clinical practice The new england journal o f medicine n engl j med 372;2 nejm.org january 8, 2015 153 This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. An audio version of this article is available at NEJM.org Caren G. Solomon, M.D., M.P.H., Editor Complicated Grief M. Katherine Shear, M.D. A 68-year-old woman seeks care from her primary physician because of trouble sleeping 4 years after the death of her husband. On questioning, she reveals that she is sleeping on a couch in her living room because she cannot bear to sleep in the bed she shared with him. She has stopped eating regular meals because preparing them makes her miss him too much; she still has meals that she cooked for him in her freezer. The patient often ruminates about how unfair it was for her husband to die, and she is alternately angry with the medical staff who cared for him and angry at herself for not recognizing his illness earlier. She finds it too painful to do things that she and her husband used to do together, and she thinks about him constantly and often wishes she could die to be with him. How should this patient be evaluated and treated? The Clinical Problem Bereavement and Grief Bereavement, the experience of losing a loved one to death, is one of the most painful occurrences in life, and it has physical, psychological, and social ramifications. Loved ones provide support and contribute to a person’s identity and sense of belonging. Grief, the response to bereavement, includes a variety of psychological and physiological symptoms that evolve over time. The manifestations and temporal evolution of grief are variable and unique to each loss; however, there are commonalities that clinicians can recognize. Acute Grief The period of acute grief, which begins after a person learns that a loved one has died, includes elements of both the “separation response” (i.e., a specific response to separation from a loved one) and the response to stress. There is strong yearning, longing, and sadness, and thoughts and images of the deceased person are prominent. The experience of hearing the deceased person’s voice, seeing the person, or sensing his or her presence may occur as a benign form of hallucination and is usually not a cause for concern.1 The bereaved person may become confused about his or her identity or social role, may tend to disengage from usual activities, and may have a sense of disbelief or shock that a loved one is gone. Symptoms of acute grief, including dysphoria, anxiety,2 depression,3 and anger, may be associated with physiological changes such as an increased heart rate or blood pressure,4 increased cortisol levels,5 sleep disturbance,6 and changes in the immune system.4 The early bereavement period has been associated with increased risks of health problems such as myocardial infarction, Takotsubo (stress) cardiomyopathy, or both.7,8 The death of a loved one is also associated with an increased risk of the development of mood, anxiety, and substance-use disorders.9 From the Center for Complicated Grief, Columbia University School of Social Work, Columbia University College of Physicians and Surgeons, New York. Address reprint requests to Dr. Shear at 1255 Amsterdam Ave., New York, NY 10027, or at email@example.com. N Engl J Med 2015;372:153-60. DOI: 10.1056/NEJMcp1315618 Copyright © 2015 Massachusetts Medical Society. The new england journal o f medicine 154 n engl j med 372;2 nejm.org january 8, 2015 Adaptation to Loss The process of adapting to a difficult loss can be lengthy, and emotions may wax and wane unpredictably. Overall, the intensity of grief diminishes as the finality and consequences of the loss are understood and future hopes and plans are revised.10 However, emotions may still surge at difficult occasions such as the anniversary of the death, family holidays, and group celebrations. Moreover, sometimes maladaptive thoughts or behaviors11 or serious concurrent problems can complicate grief, slowing or halting the process of adaptation. Complicated Grief The condition of complicated grief,12 which is also called prolonged grief disorder,13 affects about 2 to 3% of the population worldwide.14,15 This condition is characterized by intense grief that lasts longer than would be expected according to social norms and that causes impairment in daily functioning. Complicated grief can follow the loss of any close relationship. Complicated grief has a prevalence of approximately 10 to 20% after the death of a romantic partner and an even higher prevalence among parents who have lost children16; it is more likely when a death is sudden or violent (e.g., by suicide,17,18 homicide,19 or accident20) and less common after the loss of a parent, grandparent, sibling, or close friend. The prevalence of complicated grief is highest among women who are older than 60 years of age.15 Clinical experience suggests that without treatment, symptoms of complicated grief diminish slowly and can persist. Neuropsychological studies suggest that certain abnormalities are associated with complicated grief, including alterations in functioning of the reward system (in response to reminders of the deceased person) detected on functional magnetic resonance imaging21 and abnormalities in autobiographical memory,22 neural systems involved in emotional regulation,23 and neurocognitive functioning.24,25 Complicated grief is associated with other health problems, such as sleep disturbance, substance abuse, suicidal thinking and behavior, and abnormalities in immune function; studies have also shown associated increased risks of cardiovascular disease and cancer.4 Sleep disturbance, in particular, may contribute to other negative health consequences of complicated grief. In addition, complicated grief may interfere with adherence to prescribed therapeutic regimens for a range of diseases. As in acute grief, the hallmark of complicated grief is persistent, intense yearning, longing, and sadness; these symptoms are usually accompanied by insistent thoughts or images of the deceased and a sense of disbelief or an inability to accept the painful reality of the person’s death. Rumination is common and is often focused on angry or guilty recrimination related to circumstances of the death. Avoidance of situations that serve as reminders of the loss is also common, as is the urge to hold onto the deceased person by constantly reminiscing or by viewing, key Clinical points complicated grief • Complicated grief is unusually severe and prolonged, and it impairs function in important domains. • Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased person. • Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means. • Randomized, controlled trials provide support for the efficacy of a targeted psychotherapy for complicated grief that provides an explanation of this condition, along with strategies for accepting the loss and for restoring a sense of the possibility of future happiness. • Other treatments include other forms of psychotherapy as well as antidepressant medication, although pharmacotherapy for this condition has not been studied in randomized trials. clinical practice n engl j med 372;2 nejm.org january 8, 2015 155 touching, or smelling the deceased person’s belongings. People with complicated grief often feel shocked, stunned, or emotionally numb, and they may become estranged from others because of the belief that happiness is inextricably tied to the person who died. They may have a diminished sense of self or discomfort with a changed social role and are often confused by their seemingly endless gri
ef. Friends and relatives are often frustrated that they cannot help, and they may become critical or stop contacting the bereaved person, increasing his or her feelings of isolation. The cause of complicated grief is probably multifactorial. Risk factors include a history of mood or anxiety disorders, alcohol or drug abuse, and multiple losses. Depression in persons who have been caregivers during a loved one’s terminal illness26 and depression early in bereavement27 are predictors of complicated grief later in bereavement. Personal factors such as these may interact with characteristics of the relationship with the deceased or with the circumstances, context, or consequences of the death to increase the risk. Losing someone with whom one has had a close relationship can be especially hard if the bereaved person had a difficult upbringing or if there are unusually stressful consequences of the death, inadequate social supports, serious conflicts with friends or relatives, or major financial problems after the death. Strategies and Evidence Evaluation and Diagnosis Consensus is currently lacking regarding the criteria and formal name for complicated grief. The Working Group on the Classification of Disorders Specifically Associated with Stress drafted a proposal, based on a review of the literature, to include a diagnosis called prolonged grief disorder in the International Classification of Diseases, 11th Revision. This proposal is accompanied by suggested consensus guidelines that are currently undergoing field testing (Reed GM: personal communication) (Table 1). Two proposals for criteria12,13 that were presented to the working group for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), resulted in the inclusion in the DSM-5 of an entity Table 1. Provisional Proposed Guidelines for the Diagnosis of Prolonged Grief Disorder in the International Classification of Diseases, 11th Revision.