Thursday, October 22, 2009

Thursday's Therapy - What is Complicated Grief, and What is "Complicated Grief Therapy"?

Thursday's Therapy

What is Complicated Grief,


What is "Complicated Grief Therapy"?

Notes taken from

American Journal of Psychiatry, July, 2009

American Psychiatric Association


Grief and Depression: Treatment Decisions for Bereaved Children and Adults

By M. Katherine Shear, M.D.

What is the difference between Grief and Depression?

Yearning (passionately missing and/or desiring to be with your loved one) is the sine qua non (indispensable factor) of grief and is not seen in depression. Yearning is the experience of wanting, a component of the brain reward system thought to be deactivated in depression. By contrast, even during the initial period of acute grief, bereaved people retain the ability to experience positive emotions. Positive emotions may be evoked in a bereaved person when recalling pleasant experiences with the deceased or when expressing pride in the loved one or telling amusing anecdotes. Moreover, sadness is not usually pervasive during grief; rather, it occurs in waves or pangs of emotion. Acute grief is associated with preoccupation with thoughts and memories of the deceased, while depression is associated with self-critical or pessimistic rumination.

What is Complicated Grief?

Complicated grief is "a form of prolonged acute grief that is clinically significant and occurs in about 10% of bereaved individuals."

Key features of Complicated Grief include:

§ Persistent intense yearning and longing for the person who died

§ Disruptive preoccupation with thoughts and memories of this person

§ Disruptive preoccupation with thoughts and memories of this person

§ Disruptive Avoidance of reminders that the person is gone

§ A range of negative emotions that include

o Deep relentless sadness

o Self-blame

o Bitterness or anger in connection with death

o An inability to gain satisfaction or joy through engaging in meaningful activities or relationships with significant others

It has been discovered that complicated grief increases activation of brain reward centers when exposed to stimuli that were reminders of the deceased loved one; this (relief factor) supports the difference between complicated grief and depression.

Complicated grief can co-occur with other psychiatric disorders, meaning the grief itself does not necessarily "create" the other disorders.

However Complicated grief can contribute to

§ Psychological Impairment

§ Functional Impairment

§ (even) Suicidality

independent of any other disorders.

Dr. Shear's belief is, "Complicated grief needs to be treated and is refractory (resistant) to standard treatment for depression. A targeted treatment may be required."


In summary, studies of adults as well as children indicate that most bereaved people experience a painful period of acute grief and go on to make a good adjustment and to restore their ability to attain joy and satisfaction in their ongoing lives.

A clinically significant minority do not enjoy this positive outcome and instead experience psychiatric sequelae, the most common of which are

§ Major Depression

§ Post-Traumatic Stress Disorder

§ Alcohol or Substance Abuse

§ Complicated Grief.

Each of these conditions needs to be recognized as early as possible and treated appropriately to prevent the development of enduring disruptive illness.


Complicated Grief shares elements of Major Depression and PTSD (See below). However treatments typically used for these disorders don't work well for people with Complicated Grief. (Below, you will see the proper grief therapy indicated for bereaved parents who decide they want therapy, according to the latest grief research (2005). It is called "Complicated-Grief Therapy.)

Elements in common with Major Depression:

§ Sadness

§ Guilt

§ Social Withdrawal

Elements in common with Post-Traumatic Stress Disorder

§ Disbelief

§ Intrusive Images

§ Avoidance Behaviors


Psychotherapy - What is Complicated-Grief Therapy?

If a grieving person does decide to pursue psychotherapy for complicated grief, be sure your therapist is well-trained in the latest "Complicated-Grief Therapy." Typically, Complicated-Grief Therapy involves several components. The therapist will help you to recall stories of your loved one's death as the therapist tape-records your recollections. Periodically, the therapist will ask you to report your level of distress. Then the therapist will have you listen to the tape between sessions.

Your therapist will try to reduce your distress levels during each session by "promoting a sense of connection to the loved one" such as

* Imagining having conversations with your deceased loved one

* Discussing positive and negative memories about him or her.

The Complicated-Grief Therapy trained therapist will also ask you to discuss what your plans and goals would be if your grief were not so intense.



"Complicated grief is common in unexpected and violent deaths," says Keith Hawton, professor of psychiatry in his Editorial: "Complicated grief after bereavement."

I would argue Complicated Grief is the norm with any parent's loss of a child.

M. Katherine Shear, M.D. – Editorial: Grief and Depression: Treatment Decisions for Bereaved Children and Adults

Psychiatry Professor Keith Hawton – Editorial: Complicated grief after bereavement

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