Complicated Grief: A Review of Current Issues

Laura E. Gibson, Ph.D.
University of Vermont
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ABSTRACT

The death of a spouse, family member or close friend is relatively common. If the death is expected and results from natural causes, survivors tend to experience less intense symptoms and those symptoms tend to resolve faster than when the death is unexpected and/or traumatic. Researchers are now trying to further differentiate normal grief reactions from more pathological reactions to either natural or traumatic deaths. A distinct cluster of symptoms can reliably be identified in some bereaved individuals that is separate from other psychiatric illnesses that may occur after experiencing the loss of a loved one, such as major depressive disorder or posttraumatic stress disorder. The term complicated grief has been used to describe these reactions. This summary describes the current issues relevant to complicated grief.

In a recent epidemiological survey, Breslau and colleagues (1998) found that 60% of the general population endorsed having experienced the sudden, unexpected death of a loved one. This event accounted for a larger percentage (31%) of posttraumatic stress disorder (PTSD) than any other single traumatic event reported in the sample. However, when examining all cases of sudden bereavement only 14% developed PTSD. These findings highlight several issues that are of relevance to the present report. First, they suggest that the majority of individuals will experience the sudden and potentially traumatizing loss of a loved one. Secondly, the findings suggest that only a minority of these individuals will develop PTSD. Third, these findings raise the question of whether there may be psychological sequelae experienced by survivors of bereavement that would be more fully captured by alternative conceptual frameworks. All of these issues will be addressed within this report.

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STUDIES OF POST-BEREAVEMENT PSYCHOLOGICAL SEQUELAE

The death of a spouse, family member or close friend is upsetting to almost everyone. Even when death is expected and results from natural causes, the loss of someone close often results in an increase in psychological symptoms. For example, Schut, De Keijser, Van Den Bout, and Dijkhuis (1991) examined self-reported PTSD symptoms in bereaved spouses. Most of the spouses died of natural causes. Despite this, the authors found that 20-31% of participants were classified as having probable PTSD during at least one follow-up point between 4-25 months after the spouse’s death. Suddenness of the death was not found to be a significant predictor of PTSD symptoms.

When death is unexpected, survivors tend to exhibit greater psychological distress and for a longer period of time than when death is due to natural causes. For example, Zisook, Chentsova-Dutton, and Shuchter (1998) compared individuals whose spouses died of natural causes with individuals whose spouses died by accident or suicide. They found that those individuals who were bereaved due to accident or suicide had significantly more PTSD symptoms. Another comparison of psychological symptoms in spouses who were bereaved due to natural causes vs. a partner’s suicide vs. non-bereaved controls found that both bereaved groups had more grief, depression, and overall psychological distress than the non-bereaved control group at all time points (Farberow, Gallagher-Thompson, Gilewski, & Thompson, 1992). At 12 months, the survivors of spousal suicides had more psychological symptoms than the spouses whose partners died of natural causes. At 2.5 years post-spousal death, the two bereaved groups did not differ in their symptomatology, although both evidenced more symptoms than the control group. Overall, these findings suggest that recovery from spousal suicide is slower than recovery from spousal death due to natural causes.

In addition, it appears that when death is not due to natural causes, both the relationship to the bereaved individual and the traumatic nature of the death significantly impact the psychological well-being of survivors. In studies of disaster and war-exposed individuals, findings suggest that closeness of the relationship with the lost person is predictive of psychological symptoms (Green, Grace, and Gleser (1985; Green, Grace, Lindy, & Gleser, 1990; Murphy, 1986).

The traumatic nature of death also significantly impacts the degree to which the bereaved develops psychological symptoms. Individuals who lose a loved one due to homicide seem to be especially at-risk of experiencing psychological difficulties. In two nationally representative, large scale, phone surveys of those individuals who lost a family member or friend to homicide (including vehicular homicide), 22-23% developed PTSD at some point after the death (Amick-McMullan, Kilpatrick, & Resnick, 1991; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Green and colleagues (2001) conducted a community study of survivors of violent death with the aim of disaggregating the effects of the traumatic loss from the effects of trauma more broadly. They found that undergraduates who experienced violent loss (i.e. suicide, homicide, or accident) as their only trauma evidenced higher rates of acute stress disorder, PTSD symptoms, and impairment in school performance compared undergraduates with no reported history of trauma or undergraduates with a history of a single physical assault as their only trauma to the other two groups.