* Essential features History of bereavement after the death of a partner, parent, child, or other loved one A persistent and pervasive grief response characterized by longing for or persistent preoccupation with the deceased, accompanied by intense emotional pain (e.g., sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to have a positive mood, emotional numbness, or difficulty in engaging with social or other activities) A grief response that has persisted for an abnormally long period of time after the loss, clearly exceeding expected social, cultural, or religious norms; this category excludes grief responses within 6 mo after the death and for longer periods in some cultural contexts A disturbance that causes clinically significant impairment in personal, family, social, educational, occupational, or other important areas of functioning; if functioning is maintained only through substantial additional effort or is very impaired as compared with the person’s prior functioning or what would be expected, then he or she would be considered to have impairment due to the disturbance Features overlapping with normal bereavement Grief reactions that have persisted for <6 mo or for longer periods that are within a normative period of grieving given the person’s cultural and religious context are viewed as normal bereavement responses and are generally not assigned a diagnosis In assessing whether the duration of the grief reaction exceeds cultural expectations, it is often important to consider whether people in the patient’s environment (e.g., family, friends, and community members) regard the response to the loss or the duration of the reaction as exaggerated or within normal limits Additional features Persistent preoccupation may be manifested as preoccupation with the circumstances of the death or as behaviors such as the preservation of all the deceased person’s belongings exactly as they were before the death; oscillation between excessive preoccupation and avoidance of reminders of the deceased may occur Other emotional reactions may include difficulty accepting the loss, problems coping without the loved one, difficulties in recalling positive memories of the deceased, difficulty in engaging with social or other activities, social withdrawal, and feeling that life is meaningless Increased tobacco, alcohol, and other substance use, as well as increased suicidal ideation and behavior may be present * Information is from G.M. Reed (personal communication). The new england journal o f medicine 156 n engl j med 372;2 nejm.org january 8, 2015 called “persistent complex bereavement disorder” (incorporating some of the criteria from each proposal) as a condition requiring further research. Questions about important losses should be part of a standard diagnostic evaluation, especially in the case of older patients, for whom loss is common. The presence of thoughts and behaviors that are indicative of complicated grief should be assessed with the use of a clinical interview. Intense grief is not pathologic; however, complicating thoughts and behaviors that impede adaptation to the loss should be identified along with grief that is inordinately intense and prolonged. Patients are sometimes ashamed of their persistently intense grief, so it is important for clinicians to ask direct questions in a sensitive and empathic way. A semistructuredinterview format to facilitate assessment of complicated grief (see the Supplementary Appendix, available with the full text of this article at NEJM.org) is a shortened version of a validated instrument. The Brief Grief Questionnaire (which is also included in the Supplementary Appendix) and the Inventory of Complicated Grief are selfreport questionnaires that can be used to screen patients for complicated grief. The clinical evaluation of a bereaved person should also include screening for other psychiatric and medical disorders, since coexisting conditions are common.28 Complicated grief must be distinguished from major depression and post-traumatic stress disorder (Table 2). Evidence to date suggests that complicated grief is best understood as an unusually severe and prolonged form of acute grief rather than a completely unique entity.29 Complicated grief is characterized by excessive avoidance of reminders of the loss, troubling maladaptive rumination about circumstances or consequences of the death, and persistence of intense and impairing acute grief symptoms beyond what is expected according to social and cultural norms. However, determination of what constitutes prolonged grief can be problematic because views on grief differ across cultures, and data are lacking to inform this determination. In addition, the typical time frame for grief reactions varies according to the circumstances of the death. For example, studies indicate that the majority of bereaved parents have positive results on screening for complicated grief 18 months after losing a child.16 The current practice is to offer treatment for complicated grief as early as 6 months after the death.13,30 Risk Assessment Survey data indicate that rates of suicidal ideation among patients with complicated grief are high31; data on rates of completed suicide in this population are lacking. Careful evaluation of suicidal intent and suicide plans should always be a part of an assessment of complicated grief. Unusual risk-taking behaviors and neglect of one’s health problems (in order to leave death to chance) are also more common in patients with complicated grief, and patients should be asked about them specifically.32 Management Psychotherapy Randomized, controlled trials have shown that psychotherapy is efficacious for complicated grief, so it is the first-line treatment. A short-term approach called complicated grief treatment30,33-35 is the treatment that has been most extensively studied to date. Its objectives are to identify and resolve complications of grief and to facilitate adaptation to loss. The treatment includes two key areas of focus: restoration (i.e., restoring effective functioning by generating enthusiasm and creat
ing plans for the future) and loss (i.e., helping patients find a way to think about the death that does not evoke intense feelings of anger, guilt, or anxiety). A portion of each of 16 weekly sessions is allotted to each area of focus. Grief monitoring and other weekly activities are assigned at the end of each session. The seven main components of treatment for complicated grief are described in Table 3. Therapy for complicated grief has been directly compared with interpersonal psychotherapy,46 which targets interpersonal problem areas, including grief, with the goal of improving mood. As compared with therapy for complicated grief, interpersonal psychotherapy is less structured, devotes less time to discussing the death or addressing avoidance of reminders of the loss, and does not involve evoking memories of or imagined conversations with the deceased person, grief monitoring, or other homework assignments. In a trial comparing therapy for complicated grief with interpersonal psychotherapy,30 response rates were significantly bet- clinical practice n engl j med 372;2 nejm.org january 8, 2015 157 Table 2. Differential Diagnosis of Complicated Grief, Major Depression, and Post-Traumatic Stress Disorder (PTSD). Characteristic Complicated Grief Major Depression PTSD Affective symptoms Depressed mood (sadness) Prominent, focused on the loss; core symptom Prominent; diagnostic criterion May be present Anhedonia (loss of interest or pleasure) Not usually present (and interest in thoughts of deceased is usually maintained) Prominent and pervasive; diagnostic criterion May be present Anxiety May be present, focused on loss and insecurity without the deceased May be present Prominent, focused on fear of recurrent danger; diagnostic criterion Yearning or longing Prominent, frequent, and intense; core symptom Not usually present Not usually present Guilt Common, focused on regrets related to the deceased Usually present, related to feeling worthless and undeserving May be present, focused on the traumatic event or its aftermath Cognitive or behavioral symptoms Difficulty concentrating May be present; not a core symptom Common; diagnostic criterion Common; diagnostic criterion Preoccupying thoughts Common, focused on thoughts and memories of the deceased; core symptom May be present, focused on negative thoughts about self, others, or the world Negative, exaggerated, distorted thoughts related to event; diagnostic criterion Recurrent preoccupying images or thoughts Common, focused on thoughts or memories of the deceased May be present Common, focused on event, usually associated with fear; diagnostic criterion Avoidance of reminders of the loss Common, focused on reminders of the finality of the loss and associated emotional distress May be present, related to general social withdrawal Common, focused on loss of sense of safety or reminders of event; diagnostic criterion Seeking proximity to the deceased person Common, focused on wanting to feel close to the deceased Not usually present Not usually present Suicidal thinking and behavior Suicidal ideation often present; increased risk of suicidal behavior Suicidal ideation present; diagnostic criterion; increased risk of suicidal behavior Suicidal ideation present, increased risk of suicidal behavior Abnormal eating behaviors Avoiding certain foods or mealtimes to avoid reminders of the loss or eating favorite foods to feel close to the deceased Change in eating due to change in appetite; diagnostic criterion Not usually present Sleep Disturbed sleep Sleep disturbance related to avoiding bed or other reminders of the loss or rumination about troubling aspects of the death Sleep disturbance common; diagnostic criterion Sleep disturbance related to anxiety; diagnostic criterion Nightmares Not usually present May be present Related to the traumatic event; diagnostic criterion The new england journal o f medicine 158 n engl j med 372;2 nejm.org january 8, 2015 ter among patients who were randomly assigned to therapy for complicated grief (51% vs. 