Stuck in Bereavement – Complicated Grief

by Lauren Stone

The experience of losing a loved one is something we can all relate to, and for some, this may be especially relevant in light of the recent Boston Marathon bombings.  In the United States, almost 2.5 million people die every year (1).  Individuals grieve in different ways in response to the common and universally stressful experience of death.  Some are overcome with shock, while others develop intense longing or sadness (2).  These painful emotions are an entirely natural response and eventually lessen.

Recovery for most people falls around 6-12 months after a loss, beginning the transition from acute to integrated grief (3).  Acute grief is intense and occurs in the short-term post loss.  Integrated grief involves the transition from acute grief to an acceptance of the loss.  In this phase, although feelings of sadness endure, one is able to resume normal proceedings and experience joy.  However, a small percentage of bereaved individuals are unable to transition to the stage of integrated grief.  They remain stuck in acute grief and experience a protracted or even halted healing process.  These approximately 7% of bereaved individuals suffer from complicated grief, a recently recognized syndrome characterized by significant distress and functional impairment (2).  Currently, researchers at the Massachusetts General Hospital are collaborating with three other partner sites, including the Columbia University School of Social Work, in the Healing Emotions After Loss (HEAL) Study. The study pilots the use of an FDA-approved antidepressant medication and a targeted psychotherapy for the treatment of complicated grief.  According to Dr. Naomi Simon, the director of the complicated grief program at Mass General, the studies under way are working toward an optimal treatment for the illness (2).

Complicated Grief’s Path to the DSM

Grief can lead to other psychiatric disorders following a loss, such as major depressive disorder or posttraumatic stress disorder (PTSD), both of which can certainly overlap with the symptoms of complicated grief.  However, complicated grief is a distinct entity.  For instance, while PTSD is characterized by fear, complicated grief is dominated by an intense sadness (2).  Those afflicted with major depressive disorder experience great sadness as well, but this sentiment is more general, compared with death-related sadness and longing in complicated grief (2).

For these reasons, physicians and researchers in the field of grief have been advocating for the establishment of complicated grief as a distinct disorder (4, 5).  In May of this year, the illness was finally included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fifth Edition as Persistent Complex Bereavement Disorder (6), and will be titled Prolonged Grief Disorder in the International Classification of Diseases (ICD-11) that the World Health Organization will introduce in 2015 (7).  The clinical criteria for the illness as presented in the DSM include symptoms such as intrusive thoughts about the death, persistent yearning for or preoccupation with the deceased, self-blame, and social, occupational, and functional impairment (6) – factors that “complicate” normal grief.  Risk factors for the illness include female sex, life trauma, type of death (namely violent, sudden, or due to suicide), and prior loss (2).  However, despite the much-anticipated recognition of complicated grief as a clinical entity, there is much unexplored territory in the illness.

Preliminary Research on Complicated Grief

In 2005, Dr. Katherine Shear, the director of the HEAL Study branch at the Columbia University School of Social Work, conducted an important randomized control trial using a targeted psychotherapeutic intervention called Complicated Grief Therapy (CGT).  Under CGT, participants demonstrated greater improvement than those who received interpersonal psychotherapy (8).  Pharmacological data are scant, though preliminary studies demonstrate that serotonin selective reuptake inhibitor (SSRI) antidepressant medications may improve grief symptoms (9, 10).  Given that many clinicians are in fact uninformed about how to recognize when a patient is at risk or to treat the illness (2), the need for evidence-based treatment standards is crucial.

HEAL Study Design and Aims

These are the gaps that the multisite HEAL Study, funded by the National Institute of Mental Health, seeks to rectify.  These researchers are testing the efficacy of the SSRI antidepressant citalopram and the targeted psychotherapy that Dr. Shear helped to develop, in an effort to optimize the treatment of complicated grief.

To be eligible for the study, individuals must be 18 years of age or older and must have been suffering from grief for 6 or more months following loss.  Interested participants begin with an initial screening visit, in which a clinician confirms whether or not the participant suffers from complicated grief.  If eligible, based on confirmation of diagnosis and overall good health, the participant is randomly assigned to one of the following four groups for 16 weeks of treatment:

• Complicated Grief Therapy (CGT) and the medication (citalopram)
• CGT and a placebo (inactive pill)
• Citalopram without CGT
• Placebo without CGT

 Other Angles and Future Research

In addition to the HEAL study, other researchers are working to better understand complicated grief.  In 2008, a research team led by Mary-Frances O’Connor, a professor of psychology at the University of Arizona, examined a particular area of the brain, the nucleus accumbens, in the context of grief.  The nucleus accumbens is a component of the mesolimbic dopamine system, which uses the neurotransmitter dopamine to control sensations of pleasure and reward (11).  In O’Connor’s study, bereaved participants with complicated grief, compared to bereaved participants without complicated grief, demonstrated reward activation in the nucleus accumbens in response to being shown cues of the deceased (12).  This finding suggests ties between attachment and reward function, a connection that is supported by animal models.  Addiction and social interactions have been found to use the same neural circuitry in rats, for instance (13).

