What is Complicated Grief

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By Rosabel Zohfeld, MSN-Ed, APRN, FNP-C

Complicated grief can be described as chronic, complex, pathological, persistent, prolonged, unresolved, and traumatic grief.  Complicated grief is a form of acute grief that can be disabling with troubling thoughts, dysfunctional behaviors, and emotions as well as in the adaptation to the loss.

The prevalence is approximately about 7% in the general population. This prevalence varies depending on the close relationship that the individual had with the deceased or lost individual, as well as the culture and setting where it occurs. The loss of a spouse is estimated to have a 10 to 20% rate of complication. The loss of a child can be as high as 60% more complicated in parents who reside in western countries. Suicide, homicide, and disaster-related generally report complicated grief that ranges from 20% to 40% of the cases.

What are the risk factors?

• Being older than 61 yrs. of age

• Female

• Low socioeconomic status

• Prior psychiatric history

• Unexpected or violent death of a loved one

• Death of a child, spouse, or young person

• Non-Caucasians

Pathogenesis:

The pathogenesis of complicated grief is not known. However, preliminary studies suggest that the neurobiology of complicated grief may differ from that of typical acute grief. Several psychological models of complicated grief have been proposed including a model based upon the loss of an attachment relationship 

Signs and symptoms 

• Prolonged acute grief lasting at least 6 to 12 months after the loss
• preoccupation with the deceased, and feelings of sorrow, emotional pain, frustration, anxiety, and guilt
• Loss of interest in ongoing life, difficulty envisioning a meaningful life without the deceased, and feeling estranged from others
• Inadequate regulation of emotions
• Excessively avoiding reminders of the loss
• Disbelief and difficulty accepting the death; feeling stunned, dazed, lost, unfocused, or emotionally numb; and intrusive thoughts or images of the death
• Maladaptive rumination about the circumstances or consequences of the death such as guilt and self-blame regarding the deceased or the death 
• intense emotional and/or physiologic reactions such as increased somatic symptoms and/or insomnia 
• Dysfunctional behaviors that are characterized by -Excessively seeking proximity to the deceased through objects like pictures, keepsakes, clothing, or places associated with the loved one
• Impaired functioning, difficulty trusting or caring for others, impaired concentration, or interference with performing daily activities

Unfortunately, suicidal ideation and behavior occur in approximately 40% to 60% of individuals with complicated grief. Patients with complicated grief may attempt suicide to find the person who died. The primary deterrents to suicide include family members.

Complicated grief is often accompanied by comorbid psychopathology such as 

•Unipolar major depression 

●PTSD 

●Anxiety disorders 

•Generalized anxiety disorder 

•Panic disorder – 10 to 20 percent

Complicated grief is associated with adverse consequences that may include 

●Increased use of alcohol and tobacco

●Poor quality of life

●General medical illnesses

●Increased mortality due to general medical conditions and suicide

Diagnosis:

A trained mental health provider may use the following criteria to diagnose an individual with complicated grief:

The patient is experiencing the death of a loved one for at least six months or more

At least one of the following symptoms has been present:

• Persistent, intense yearning or longing for the person who died

• Frequent preoccupying thoughts about the deceased

• Frequent intense feelings of loneliness or that life is empty or meaningless without the person who died

• Recurrent thoughts that it is unfair or unbearable to live without the deceased, or a recurrent urge to find or join the deceased

• Frequent troubling rumination about the circumstances or consequences of the death

• Recurrent disbelief or inability to accept the death

• Anger or bitterness about the death

• Persistently feelings of shock, stun, or numbness since the death

• Marked change in behavior such as avoiding people, places, or situations that remind one of the loss

• Intense emotional or physiologic reactions 

• Wanting to see, touch, hear or smell things to feel close to the person who died

Evaluation

The initial evaluation for patients with a possible diagnosis of complicated grief includes:

• a psychiatric history

• mental status examination

• general medical history, physical examination

• focused laboratory tests. 

All patients with complicated grief must be queried specifically about suicidal ideation and behavior.

Where Can you find help?

If you or a loved one is experiencing signs and symptoms of complicated grief, there is help available. A trained mental health professional can help you or your loved one with the diagnosis and treatment and can refer you to other professionals as well as provide you with the necessary resources to help you overcome complicated grief.

Sources:

https://www.uptodate.com/contents/complicated-grief-in-adults-epidemiology-clinical-features-assessment-and-diagnosis?search=complicated%20grief&source=search_result&selectedTitle=1~30&usage_type=default&display_rank=1#H4668475