28%); the findings of another trial35 were similar (69% vs. 32%). Other (generally smaller) randomized, controlled trials have tested treatments similar to therapy for complicated grief; these forms of treatment are administered individually,36,37 in groups,38,39 or over the Internet.40-42 Treatment for complicated grief has primarily been compared with supportive counseling or placement on a wait list for treatment. Taken together, these trials suggest that interventions that include strategies to reduce avoidance of thoughts about the death and avoidance of activities and places that are reminders of the loss are more effective than those that do not. Two small studies41,43 have suggested that interventions focused on behavioral activation (i.e., increasing enjoyable activities) alone are effective, though these methods also include encouraging patients to do things even when these activities are reminders of the loss. Whereas therapy for complicated grief that has been proved to be efficacious is currently the preferred form of treatment, in patients for whom this is not available, a reasonable approach is an intervention37 that provides information about adaptation to grief and includes both strategies to reduce avoidance of reminders of the loss and strategies for behavioral activation. Pharmacotherapy Although data are lacking from randomized trials to inform the use of pharmacotherapy for complicated grief, antidepressant medication is used commonly in practice. Five open-label trials that involved a total of 50 patients suggested improvement in patients who received antidepressants, but not benzodiazepines.47,48 In addition, in a study of therapy for complicated grief, rates of completion of this therapy were significantly higher among participants who continued to receive stable doses of antidepressants than among those who were not receiving antidepressants (91% vs. 58%). In addition, the rates of response to therapy for complicated grief (61%) and to interpersonal therapy (40%) among patients who were receiving antidepressants were higher than those among patients who were not receiving antidepressants (42% and 19%, respectively), although these differences were not significant.49 Table 3. Core Components of Treatment for Complicated Grief. Component Description Evidence from Randomized, Controlled Trials Establishing lay of the land Discussion of the nature of loss, grief, and adaptation to loss; description of complications of grief and their effects; description of the treatment and rationale for procedures in the treatment Shear et al.,30 Shear et al.,35 Boelen et al.,36 Acierno et al.,37 Rosner et al.,38 Bryant et al.,39 Kersting et al.,40 Litz et al.,41 Wagner et al.,42 Papa et al.,43 Shear et al.44 Promoting selfregulation Self-monitoring, self-observation, and reflection; reappraisal of troubling thoughts and beliefs; extending compassion to oneself; “dosing” emotional pain by confronting it and setting it aside Shear et al.,30 Shear et al.,35 Boelen et al.,36 Rosner et al.,38 Bryant et al.,39 Kersting et al.,40 Litz et al.,41 Wagner et al.,42 Rosner et al.45 Building connections Strategies for meaningful connections with others; sharing pain and letting others help Shear et al.,30 Shear et al.,35 Rosner et al.,38 Kersting et al.,40 Wagner et al.,42 Rosner et al.45 Setting aspirational goals Exploring ambition for personal goals and activities that engender eagerness and hope; generating enthusiasm and other positive emotions in ongoing life; creating sense of purpose and possibilities for future happiness Shear et al.,30 Shear et al.,35 Acierno et al.,37 Bryant et al.,39 Litz et al.,41 Papa et al.43 Revisiting the world Strategies for confronting or revisiting avoided situations Shear et al.,30 Shear et al.,35 Boelen et al.,36 Acierno et al.,37 Rosner et al.,38 Bryant et al.,39 Kersting et al.,40 Rosner et al.45 Storytelling Recounting and reflecting on the story of the death in order to create an acceptable account; practice in confronting pain and setting it aside Shear et al.,30 Shear et al.,35 Boelen et al.,36 Rosner et al.,38 B
ryant et al.,39 Wagner et al.,42 Rosner et al.45 Using memory Reviewing positive memories of the deceased and inviting reminiscence of negative memories; describing an imagined conversation with the deceased Shear et al.,30 Shear et al.,35 Rosner et al.,38 Bryant et al.,39 Wagner et al.,42 Rosner et al.45 clinical practice n engl j med 372;2 nejm.org january 8, 2015 159 Areas of Uncertainty Data are lacking on risk factors for complicated grief, its frequency among bereaved persons in various age groups, and its natural history. Consensus is needed regarding diagnostic criteria. Data are also lacking on associated sleep disturbance and its treatment, as are data from randomized, double-blind trials evaluating the effects of antidepressants and other medications (e.g., oxytocin) on patients with complicated grief. A multicenter trial (ClinicalTrials.gov number, NCT01179568) is under way to assess the efficacy of antidepressant medication alone or in combination with therapy for complicated grief. Guidelines There are currently no professional guidelines for management of complicated grief, although some have been proposed (Table 1). Conclusions a nd Recommendations Four years after the death of her husband, the woman in the vignette continues to have severe yearning and sadness and preoccupying thoughts and memories of him that are impairing all aspects of her daily functioning. Complicating features are present, including extensive avoidance of reminders of her husband and troubling rumination about the circumstances of his death. Further assessment should include specific questions regarding other features of complicated grief (see the Supplementary Appendix), the patient’s history with respect to mood disorders or anxiety and use of alcohol or drugs, and determination of whether the patient has suicidal ideation or plans. Attention to other medical problems is also warranted, as is adherence to associated treatment recommendations. Treatment options — including various forms of psychotherapy and pharmacotherapy — should be discussed with the patient. If a therapist who is skilled in therapy for complicated grief is available, I would recommend such therapy, since data from randomized trials show a greater benefit associated with this form of therapy than with other forms of psychotherapy. If this therapy is not available, I would recommend psychotherapy focused on accepting the loss and restoring effective functioning; the patient should be gently encouraged to return to activities that she has been avoiding because of associations with her husband. In addition, although data are lacking from randomized trials of the use of antidepressant medication for complicated grief, clinical experience and limited observational data suggest that this option warrants consideration, either in conjunction with psychotherapy or alone if the patient has no access to or interest in psychotherapy. No potential conflict of interest relevant to this article was reported. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. References 1. Grimby A. Bereavement among elderly people: grief reactions, post-bereavement hallucinations and quality of life. Acta Psychiatr Scand 1993;87:72-80. 2. Shear MK, Skritskaya NA. Bereavement and anxiety. 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f grief: a taxometric investigation of prolonged and normal reactions to loss. J Psychopathol Behav Assess 2009;31:190- 201. 30. Shear K, Frank E, Houck PR, Reynolds CF III. Treatment of complicated grief: a randomized controlled trial. JAMA 2005; 293:2601-8. 31. Szanto K, Prigerson H, Houck P, Ehrenpreis L, Reynolds CF III. Suicidal ideation in elderly bereaved: the role of complicated grief. Suicide Life Threat Behav 1997;27:194-207. 32. Szanto K, Shear MK, Houck PR, et al. Indirect self-destructive behavior and overt suicidality in patients with complicated grief. J Clin Psychiatry 2006;67: 233-9. 33. Shear MK. Complicated grief treatment (CGT) for prolonged grief disorder. In: Schnyder U, Cloitre M, eds. Evidence based treatment for trauma-related psychological disorders — a practical guide for clinicians. Zurich: Springer (in press). 34. Shear MK, Frank E, Foa E, et al. Traumatic grief treatment: a pilot study. Am J Psychiatry 2001;158:1506-8. 35. Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry 2014;71:1287-95. 36. Boelen PA, de Keijser J, van den Hout MA, van den Bout J. Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 2007; 75:277-84. 37. Acierno R, Rheingold A, Amstadter A, et al. Behavioral activation and therapeutic exposure for bereavement in older adults. Am J Hosp Palliat Care 2012;29: 13-25. 38. Rosner R, Pfoh G, Kotoucova M. Treatment of complicated grief. Eur J Psychotraumatol 2011;2:7995. 39. Bryant RA, Kenny L, Joscelyne A, et al. Treating prolonged grief disorder: a randomized clinical trial. JAMA Psychiatry 2014 October 22 (Epub ahead of print). 40. Kersting A, Dölemeyer R, Steinig J, et al. Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychother Psychosom 2013; 82:372-81. 41. Litz BT, Schorr Y, Delaney E, et al. A randomized controlled trial of an Internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder. Behav Res Ther 2014;61:23- 34. 42. Wagner B, Knaevelsrud C, Maercker A. Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Stud 2006;30:429- 53. 43. Papa A, Sewell MT, Garrison-Diehn C, Rummel C. A randomized open trial assessing the feasibility of behavioral activation for pathological grief responding. Behav Ther 2013;44:639-50. 44. Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry 2014;71:1287-95. 45. Rosner R, Pfoh G, Kotoučová M, Hagl M. Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial. J Affect Disord 2014;167:56-63. 