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COMPLICATED GRIEF

The review above highlights differences in the impact of death on survivors depending on circumstances of the death. If the death is expected and results from natural causes, survivors tend to experience less intense symptoms and those symptoms tend to resolve faster than when the death is unexpected and/or traumatic. Researchers are now trying to further differentiate normal grief reactions from more pathological reactions to either natural or traumatic deaths.

The terms “complicated” and “traumatic” grief have been used interchangeably in the research literature. To be consistent with the majority of studies that have examined this construct, the term “complicated grief” (CG) will be used throughout this report. Several studies of CG have been conducted, sets of diagnostic criteria for the condition have been forwarded, and a scale for assessing these symptoms has been widely studied and applied (Prigerson, Maciejewski, et al., 1995). Two independent groups of researchers have proposed diagnostic criteria for CG, with a high degree of consensus (Horowitz et al., 1997; Prigerson, Shear, et al., 1999). Key features of CG include: a) a sense of disbelief regarding the death, b) anger and bitterness over the death, c) recurrent pangs of painful emotions, with intense yearning and longing for the deceased, and d) preoccupation with thoughts of the loved one, including distressing intrusive thoughts related to the death (Shear, Frank, Houck, & Reynolds, 2005).

To date, CG has been applied to symptoms experienced both by individuals who have survived a traumatic loss of life (e.g. homicide or disaster survivors) and also to individuals who are bereaved by distressing but not necessarily “traumatic” circumstances (e.g., old age). More research is needed in order to determine whether the loss of life due to horrific circumstances (e.g. human-caused disasters, homicide, etc.) is associated with unique symptoms beyond those captured by PTSD or complicated bereavement (Gray, Prigerson, & Litz, 2004).

Since the terrorist attacks of September 11th, there has been a realization that disastrous events are marked not merely by a high incidence of direct trauma exposure in the population, but also by high rates of bereavement. For example, one estimate suggested that the 9/11 terrorist attacks left approximately 6 million individuals bereaved in the United States (Schlenger et al., 2002). Although the recent attention to disaster mental health has brought increased attention to the construct of CG, it is clear that the vast majority of traumatic bereavement in the U.S. results from smaller scale events, such as motor vehicle accidents.

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Consensus Conference Criteria for Complicated Grief

A consensus conference was held to develop diagnostic criteria for CG, in an effort to bring more consistency to the research and clinical literature (Prigerson, Shear, et al., 1999). An updated version of the traumatic grief diagnostic algorithm was published in 2001 (Prigerson & Jacobs, 2001), based on additional data suggesting that a 6-month symptom duration was more accurate than a 2-month duration criterion in terms of the predictive validity of the diagnosis. The revised consensus criteria are presented below:

Criterion A: Person has experienced the death of a significant other and response involves 3 of the 4 following symptoms, experienced at least daily or to a marked degree:

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Criterion B: In response to the death, 4 of the 8 following symptoms experienced at least daily or to a marked degree:

Criterion C: Disturbance (symptoms listed) must endure for at least 6 months

Criterion D: The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

Horowitz et al. (1997) Criteria for Complicated Grief

A separate group of researchers developed criteria for CG based on longitudinal interviews with bereaved individuals conducted at 6 and 14 months post-bereavement. Horowitz et al. (1997) proposed that a diagnosis of CG be applied only if symptoms have not remitted after 14 months, as opposed to the 6-month criterion forwarded by Prigerson and Jacobs (2001). Horowitz and colleagues’ proposed diagnostic criteria are as follows (Horowitz et al., 1997, p. 909):

A. Event criterion/prolonged response criterion:

Bereavement (loss of a spouse, other relative, or intimate partner) at least 14 months ago (12 months is avoided because of possible intense turbulence from an anniversary reaction)

B. Signs and symptoms criteria:

In the last month, any 3 of the following 7 symptoms with a severity that interferes with daily functioning

Intrusive symptoms:

Signs of avoidance and failure to adapt:

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Differences and Similarities among Complicated Grief, Major Depressive Disorder, and Posttraumatic Stress Disorder

A distinct cluster of symptoms can reliably be identified in some bereaved individuals that is separate from other psychiatric illnesses that may occur after experiencing the loss of a loved one, such as major depressive disorder (MDD) or PTSD (e.g. Shear et al., 2005; Prigerson et al., 2000; Prigerson , Frank, et al., 1995; Prigerson et al., 1996). Between 10-20% of bereaved individuals can be expected to experience symptoms consistent with complicated bereavement (Jacobs, 1993; Middleton, Burnett, Raphael, & Martinek, 1996).