Another important advance in the field of grief came from the Harvard University Department of Psychology.  In an article published this year, graduate student Don Robinaugh and professor Richard McNally present their results from a study in which they had recruited conjugally bereaved adults to examine autobiographical memory specificity (14).  Robinaugh and McNally found that participants with complicated grief had difficulty recalling past and imagining future events without the deceased.  However, these same participants had relatively little difficulty imagining future events with the deceased.  McNally views the results as seeming to “narrow in” on potential cognitive bases for some of the clinical symptoms of complicated grief.  For instance, a difficulty moving beyond the grief and imagining the future without the deceased, yet ability to imagine a “counterfactual future” with the deceased, may be the basis for the tension behind painful yearning for the lost loved one.  McNally believes there could be ways of saying “aha” – that this is a problem or deficit that comes with complicated grief.  With this, he explains, comes the potential to rectify these deficits.  This is an advantage of experimental psychopathology approaches, in which we can “illuminate patterns of deficits” that highlight possibilities for therapeutic interventions (15).

McNally points out that grief is painful enough, but if it goes untreated, there is the risk for other non-psychiatric medical consequences such as heart attacks and a taxed immune system.  The “real problem,” he summarizes, is those who are suffering and not being helped.  He views the most important future research directions as figuring out why some individuals develop complicated grief and others do not, as well as better understanding the psychopathology of the illness and documenting the efficacy of existing interventions (15).  The results of studies targeting neuroanatomical or cognitive correlates of complicated grief may have implications for future treatment of the disorder.

Conclusion

It is evident that DSM recognition of complicated grief is only the beginning.  In light of the paucity of evidence-based treatment standards, as well as the potentially grave consequences of developing complicated grief, there is clearly a pressing need for further grief research.  Hopefully, the studies under way and those that take place in the future will facilitate a better understanding of the illness and its correlates, and will continue to optimize the treatment of complicated grief.

References

1. D.L. Hoyert, J. Xu, Deaths: preliminary data for 2011. Washington, DC: US Dept of Health and Human Services, Centers for Disease Control and Prevention (2012).
2. N.M. Simon, Treating complicated grief. JAMA. 310, 416-423 (2013).
3. G.A. Bonanno, C. B. Wortman, D.R. Lehman, R.G. Tweed, M. Haring et al., Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J. Pers. Soc. Psychol. 83, 1150-1164 (2002).
4. H.G. Prigerson, E. Frank, S.V. Kasl, C.F. Reynolds, B. Anderson, et al., Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. Am. J. Psychiatry. 152, 22-30 (1995).
5. N.M. Simon, M.M. Wall, A. Keshaviah, M.T. Dryman, N.J. LeBlanc, et al., Informing the symptom profile of complicated grief. Depress. Anxiety. 28, 118-126 (2011).
6. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.) (American Psychiatric Association, Washington, D.C., 2013).
7. A. Maercker, C.R. Brewin, R.A. Bryant, M. Cloitre, G.M. Reed et al., Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11. Lancet. 381, 1683-1685 (2013).
8. K. Shear, E. Frank, P.R. Houck, C.F. Reynolds, Treatment of complicated grief: a randomized controlled trial. JAMA. 293, 2601-2608 (2005).
9. N.M. Simon, E.H. Thompson, M.H. Pollack, M.K. Shear, Complicated grief: a case series using escitalopram. Am. J. Psychiatry. 164, 1760-1761 (2007).
10. M. Zygmont, H.G. Prigerson, P.R. Houck, M.D. Miller, M.K. Shear, et al., A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief. J. Clin. Psychiatry. 59, 241-245 (1998).
11. K.C. Berridge, T.E. Robinson, What is the role of dopamine in reward: hedonic impact, reward learning, or incentive salience? Brain. Res. Rev. 28, 309-369 (1998).
12. M.F. O’Connor, D.K. Wellisch, A.L. Stanton, N.I. Eisenberger, M.R. Irwin, et al.,. Craving love? Enduring grief activates brain’s reward center. Neuroimage. 42, 969-972 (2008).
13. J. Panksepp, B. Knutson, J. Burgdorf, The role of brain emotional systems in addictions: a neuro-evolutionary perspective and new ‘self-report’ animal model. Addiction. 97, 459-469 (2002).
14. D.J. Robinaugh, R.J. McNally, Remembering the past and envisioning the future in bereaved adults with and without complicated grief. Clin. Psych. Science. 1, 290-300 (2013).
15. R. McNally, personal communication.