46. Weissman MM, Markowitz JC, Klerman G. Comprehensive guide to interpersonal psychotherapy for depression. New York: Basic Books, 2000. 47. Simon NM. Treating complicated grief. JAMA 2013;310:416-23. 48. Bui E, Nadal-Vicens M, Simon NM. Pharmacological approaches to the treatment of complicated grief: rationale and a brief review of the literature. Dialogues Clin Neurosci 2012;14:149-57. 49. Simon NM, Shear MK, Fagiolini A, et al. Impact of concurrent naturalistic pharmacotherapy on psychotherapy of complicated grief. Psychiatry Res 2008;159:31-6. Copyright © 2015 Massachusetts Medical Society. nejm clinical practice center Explore a new page designed specifically for practicing clinicians, the NEJM Clinical Practice Center, at NEJM.org/clinical-practice-center. Find practice-changing research, reviews from our Clinical Practice series, a curated collection of clinical cases, and interactive features designed to hone your diagnostic skills. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Psychiatry 75(1) Spring 2012 76 © 2012 Guilford Publications, Inc. Pål Kristensen, PsyD, Lars Weisæth, M.D., Ph.D., and Trond Heir, M.D., Ph.D., are affiliated with the Norwegian Centre for Violence and Traumatic Stress Studies at the University of Oslo in Norway. Address correspondence to Pål Kristensen at the Norwegian Centre for Violence and Traumatic Stress Studies, Kirkeveien 166, Building 48, 0407 Oslo, Norway. E-mail: Pal.Kristensen@nkvts.unirand.no. Bereavement after Violent Losses Kristensen et al. Bereavement and Mental Health after Sudden and Violent Losses: A Review Pål Kristensen, Lars Weisæth, and Trond Heir This paper reviews the literature on the psychological consequences of sudden and violent losses, including disaster and military losses. It also reviews risk and resilience factors for grief and mental health and describes the effects and possible benefit of psychosocial interventions. The review shows gaps in the literature on grief and bereavement after sudden and violent deaths. Still, some preliminary conclusions can be made. Several studies show that a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved. The prevalence of mental disorders such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD, also termed complicated grief) varies widely, however, from study to study. Also, mental health disorders are more elevated after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seems to be slower. Several factors related to the circumstances of the loss may put the bereaved at heightened risk for mental distress. These factors may be differentially related to different outcomes; some increase the risk for PTSD, others for PGD. Given the special circumstances, bereavement following sudden and violent death may require different interventions than for loss from natural death. Recommendations for future research and clinical implications are discussed. Sudden and violent deaths usually include deaths from accidents, suicides, or homicides (Farberow, Gallagher-Thompson, Gilewski, & Thompson, 1992). In Western countries, such deaths account for approximately 5% of the total number of annual deaths (Norris, 1992). Sudden and violent deaths may also include disaster and war-related deaths. Those affect a great number of people every year, both adults and children, especially in poor countries. For example, in 2004, approximately 220,000 people died after a tsunami struck the coast of Southeast Asia, and approximately the same number of causalities was reported after the Haitian earthquake in 2010 (Centre for Research on the Epidemiology of Disasters, 2010). Thousands of civilians and soldiers have lost their lives during the recent wars in Afghanistan and Iraq (Papa, Neria, & Litz, 2008). Most people adjust well after the loss of a loved one with the support of family and Kristensen et al. 77 close friends; they do not have lasting difficulties or need professional help (Bonanno, 2004; Stroebe, Schut, & Stroebe, 2007). Some deaths, however, such as the sudden and violent loss of a family member, may be followed by a particularly difficult course of bereavement (Rando, 1996). Some epidemiological studies have found that a sudden, unexpected, or violent loss of a loved one is one of the most common life events leading to post-traumatic stress disorder (PTSD) (Breslau et al., 1998; Van Ameringen, Mancini, Patterson, & Boyle, 2008). Still, the overall mental health consequences of violent losses for the next of kin are uncertain. Also, the need for and benefits of professional help from the public health care system are not clear. Concepts such as traumatic loss (Green et al., 2001), traumatic death (Rando, 1996), and traumatic bereavement (Raphael & Martinek, 2004) have all been used more or less interchangeably with sudden and violent deaths in the bereavement and trauma literature. However, some have argued that sudden and violent death should be used to denote the objective mode of death and that terms such as traumatic loss should be used to describe the subjective aspects or consequences of the loss experience (Currier, Holland, & Neimeyer, 2006). This paper reviews the literature on the psychological consequences of sudden and violent deaths. It also reviews risk and resilience factors for grief and mental health outcomes and describes the effects and possible benefit of psychological interventions commonly used in the aftermath of sudden and violent losses. We searched PubMed, Medline, and PsychINFO for relevant publications related to traumatic bereavement and/or sudden and violent losses. CHARACTERISTICS OF SUDDEN AND VIOLENT LOSSES The sudden and violent loss of a loved one can be a devastating experience for the next of kin. Any sudden loss makes it difficult for relatives to grasp the reality that a close family member has died. Suddenness also hinders bereaved relatives from bidding a final farewell and carrying out any last services for the loved one. Further, violent deaths may strike in horrifying ways, with relatives as helpless witnesses. After a sudden and violent death, the body may be severely mutilated or disfigured; this can hinder viewing of the body. Disaster and war-related losses are often characterized by unique stressors (Raphael, 1986). One common stressor is the delay until death can be confirmed. Without an official confirmation, fantasies about the missing can create anxiety and denial about the most likely outcome. Eventually, some bodies may not be recovered at all, leaving the bereaved family without a proper burial ceremony or site to visit. Bereaved survivors may experience threats to their own lives and grotesque witness impressions that may have an enduring effect on their mental health (Hussain, Weisæth, & Heir, 2010). Other relatives may be far away from the disaster or war area, experiencing high levels of uncertainty and helplessness (Weisæth, 2006). The violent nature of the loss can promote a complex interplay of grief and posttraumatic stress reactions, which can either be intertwined or fluctuating with one condition dominating the other (Raphael, 1997). PTSD symptoms, such as reliving the scene of the death, may hinder the resolution of normal grief. Re-enactment of the death or reliving the death scene can also occur without witnessing the death (Rynearson, 2001). Recently, a new psychiatric diagnosis called prolonged grief disorder (PGD, also termed complicated grief) has been proposed for DSM-V and ICD-11 (Prigerson et al., 2009; Shear et al., 2011), and the current suggestion is to categorize PGD as an adjustment disorder (American Psychiatric Association, 2011). PGD consists of a set of grief-specific symptoms, such as yearning for the deceased, difficulties accepting the death, and difficulties moving on in life, that are distinct 78 Bereavement after Violent Losses from both post-traumatic stress disorder (PTSD) and depression (MDD) (Boelen, van de Schoot, van den Hout, de Keijser, & van den Bout, 2010; Golden & Dalgliesh, 2010; Prigerson et al., 1996). It is estimated that 10–15% of the bereaved population will suffer from PGD after loss due to natural causes (Prigerson, 2004). In this paper we have chosen to use the term prolonged grief disorder or PGD to denote maladaptive grief. THE MENTAL HEALTH CONSEQUENCES OF SUDDEN aND VIOLENT LOSSES Losses from Homicide, Suicide, or Accident A wide variety of mental health problems, such as PGD, MDD, PTSD, alcohol and drug abuse/dependence, and suicidal ideation, has been reported by bereaved relatives after sudden and violent losses (AmickMcCullan, Kilpatrick, & Resnick, 1991; Brent, Melham, Donohoe, & Walker, 2009; Dyregrov, Nordanger, & Dyregrov, 2003; Melham, Walker, Moritz, & Brent, 2008; Murphy, Tapper, Johnson, & Lohan, 2003; Zinsow, Rheingold, Hawkins, Saunders, & Kilpatrick, 2009). The majority of studies have focused on trauma-specific symptoms such as PTSD and depression. The prev