There is significant comorbidity between CG with MDD ranging from 21% (Horowitz et al., 1997) to 54% (Prigerson, Frank, et al., 1995), In addition, MDD is similar to CG in terms of the experience of sadness, loss of interest, loss of self-esteem, and sense of guilt that occur in both disorders. However, there are some very clear differences between the two (Sheer et al., 2005). Whereas MDD is characterized by pervasive sadness, CG is characterized by sadness specific to missing the deceased individual. Whereas an individual with MDD experiences loss of interest or pleasure, an individual with CG symptoms may experience pleasurable thoughts of the deceased and may continue to have interest, longing, and yearning for the deceased. Whereas an individual with MDD may suffer from a pervasive sense of guilt, an individual with CG symptoms is more likely to experience guilt specific to interactions with the deceased. Finally, whereas an individual with MDD may ruminate generally about past failures, an individual suffering from CG may be preoccupied with thoughts specific to the deceased. Shear et al. (2005) note that further distinctions between the disorders include the fact that CG may be accompanied by intrusive images of the person dying, and by avoidance of situations and people related to reminders of the loss. Neither of these symptoms is consistent with MDD. In contrast to symptoms of MDD, symptoms of CG are not significantly reduced by either interpersonal therapy or by tricyclic antidepressants (Reynolds et al., 1999; Pasternak et al., 1991). Such findings suggest that CG should be conceptualized as a disorder distinct from MDD for purposes of assessment and treatment.

There is also significant comorbidity between PTSD and CG ranging from 30% (Melhem, 2004) to 50% (Silverman et al., 2000). PTSD and CG are similar in that they both evolve from the experience of a traumatic event, and both may be accompanied by a sense of shock, helplessness, intrusive images, and avoidance behavior. However, Shear and colleagues (2005) suggest that whereas PTSD is typically triggered by physical threat, CG is triggered by loss. Further, the primary emotional state associated with PTSD is fear, in contrast to the sadness that characterizes CG. Although nightmares are common among individuals with PTSD, they are uncommon among individuals with CG. Finally, whereas painful reminders are linked to the trauma in the case of PTSD, painful reminders may be less predictable and more pervasive in the case of CG, according to Shear et al. (2005). These authors also note that individuals experiencing CG tend to experience yearning and longing for the person who died and tend to experience pleasurable memories of the person who died, neither of which would characterize PTSD.

Although traumatic loss of a loved one could qualify as a Criterion A event for PTSD or a precipitant to a major depressive episode, there is compelling empirical evidence to suggest that posttraumatic adaptation to the loss of a loved one through violent death is not fully captured by the symptoms of PTSD or MDD. The CG framework provides a broader description of the range of sequelae that may accompany tragic loss. Studies examining the prevalence of PTSD, MDD and CG provide evidence to suggest that after the loss of a loved one, individuals meeting full diagnostic criteria for CG do not necessarily meet criteria for PTSD or MDD. For example, in a study of friends of high school students who had committed suicide, under 50% of the participants with syndromal levels of CG met diagnostic criteria for PTSD, six years after the suicide (Prigerson, Bridge, et al., 1999). Likewise, Silverman, Johnson, and Prigerson (2001) found that two-thirds of recently widowed participants meeting criteria for CG failed to meet criteria for PTSD, and over one-third failed to meet diagnostic criteria for either PTSD or MDD. In sum, limiting the assessment of psychological sequelae after bereavement to PTSD or MDD appears to miss a substantial number of people with lingering distress and functional impairment related to their loss.

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Problematic Health and Behavioral Correlates of Complicated Grief

Bereaved individuals with high levels of CG symptoms have a higher level of dysfunction than those with lower levels of such symptoms (e.g., Prigerson, Frank, et al., 1995, Prigerson et al., 1997; Silverman et al., 2000; Prigerson et al., 1996). In addition, symptoms of complicated bereavement may endure for several years among some individuals (e.g. Prigerson et al., 1997). When present, such symptoms are predictive of a multitude of problematic health behaviors and outcomes, over and above depressive symptoms. Among the adverse outcomes are increased risk of cardiac events, high blood pressure, and cancer (Prigerson et al., 1997); suicidality (Prigerson et al., 1995; 1997); social dysfunction (e.g., Silverman et al., 2000); low energy (e.g., Prigerson, Shear et al., 1999); and global impairment (e.g., Prigerson, Frank, et al., 1995; Prigerson et al., 1997).

