditions for Further Study in the new DSM-5.[11]

Description

Complicated grief is considered when an individual’s ability to resume normal activities and responsibilities is continually disrupted beyond six months of bereavement. Six months is considered to be the appropriate point of CGD consideration, since studies show that most people are able to integrate bereavement into their lives by this time.[12][13][14][15][16]

Symptoms

The symptoms of complicated grief are mentioned in the most-recently proposed diagnostic criteria; they include maladaptive thoughts and behaviors related to the death or the deceased, continuous emotional dysregulation about the death, social isolation and suicidal ideation.[17] Central to complicated grief is the presence of yearning.[1]

Causes and predictors

Although more research is needed to determine the multiple pathways to complicated grief disorder, preexisting conditions (such as major depression, PTSD, and sleep disorders) are thought to exacerbate the interruption of the natural healing process.[17]

There are some known predictive characteristics for CGD.[17] An individual is at increased risk for CGD if they are:

Consequences

Untreated CGD has clinically significant consequences. A high level of impairment can be pervasive,[3][4][6][10][18][33][34][35][36][37][38][39][40] including destructive thoughts and behaviors (such as substance abuse).[16][41] CGD may worsen the course of preexisting disorders and contribute to the development of new ones.[42][43]

Incidence

CGD is an atypical grief response, occurring only in a minority of the bereaved population.[16][24] It is considered more common in those experiencing disasters,[5][18][44][45] violence,[46][47][48][49] the loss of a child,[50][51][52] and the loss of a spouse.[19][53]

It has also been found in family members (or friends) of:

CGD is found to be prevalent cross-culturally in Europe,[20][23][58][59][60][61][62][63][64] the Middle East,[44][65] Africa,[66] and Asia.[28][67][68][69][70][71]

Treatment

CGD is relatively unresponsive to antidepressants[72] or interpersonal psychotherapy;[73] however, recent studies support the use of CG-targeted psychotherapy[54][74][75] (similar to PTSD-targeted psychotherapy). Other methods of psycho-pharmacological treatment are under investigation.

Complicated grief therapy (CGT)

CGT was developed in 2001 by Shear et al. (2001)[76] and has been researched extensively by its creators and other researchers. CGT identifies the areas of CGD that is impeding the individual to grieve naturally. This is completed through a 16-weekly therapy session. These sessions are based on seven principles that help the individual understand and accept their grief, manage and monitor symptoms, think about the future, reconnect with others, tell the death story, learn to live with reminders, and connect with memories.[77] This treatment has been found to show greater response rates and faster response times compared to interpersonal psychotherapy for CGD.[78]

Although the DSM-5 work groups have suggested using "adjustment disorder, specified as bereavement-related" to diagnose complicated grief, opposing opinions contend that this does not fit the nature of CGD and is an inappropriate diagnosis for those suffering from CGD.[17][79] The DSM-5 has now included Persistent complex bereavement disorder as a diagnosis under conditions for further study.[1]

Ethical considerations

Medicalizing (or misdiagnosing) normal grief

Following the DSM-5 work groups’ recommendation to remove the bereavement-exclusionary criteria,[80] there is some concern that the addition of CGD may increase the possibility of medicalizing the grieving process. However, proponents of CGD claim that with proper clinical assessment only those with abnormally incapacitating levels of grief will receive this diagnosis and benefit from treatment. Furthermore, despite the possibility of diagnosis-related stigma the clinical necessity for treatment is a priority for those suffering from CGD.[17]

Cultural norms for grief

An individual’s culture plays a large role in determining an inappropriate pattern of grief, and it is necessary to consider cultural norms before reaching a CGD diagnosis.[17] There are cultural differences in expected emotional levels, their expression and duration; the external symptoms of grief differ in non-Western cultures, presenting increased somatization.[81]

See also

References
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