alence of these symptoms varies considerably, but some studies have found high levels of distress several years after the death. In a follow-up of 171 parents who lost children to violent death, Murphy and colleagues (1999a) found that 21% of mothers and 14% of fathers met criteria for PTSD two years after the death. After five years, 28% of mothers and 12.5% of fathers continued to meet PTSD diagnostic criteria (Murphy, Johnson, Chung, & Beaton, 2003), percentages that are considerably higher than for women and men in the general population (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Symptoms of re-experiencing visual or mental imagery of the death were frequently reported both in mothers (61%) and in fathers (55%). Sleep problems, ruminations about what caused the death and how it could have been prevented, and difficulties finding meaning in the loss are also commonly reported after violent losses (Currier et al., 2006; Hardison, Neimeyer, & Lichstein, 2005; Lehman, Wortman, & Williams 1987). Symptoms of mental distress may decrease slowly after sudden and violent losses, and a small increase has even been reported during the second year of loss (Murphy et al., 1999b). Several circumstances may contribute to this particular bereavement course. First, the shock and numbness frequently experienced after these losses (Lindemann, 1944) slowly wear off as the reality of the loss gradually sinks in. Second, the synergy of trauma reactions and grief may delay recovery (Armour, 2006). Third, there is often marked erosion of social support over time, which can increase distress. Finally, the bereaved may expect to be better after the first year or so, and when they are not, that causes distress. Deaths caused by suicide, homicide, and accident share some common features (e.g., suddenness and violence), but they also possess some unique stressors. Homicide, for example, involves media coverage and contact with the criminal justice system, which can constitute an additional burden for the next of kin (Gintner, 2001). There is some evidence that those bereaved by homicide exhibit higher levels of PGD and PTSD than those bereaved by accident or suicide (Currier et al., 2006; Murphy, Johnson, Wu, Fan, & Lohan, 2003). Those bereaved by suicide, on the other hand, often report higher levels of grief-specific symptoms, such as rejection, shame, stigma, and blame, and they may be more inclined to conceal the cause of death (Sveen & Walby, 2008). Kristensen et al. 79 Disaster Losses Loss of lives is an unfortunate, but common consequence of disasters (Norris & Wind, 2009). Loss of family members, close friends, or acquaintances often heightens the risk of mental health problems in populations struck by disaster (Fullerton, Ursano, Kao, & Bharitya, 1999; Heir & Weisæth, 2008; Norris et al., 2002). The two most commonly studied mental health disorders after disasters are PTSD and MDD (Galea et al., 2002), and the prevalence of these disorders varies from 5–68 % (PTSD) and 10–45 % (MDD) among disaster-bereaved populations (Bonanno, Galea, Bucciarellyi, & Vlahov, 2006; Kristensen, Weisæth, & Heir, 2009; Kuo et al., 2003; Neria et al., 2008; Pfeffer, Altemus, Heo, & Jiang, 2009). The connection between disaster losses and PTSD seems mainly to be a result of the threat to life and/or witnessing death. There is, however, also some evidence that the correlation between disaster-related bereavement and PTSD may be directly related to the loss, not only by witnessing death or viewing the body, but also by experiencing horrifying imagery regarding the manner of death and the degree of suffering before death (Goenjian et al., 1994). More recently, it is evident that disaster losses may result in a broader range of mental health problems, including psychosomatic pain, functional impairment, and prolonged grief disorder (Neria et al., 2008; Maguen, Neria, Conoscenti, & Litz, 2009). PGD has been reported in 14–76% of bereaved populations after natural and humancaused disasters (Ghaffari-Nejad, AhmadiMousavi, Gandomkar, & Reihani-Kermani, 2007; Johannesson et al., 2009; Kristensen et al., 2009; Neria et al., 2007; Shear, Jackson, Essock, Donahue, & Felton, 2006). Co-morbidity of PGD and PTSD are common after disaster losses and can have a significant impact on adjustment (Pfefferbaum et al., 2001). Still, a substantial number of the disaster bereaved display symptoms of PGD alone. Two recent studies, one after the 2004 tsunami and one after the 9/11 terror attacks, show that 30–50% of the bereaved with PGD did not meet criteria for other kinds of psychopathology (Bonanno et al., 2007; Kristensen et al., 2009). Those who suffered from PGD alone were considerably impaired in their daily functioning. Few longitudinal studies of disasterbereaved populations exist. Although the level of distress commonly decreases with time, bereavement seems to have considerable long-term impact on psychological distress and appears to slow down the recovery process (Johannesson, Lundin, Fröyd, Hultman, & Michel, 2011). Green and colleagues (1990) found that loss of a household member predicted depression and PTSD 14 years after the Buffalo Creek dam collapse in 1972. In a follow-up study after the Piper Alpha platform disaster in 1988, where the majority reported that they had lost close friends, 21% met criteria for post-traumatic stress disorder 10 years after the disaster (Hull, Alexander, & Klein, 2002). War or Military Losses Loss and bereavement are an integral part of military experiences, but there is a dearth of studies examining the psychological consequences of loss in military settings, particularly in the next of kin. A recent longterm follow-up study of bereaved parents after the accidental loss of sons during military service showed that 44% of the parents suffered from MDD during the first two years of their loss (Kristensen, Heir, Herlofsen, Langsrud, & Weisæth, 2012). Also, one study of Israeli parents showed that approximately 30% reported prolonged grief 2.5 years after the loss of sons due to military operations or accidents (Ginzburg, Geron, & Solomon, 2002). Bereaved civilian war survivors are also known to be at increased risk for prolonged grief and other mental health disorders (Momartin, Silove, Manicavasagar, & Stel, 2004). In a sample of bereaved who had lost 80 Bereavement after Violent Losses first degree relatives seven years earlier due to war-related violence in Kosovo, 38% met criteria for PGD, 55% for PTSD, and 38% for MDD (Morina, Rudari, Bleichhardt, & Prigerson, 2010). Convergent with studies of the disaster bereaved, approximately half the participants had PGD without other mental health disorders. Finally, loss of comrades or friends during war or combat has been associated with elevated risk of prolonged grief, depressive symptoms, anger, and guilt (Papa et al., 2008). In their study of Vietnam veterans, Pivar & Field (2004) found that, approximately 30 years after combat losses, the level of prolonged grief was comparable to that of bereaved individuals whose spouse had recently died, suggesting that the loss of comrades may play a significant role in the distress suffered by combat veterans. SUDDEN AND VIOLENT LOSSES VERSUS NATURAL LOSSES A common assumption is that sudden, unexpected, and violent losses are followed by a more difficult grieving process than losses from natural deaths (Parkes, 1998). This has been confirmed in several empirical studies showing a heightened risk for PGD, MDD, and PTSD after violent losses (Brent et al., 2009; Currier, Holland, Coleman, & Neimeyer, 2008; De Groot, Keijser, & Neeleman, 2006; Hardison et al., 2005; Kaltman & Bonanno, 2003; Keesee, Currier, & Neimeyer, 2008; Lundin, 1984; Mancini, Prati, & Black, 2011; Miyabayashi, & Yasuda, 2007; Schaal, Jacob, Dusingizemungu, & Elbert, 2010; Winjegaards de-Meij et al., 2005; Zisook, Chentsova-Dutton, & Shuchter, 1998). In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural
losses, Currier and colleagues (2006) showed that the violence of the loss, but not the suddenness, predicted the increased PGD risk. Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss, but not the suddenness, has also been shown to account for the increased PTSD risk in the bereaved (Kaltman & Bonanno, 2003). Prospective studies have also suggested that the trajectory of grief and mental health outcomes may follow a different course after sudden and violent losses. A 2.5-year followup study of 199 naturally and 108 suicidebereaved spouses found that symptoms of depression did not improve until after the first year in suicide bereavement, while those who had experienced a natural loss reported a major decline in symptoms during the first six months (Farberow et al., 1992). However, at the 2.5-year follow-up, symptoms had declined to the same level in both groups. Others studies support the notion that depressive symptoms may be more persistent after sudden and violent losses (Brent et al., 2009; Kaltman & Bonanno, 2003). Risk Factors for Mental Health Complaints after Sudden and Violent Losses Identifying subgroups that may be at particular risk for mental health problems may be an effective strategy to channel professional help to those who need it (Stroebe, Folkman, Hansson, & Schut, 2006). Risk factors can be defined as a variable that, when present, increases the likelihood of poor outcome (Stroebe, 2006) and may be divided into personal, interpersonal, and situational factors (Stroebe & Schut, 2001). Table 1 lists studies that have examined risk factors for mental health complaints after sudden and violent losses. Personal risk factors, such as female gender and pre-existing psychiatric difficulties, have been shown to increase the probability for mental distress (Brent et al., 2009; Ghaffari-Nejad et al., 2007; Murphy, Johnson, Chung, & Beaton, 2003). Interpersonal risk factors, such as kinship and social support, may also affect outcomes (Hibberd, El- Kristensen et al. 81 wood, & Galovski, 2010). Close kinship, and in particular loss of a child, has been found to increase the risk of PGD after suicide (Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004), natural disasters (Johannesson et al., 2009; Kristensen, Weisæth, & Heir, 2010), and mass violence (Neria et al., 2007). Low perceived social support has been associated with depression after disaster-related bereavement (Fullerton et al., 1999), and social isolation has been related to difficulties in adjustment after the sudden and violent loss of child (Dyregrov et al., 2003). Finally, situational risk factors or factors related to the circumstances of the loss are likely to affect the course of bereavement. The significance of several of these factors is