Risk Factors for the Development of Complicated Grief Symptoms

Although variations in the definitions of CG make it difficult to compare risk factors for the development of this condition, there are certain risk factors that clearly increase the likelihood that bereavement may be prolonged or may be associated with more pathological outcomes. One review of the literature found that the presence of the following factors increased the likelihood that bereavement would be prolonged or would be accompanied by more psychological problems: a) unexpected, sudden, or untimely death, b) horrific (grotesque) or painful death, c) death that is violent or stigmatized (e.g. suicide, homicide, death from AIDS), d) death involving multiple losses, and e) death of a child (e.g. Sanders, 1993).

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TREATMENT OF COMPLICATED GRIEF

Prior to the dissemination of the criteria for CG, treatment studies focused on a variety of symptoms in bereaved individuals ( e.g., Mawson, Marks, Ramm, & Stern, 1981; Reynolds et al., 1999; Sireling, Cohen & Marks, 1988). A new generation of treatment research is targeting symptoms of CG as defined by the consensus criteria. (Prigerson & Jacobs, 2001). Only one study specifically targeted CG symptoms and in that study the traumatic grief was not the result of disaster or mass violence. Shear and colleagues (Shear, Frank, Houck, & Reynolds, 2005) conducted an RCT comparing interpersonal psychotherapy (IPT; n=46) with CG treatment (CGT; n=49) administered over the course of 16 sessions. Participants were bereaved adults who scored at least 30 on the Inventory of Complicated Grief, at least six months post-bereavement. Complicated grief was determined by an independent evaluator to be the most significant presenting clinical issue. The average time post-bereavement was approximately two years. Interestingly, approximately 20% of participants met criteria for comorbid MDD and approximately 23% met criteria for PTSD, as determined by independent interviewers. The CG treatment consisted of a manualized CBT protocol that utilized psychoeducation as well as coping skills and exposure techniques for retelling the story of the death and confronting avoided situations. The IPT treatment utilized a manualized IPT approach that has been found to be efficacious for the treatment of depression.

Thirty-three percent of the participants in each group had lost their loved one to violent death. Both treatments were associated with reductions in CG symptoms, although the CG treatment was associated with more treatment responders (51% vs. 28%) and faster symptom reduction. Participants were coded as treatment responders if they showed a decrease in their Inventory of Complicated Grief score of 20 points or more. However, despite the fact that CGT was associated with a better response, half of the participants were not classified as treatment responders. Twenty-seven percent of the CGT participants and 26% of the IPT participants discontinued treatment early. Of the treatment completers, individuals who received CGT showed more improvement on depression, work, and social adjustment scores as well as CG symptoms. No differences emerged between the treatments on general anxiety symptoms. Although this trial found that a substantial number of participants failed to show a therapeutic response to the treatment, the results were an improvement over existing interpersonal treatments for complicated bereavement.

CONCLUSIONS

Although the experience of bereavement is associated with increased rates of PTSD and MDD, it is also clear that some bereaved individuals experience a unique constellation of symptoms outside of the anxiety and depressive disorder spectrum. The notion that traumatic loss might be associated with a unique constellation of symptoms possesses strong face validity. As Gray and colleagues have noted (2004), it is widely acknowledged in the field of traumatic stress that certain interpersonal traumas are accompanied by psychological sequelae beyond those captured by PTSD or MDD alone. Similarly, it appears that in some instances, the complex set of psychological reactions following traumatic bereavement is best captured by the construct of CG. There are a dearth of treatment outcome studies that have directly targeted CG symptoms. Most studies of bereaved individuals have targeted general symptoms such as anxiety, depression, and PTSD, and found modest post-treatment improvement in response to a wide array of interventions. The one study to date that directly targeted symptoms of CG found substantial improvement in about half of the sample, but found that the other half of the participants failed to respond to the treatment (Shear et al., 2005). Further research is needed to develop efficacious and tolerable interventions for bereaved individuals experiencing clinically significant CG symptoms.

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ABOUT THE AUTHOR

Laura E. Gibson, Ph.D. is an Assistant Research and Clinical Professor in the Department of Psychology at the University of Vermont. She has worked as a consultant to the National Center for PTSD, Executive Division, since 2001, in the area of evidence-based treatments for trauma after disasters and mass violence. In that role, she has published several reviews, co-authored a treatment manual that has been used with survivors of the 9-11 terrorist attacks in NYC and hurricane survivors in Florida, and given national talks and workshops on cognitive behavioral therapy for post-disaster distress. Dr. Gibson is also conducting an NIH funded grant on PTSD and smoking cessation, and works as a consultant to the Vermont State Hospital and the Vermont Department of Corrections in the area of evidence-based assessment and treatment of high risk clients, many of whom suffer from PTSD.