discussed in more detail below. Blaming Others or Being Blamed for the Death The perception of responsibility or blame for the death is often considered important for the adjustment to loss (Rando, 1996). Mental distress is assumed to be more elevated after losses from human-caused disasters, either technological accidents or mass violence (Norris et al., 2002). While natural disasters are perceived as unavoidable, human-caused disasters strike more suddenly, without forewarning, and there is often someone to blame, which may influence the psychological reactions of the bereaved (Weisæth, 2006). A study of parents who lost sons in an avalanche during a military operation showed that those who perceived the death as preventable displayed excessive anger and bitterness related to the loss (Kristensen et al., 2012). Blaming others for the death of a loved one can increase the duration and severity of depression and PGD (Brent et al., 2009; Melham et al., 2007), while feeling blamed for the death has also been associated with higher PGD scores (Melham et al., 2007). Magnitude of Losses Large-scale accidents and disasters involving multiple deaths often receive more attention from the media, authorities, and the public health care system than “ordinary” deaths. The publicity may lead to increased sympathy and support, but can also be followed by an involuntarily “disaster identity” (Raphael, 1986). Research comparing the psychological effect of disaster losses and single, violent losses is scarce, but Rubonis and Bickman (1991) shed some light on this research question when they found that the number of human causalities in a disaster was associated with higher estimates of morbidity. They assumed that a higher death rate could be an indication that more survivors experienced a threat to their own lives, and that this could explain the higher rates of psychopathology. Self-Blame and Guilt Experiencing guilt or self-blame is a common reaction after sudden and violent losses (Lehman et al., 1987). Bereaved disaster survivors may experience the feeling of not having done enough to save those who died, or of guilt related to their own survival (Weisæth, 1989). Hull, Alexander, and Klein (2002) found, for example, that 70% of survivors reported acute guilt after the Piper Alpha platform disaster in 1988 and that more than one-third had survivor guilt 10 years after the disaster. Guilt, or the feeling that they might have done something to prevent the death, has been shown to correlate with PTSD, depression, and PGD among disaster bereaved (Kuo et al., 2003) and in adolescents bereaved by suicide (Melham et al., 2004). 82 Bereavement after Violent Losses TABLE 1. Studies Examining Risk Factors for Mental Health Complaints among Different Bereaved Populations after Sudden and Violent Loss of a Close Family Member or Acquaintance Specific risk factors Authors Population Outcome Personal risk factors Female gender Morina et al. (2009) Civilian war survivors (n = 60) Women were more likely to have PGD than men Ghaffari-Nejad et al. (2007) Earthquake survivors (n = 400) Women scored higher on PGD Murphy et al. (2003) Parents, suicide, homicide, accident (n = 173) More women than men met criteria for PTSD Pre-existing mental health difficulties Brent et al. (2009) Children/young adults lost parents, suicide, accidents, or natural deaths (n = 176) Past history of depression increased depression risk in the 9 months following the death Melham et al. (2004) Adolescents lost peer in suicide (n = 146) Past history of depression was associated with PGD and PTSD Interpersonal risk factors Close kinship Kristensen et al. (2010) Natural disaster victims (n = 130) Loss of a child or spouse increased PGD risk Johannesson et al. (2009) Natural disaster victims (n = 495) Loss of a child increased PGD risk Neria et al. (2007) Victims of terrorist attacks (n = 707) Loss of adult child increased PGD risk Mitchell et al. (2004) Suicide-bereaved adults (n = 60) Significant differences in grief scores between closely related and distantly related survivors Lack of perceived social support and social isolation Dyregrov et al. (2003) Parents, suicide, accidents, SIDS (n = 173) Self-isolation predicted psychosocial distress Fullerton et al. (1999) Airline disaster survivors (n = 71) Low perceived social support predicted depression at two months post-disaster Situational risk factors Blaming others/being blamed Kristensen et al. (2012) Parents, natural disaster (n = 32) Blaming others for the death was associated with exces- sive anger and bitterness Brent et al. (2009) Children/young adults lost parents in suicide, accident, or natural death (n = 176) Blaming others for the death increased risk of depression Melham et al. (2007) Children/adolescents lost parents in suicide, accidents, or sudden natural deaths (n = 129) Feeling that others were accountable for the death and/ or feeling that others were blaming him or her for the death was associated with higher PGD scores. Self-blame/guilt Melham et al. (2004) Adolescents lost peer in suicide (n = 146) Feeling that one could have done something to prevent the death was associated with PGD, MDD, and PTSD Kuo et al. (2003) Earthquake survivors (n = 12
0) Initial feelings of guilt increased PTSD risk Kristensen et al. 83 Hull et al. (2002) Survivors of oil platform disaster (n = 33) Survivor guilt was associated with higher levels of PTSD Life threat Kristensen et al. (2009, 2010) Natural disaster victims (n = 130) Life threat increased risk for PTSD, but not PGD Morina et al. (2009) Civilian war survivors (n = 60) Life threat was associated with elevated risk for PTSD and MDD, but not PGD Witnessing death or find- ing the deceased Melham et al. (2007, 2008) Children/adolescents lost parents in suicide, accidents, or sudden natural deaths (n = 140) Being at the scene when death occurred predicted new- onset PTSD, but not PGD Hull et al. (2002) Survivors of oil platform disaster (n = 33) Witnessing death was correlated with higher PTSD symptoms Brent et al. (1992) Adolescents lost peer in suicide (n = 58) Subjects who either witnessed the suicide or found the body had more PTSD symptoms than those who did not Waiting for death confir- mation/confirmation of death vs. presumed dead Kristensen et al. (2010) Natural disaster victims (n = 130) Time to death confirmation increased risk for PGD Powell et al. (2010) Civilian war survivors (n = 112) Those who had a husband listed as missing had much higher scores on grief and depression than those whose husband was confirmed dead Multiple losses Schaal et al. (2010) Survivors of genocide (n = 400) The number of reported losses did not increase the PGD risk Souza et al. (2007) Natural disaster victims (n = 262) The number of disaster-related deaths was associated with emotional distress Montezari et al. (2005) Earthquake survivors (n = 761) Loss of more family members was associated with more severe psychological distress 84 Bereavement after Violent Losses Life Threat Experiencing a threat to one’s own life and the loss of a loved one often co-occur among the disaster bereaved as well as civilians exposed to warfare (Kristensen et al., 2009; Mollica et al., 1999). The association between life threat and mental distress is a key feature of psychotraumatology, particularly when considering the PTSD diagnosis (Neria, Nandi, & Galea, 2008). A recent study of Norwegians who had lost a close relative during the 2004 tsunami showed that those who were directly exposed to the tsunami disaster and had experienced a severe threat to their own lives had a much higher prevalence of PTSD compared to those who were not directly exposed to the disaster, 34% vs. 5% (Kristensen et al., 2009). On the other hand, experiencing a life threat has not been shown to increase the risk of PGD in the bereaved (Kristensen et al., 2010; Morina et al., 2010); this underlines the distinction between PTSD and PGD. Witnessing the Death or Finding the Deceased Approximately 5% of violent deaths are witnessed by their loved ones (Rynearson, 2010). In DSM-IV, witnessing death is one of the event criteria specified in the PTSD diagnosis (American Psychiatric Association, 1994), and witnessing death has consistently been linked to PTSD after violent losses (Brent et al., 1992; Hull et al., 2002; Melham et al., 2008). But finding the deceased or being at the scene of the death—for example, seeing the victim or the remainder (such as blood on the wall after a suicide with a firearm)—has also been associated with PTSD symptoms (Brent et al., 1992; Melham et al., 2004). However, these factors have not been found to increase the risk of PGD, which again underlines the distinction between PTSD and PGD (Melham et al., 2007). Waiting for Confirmation of Death/ Confirmed Dead versus Presumed Dead Waiting for confirmation of death is particularly stressful for the next of kin and can delay or prolong the grieving process (Kristensen et al., 2010). Another consequence of violent losses, particularly during war, acts of terrorism, and natural disasters, are that bodies are not recovered. Clinical reports have noted that not recovering the body can lead to unresolved grief and feelings of helplessness, depression, somatization, and relationship conflicts (Boss, 2002). Empirical studies are, however, scarce. A recent study of women whose husbands were either confirmed dead (n = 56) or were listed as missing (n = 56) after the war in Bosnia and Herzegovina showed that the group with unconfirmed losses had higher levels of traumatic grief (measured with the UCLA Grief Inventory) and severe depression (measured with the General Health Questionnaire), even when current stressors were accounted for (Powell, Butollo, & Hagl, 2010). Multiple Losses Losing several family members simultaneously is common, especially in disasters. Multiple losses may deprive the bereaved of their natural support system and can leave relatives feeling overwhelmed or stuck in their grief, a phenomenon commonly referred to as bereavement overload (Neimeyer & Holland, 2006). The number of losses of household family members has been shown to predict emotional distress and depression among those bereaved by disasters (Montezari et al., 2005; Souza, Bernatsky, Reyes, & de Jong, 2007). However, in a study of orphans and widows bereaved by the 1994 Rwandan genocide, the number of reported losses did not increase the risk of PGD; the authors suggest that the attachment to the Kristensen et al. 85 deceased may be more important than the total number of losses (Schaal et al., 2010). RESILIENCE AND PROTECTIVE FACTORS Developmental researchers have for many years documented resilience among children growing up under adverse socioeconomic conditions (e.g., Rutter, 1987). More recently, there has been increased interest in resilience after both disasters and loss (e.g., Bonanno, 2004). Resilience to loss is defined as bereaved persons showing a stable pattern of low distress over time and has been distinguished from maladaptive grief or the more traditional trajectory of recovery (Bonanno, 2004). The percentage of individuals showing a resilient trajectory after natural, expected deaths is substantial (Bonanno et al., 2002). The available data on resilience after sudden and violent losses is limited. Still, one study indicates that while the level of resilience is clearly reduced compared to losses following natural deaths, it may be quite significant. Bonanno and colleagues (2006) showed that approximately 30% of those who both lost a loved one and witnessed the 9/11 attacks on the World Trade Center were considered resilient, that is, defined as having either no PTSD symptoms or only one symptom during the six months following the attacks. Approximately the same pattern emerged even when the researchers narrowed the definition of resilience to also include absence of depression. Protective factors can be defined as variables that, when present, increase the likelihood of good outcome (Stroebe et al., 2006). Murphy and colleagues (1999b) found that higher scores on self-esteem and self-efficacy predicted lower mental distress in bereaved parents after the violent loss of their young adolescent child. Similar results were found in a study of those bereaved by disaster (Murphy, 1984). Also, finding meaning in the loss, for example through religion/ spiritual beliefs, has been related to lower mental distress and grief after violent losses (Murphy, Johnson, & Lohan, 2003; Schaal et al., 2010). The role of social support has shown non-conclusive results in the general bereavement literature (e.g., Stroebe, Stroebe, Abakoumkin, & Schut, 1996). Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses (Reed, 1993; Sprang & McNeil, 1998). PSYCHOSOCIAL INTERVENTIONS AFTER SUDDEN AND VIOLENT LOSSES Early Interventions In the acute phase, a primary aim is to help bereaved families grasp the reality of their loss and to facilitate acceptance (Weisæth, 2006). There has been a general tendency among both laypersons and professionals to protect bereaved families and individuals after violent deaths, for example, by painting a more comforting picture of the death (“died during sleep” or “most likely no pain”). An alternative st
rategy is called confrontational support, in which bereaved families are confronted with the brutal reality of death in a caring and supportive manner (Winje & Ulvik, 1995). This strategy can be implemented during various phases after sudden and violent losses, such as when the message of death is conveyed, along with information on the circumstances and cause of death, when the family visits the site of the death, and when the family is invited to view the deceased. An example of confrontational support is the program conducted after 16 soldiers died in an avalanche in northern Norway in 1986. As part of the collective follow-up after the disaster, the bereaved parents attended a memorial service, viewed their dead sons, visited the disaster area where their sons had died, and met with their sons’ military lead- 86 Bereavement after Violent Losses ers, survivors, and comrades in order to receive first-hand information. Although the deaths had a profound effect on the parents and they partly blamed military leaders for their sons’ deaths, still, they valued this support and did not regret participating (Kristensen & Franco, 2011). Several non-psychotherapeutic interventions or rituals conducted in the early phases may be important for longer-term adjustment. The death notification process can potentially influence mental health and grief, but few studies have empirically examined this (Stewart, 1999). One study of close relatives bereaved by homicide found that being satisfied with the way the notification was handled was related to less mental distress (Thompson, Norris, and Ruback, 1998). Another common ritual or intervention, the viewing of the body, is considered important in confronting the reality of the loss and bidding a final farewell (Paul, 2002; Worden, 2009). There may be uncertainty among professionals as to whether bereaved relatives should view the body in the aftermath of a sudden and violent death. However, given the choice, few seem to regret viewing the deceased (Chapple & Ziebland, 2010), and the decision not to view is more often regretted (Sing & Raphael, 1981; Winje & Ulvik, 1995). In some cases, viewing the body may increase anxiety and distress in the short term, but lessen distress in long term (Hodgkinson, Joseph, Yule, & Williams, 1993). One frequently reported complaint of the next of kin is missing information and unanswered questions related to the loss (Merlevede et al., 2004). Obtaining information and facts about what happened (for example, the cause of death) can be important in bereaved relatives’ efforts to try to make sense of the death, but this has not been shown to promote better adjustment (Winje, 1998). This may be part of a normal adjustment phase. However, the persistent need for information after factual information has been provided—ruminations revolving around the deceased’s feelings just before death, or the deceased’s suffering, and so forth—has been associated with poorer adjustment in the long term (Lehman et al., 1987; Winje, 1998). As for other dramatic life events, rituals often have significant meaning after sudden and violent deaths. One such ritual is visiting the site where death occurred, which is frequently observed after traffic accidents (Clark & Franzmann, 2006). Recent research has showed that visiting the site of death may also be important for bereaved families after disasters. For example, 87% of bereaved Norwegians visited the site of death after the 2004 tsunami disaster (Kristensen, Tønnessen, Weisæth, & Heir, in press). The visitors reported that the primary effect was a better understanding of what had happened to their loved ones. The feeling of closeness to the deceased and the experience of togetherness with family and other bereaved families were also considered important. Visiting the site of death was associated with greater acceptance of the loss and a lower level of avoidance behavior (Kristensen et al., in press). The memorial service is another ritual that may facilitate a confirmation of the reality of the death and release feelings of grief after disasters and large-scale accidents (Danbolt & Stifoss-Hansen, 2007). There is no empirical evidence for the effect of providing psychological interventions for the bereaved as a routine (Stroebe et al., 2006). Early interventions after trauma and loss, such as Critical Incident Stress Debriefing (CISD), have been the subject of much controversy due to a lack of documented benefit or even speculation of harm (McNally, Bryant, & Ehlers, 2003). Some even stress that debriefing is contra-indicated for those who are recently and traumatically bereaved (Raphael & Wooding, 2004). When grief counselling is directed toward members of high-risk groups, such as people who have experienced sudden and violent losses, only modest effects have been found (Currier, Neimeyer, & Berman, 2008). Also, a recent meta-analysis showed that interventions Kristensen et al. 87 aimed at preventing PGD do not appear to be effective (Wittouck, Van Autreve, De Jaegere, Portzky, & Van Heeringen, 2011). Longer-Term Interventions Overall, grief counselling or therapy seems to be most effective when the bereaved show clear symptoms of PGD or other mental health problems secondary to loss (Currier, Neimeyer et al., 2008). A recent meta-analysis confirmed that treatment interventions effectively reduce symptoms of prolonged grief disorder (Wittouck et al., 2011). Both cognitive-behavioral interventions (Boelen, de Keijser, van den Hout, & van den Bout, 2007) and more grief-specific treatment models of PGD, which have included elements from the Dual Process Models of coping with bereavement (Stroebe & Schut, 1999) and exposure techniques (Shear, 2006) have shown promising results for those bereaved after violent and natural deaths (Shear, Franck, Houck, & Reynolds, 2005). Different psychological longer-term interventions have been described in the literature, for example, in trauma- and grief-focused groups of adolescents after community violence (Salloum, Avery, & McClain, 2001) and war (Layne et al., 2008), collective family-based interventions after technological and natural disasters (Dyregrov, Straume, & Sari, 2009), and group intervention for bereaved parents (Murphy et al., 2002) and for homicide survivors (Rynearson, Favell, & Saindon, 2002). These studies have not always examined outcomes systematically, and the results are mixed: some studies show reduction in mental distress while others do not. For example, in a study of bereaved parents who had lost a young adolescent child in accidents, homicide, or suicide, Murphy and colleagues (2002) found that mothers who were more distressed at baseline benefited most from a 10-week group intervention. Fathers, on the other hand, showed no effect from the treatment. CONCLUSION Sudden and violent deaths affect thousands of people worldwide every year, and these deaths are often followed by a difficult bereavement course. This review has revealed several gaps in the literature on grief and bereavement after sudden and violent losses, but some preliminary conclusions can be made. While the majority of bereaved persons eventually will adjust even to such difficult losses, a significant number of bereaved persons will suffer from mental distress in the aftermath of their loss. The trajectory of recovery seems to be slower after violent losses than after losses from natural deaths. The prevalence of mental disorders varies widely, however, from study to study. The high variability in studies of mental disorders, for example, among the disaster bereaved, may result from examining different samples, the level of exposure to the disaster, the kinship or relationship to the deceased, and the time since death. The reliance on convenience samples commonly used in many disaster studies may, for example, lead to greater estimates of pathology compared to community- or population-based samples (Bonanno, Brewin, Kaniasty, & LaGreca, 2010). The majority of studies have focused on traumaspecific symptoms such as PTSD
and depression, but more recently some studies have included measures of maladaptive grief or PGD. Studies of other outcomes are scarce. The study of risk factors—personal, interpersonal, and situational—is important because they can reveal who might be more vulnerable for suffering from mental health complaints after violent losses. Several situational risk factors, such as witnessing the death or finding the deceased, life threats, blaming others or being blamed for the death, are all likely to influence how bereaved persons and families adapt to their loss. While PGD, PTSD, and PGD share some risk factors, these factors may also be differentially related to different outcomes; some are more associated with PTSD, others with PGD, 88 Bereavement after Violent Losses underlining a distinction between these two disorders. This finding emphasizes the need for measuring different outcomes when conducting research after sudden and violent losses (Van der Houwen, et al., 2010). However, little is known about the relative impact of different risk factors and of the potential interaction or additive effects of these factors (Stroebe et al., 2006). For example, it is reasonable to assume that the type of loss (e.g., loss of a child) and the degree of exposure to the death (e.g., witnessing the death) may interact and influence outcome. Analysis of risk factors alone may not be enough to understand why some people struggle and others cope well with their loss. A few studies suggest that resilience may be more common among persons who have experienced violent losses than what has previously been expected. Little is currently known about factors that may promote resilient outcomes, but multiple pathways to resilience after loss are possible, often involving a complex interplay of risk and resilience factors (Bonanno, Westphal, & Mancini, 2011). It is also important to bear in mind that risk and resilience factors sometimes may be the same depending on other circumstances, such as past history. Some research suggests, for example, that only prior stressors that resulted in PTSD tend to predict PTSD at subsequent exposure to trauma (Breslau, Peterson, & Schultz, 2008). Whether resilience to prior stressors, such as loss, also may predict resilience to subsequent loss is unknown. While several studies have indicated that previous losses can be a risk factor for mental distress after new losses (e.g., Silverman, Johnson, & Prigerson, 2001), other studies suggest that previous losses may also operate as a buffer (Kristensen et al., 2010). Several mechanisms can account for the latter outcome. Prior experience of loss can, for example, have a maturing or learning effect on some bereaved individuals, enhancing their ability to cope with distressing emotions. As this review shows, the special circumstances of sudden and violent losses may require different interventions than deaths following natural losses. Some interventions or rituals, such as viewing the deceased, information about the death, visiting the site of death, and so forth, may be particularly important in the early phases after violent losses in order to help bereaved families and individuals grasp the reality of their loss and to facilitate acceptance. The term confrontational support may be a useful categorization of these interventions when bereaved families are confronted with the brutal reality of death in a caring and supportive manner (Winje & Ulvik, 1995). Other interventions, such as grief and trauma therapy, may be indicated if the grieving process is not progressing naturally. While different interventions following sudden and violent losses have been noted, few studies have measured their effect. Both ethical and practical issues may account for this. The chaos and uncertainty that are characteristic of disasters make it more difficult to test the effectiveness of early interventions, for example, by using randomized controlled trials (Raphael & Maguire, 2009). Recommendations for Future Research This review reveals several limitations that should be the focus of future research. While research on violent losses generally is evolving, there are strikingly few studies examining the mental health consequences of military or war-related losses. There is also a need to explore in more detail how families are affected by sudden and violent losses. Research has so far mainly focused on individual reactions to loss and trauma. Some recent studies have demonstrated that sudden and violent losses can have a significant impact both at the individual and at the family level, with the possibility for mutual influence on the intensity and course of grief (Kristensen et al. 2012; Nickerson et al., 2011). The use Kristensen et al. 89 of multilevel analysis may be an appropriate method for approaching these issues. Methodologically, the majority of studies after sudden and violent losses have used self-report questionnaires and only a few have used structured clinical interviews, which limit the possibility of making more precise estimations of prevalence of mental disorders. Future studies should also incorporate grief measures. Studies examining PGD are important due to the recent findings documenting the unique contribution that PGD can have on failure to adapt to the loss (Bonanno et al., 2007). The lack of longitudinal follow-up studies limits our understanding of the trajectory of grief and the potential long-term mental health effects of violent losses. Also, while some studies have begun to explore mediating factors between violent losses and prolonged grief or PTSD (e.g., Currier et al., 2006; Mancini et al., 2011), the psychological mechanisms underlying the impact of violent losses are poorly understood and should be explored further. In addition, there is a need for resilience studies examining factors that can protect the bereaved from a maladaptive bereavement process after violent losses. Finally, there is a need for more studies of interventions or rituals that may affect adjustment to sudden and violent losses, including bereaved persons’ experiences with death notification, information related to the death, visits to the site of death, and so forth. Also, the effect of grief and trauma therapy, either individually and/or collectively, needs to be further examined. Questions such as the type and timing of intervention should be addressed. Recommendations for Clinicians It is important for clinicians to know that grief may follow a different course after sudden and violent losses compared with losses from natural deaths. The nature and circumstances of these deaths makes it more difficult for the bereaved to grasp the reality of the loss, and grief reactions may intensify when the shock, disbelief, and denial gradually wear off. Especially when persons are missing and death is not confirmed, a different time frame of grief can be expected. Clinicians should be aware of the increased risk of mental health disorders and impaired functioning often found after sudden and violent losses. Regular General Practitioners (RGPs) may be assigned a particular responsibility for screening bereaved persons for mental health difficulties. While grief traditionally has been associated with depression (Zisook & Shear, 2009), recent research has shown that there may be more to grief than MDD. PTSD is mainly associated with direct exposure to the death, but symptoms such as re-enactment of the death or reliving the death scene can occur without having witnessed the death (Rynearson, 2001). The heightened risk for PGD found among the violently bereaved suggests that clinicians should be familiar with the core symptoms and how to screen for or diagnose the disorder. While PGD is still not formally accepted as a new diagnostic entity, clinicians should be able to distinguish PGD both from normal, acute grief and from MDD and PTSD (Shear & Mulhare, 2008). Screening for other anxiety disorders, alcohol and substance abuse, and suicidal ideation may also be indicated. Also, although more research is needed to ensure that evidence-based treatments are available, clinicia
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