What Is Complicated Grief

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Bereavement and grief are universal experiences. Many features of acute grief resemble symptoms of major depression. Consequently, there is a long history of linking grief and depression in psychiatric thinking. Bereavement triggers an episode of major depression in about 20% of individuals who lose a loved one. However, not all grief-related problems meet criteria for major depressive disorder. There is a rich clinical literature describing pathological grief reactions, under various designations, including abnormal grief, unresolved grief, and complicated grief (CG). However, the absence of a reliable method of identifying the condition and/or for evaluating its severity has obstructed the development and testing of treatments. This problem was addressed when Prigerson et al. developed a simple 19-item questionnaire that reliably identifies bereaved individuals who have persistent, intense grief and poor long-term outcomes (Prigerson et al., 1995a, 1995b). The condition so described, called either "complicated grief' or "traumatic grief," is a chronic debilitating condition characterized by symptoms of separation distress, traumatic distress, sadness and other dysphoric affects, and social withdrawal. Armed with a reliable and valid assessment instrument, we embarked on a project to find an efficacious treatment for this condition.

CG involves such as involves symptoms that are similar to those of posttraumatic stress disorder (PTSD), intrusive thoughts and images and avoidance behaviors. Additionally, the presence of separation distress differentiates CG from major depression and PTSD, as well as other existing DSM-IV

diagnoses. Unique to this grief-based syndrome, separation distress is characterized by intense yearning and longing, a tendency to engage in reveries about the deceased, and the desire to remain close to, or seek proximity to, items belonging to the deceased. Thus, given that CG includes symptoms not targeted by other approaches, and given disappointing results in most intervention studies, we concluded that we needed to develop a targeted approach.

A significant portion of the literature related to abnormal grief consists of clinical reports and conjectures. Although clinical observations can be very valuable, little emphasis is placed on the ability to systematically replicate findings, and little attention is paid to standardizing terminology. As a result, terms such as "bereavement," "grief," and "mourning" are used inconsistently and sometimes interchangeably. In this chapter we follow suggestions of Stroebe (1997) in defining "bereavement" as the state of having lost someone close. We use the term "grief" to designate the response to bereavement that generally consists of a distressing state of unease, with yearning and longing for the person who died, preoccupation with thoughts and images of the deceased, pangs of sadness, especially upon contact with reminders of the deceased, and transient social withdrawal. Consistent with existing data, we view natural grief as varying in intensity and characteristics, depending upon the circumstances of the death, the nature of the relationship to the deceased, and the life context of the bereaved person. We further consider grief to be an enduring reaction to loss that is initially preoccupying and later recedes in importance, as it becomes integrated as a "background" state. Notwithstanding variability in early manifestations, most bereaved individuals eventually experience a diminution in grief intensity and reengage in a satisfying life without the deceased. For an unfortunate minority, grief remains the primary focus and becomes a chronic condition, associated with high levels of distress and serious functional impairment. Accumulating evidence suggests that the state of the bereaved at 6 months after the loss predicts the long-term outcome.

Until the past few decades, ideas about grief were dominated by psychoanalytic thinking that included several basic assumptions. Effective grief was considered to require a period of emotionally intense "grief work" that progressed to resolution. If grief work was not done, a delayed grief reaction could be expected. If grief work was not effective, the bereaved individual would experience unresolved, incomplete, or pathological grief. There was a belief that one could not "move on" until the attachment to the deceased was relinquished, a process often referred to as "letting go." The origin of a pathological grief reaction was considered to reside in an ambivalent relationship to the deceased. Data were not available when these ideas were formulated. Now that empirical evidence is accumulating, many of the findings challenge these basic assumptions.

Evidence indicates that intense negative emotion in early bereavement is associated with a higher rather than a lower likelihood of persistent grief intensity (Bonanno, Keltner, Holen, & Horowitz, 1995), and the corollary, the experience of positive emotions early in bereavement predicts better outcome (Bonanno & Keltner, 1997). Studies of the trajectory of grief over as long as 5 years have failed to document the occurrence of delayed grief (Bonanno & Field, 2001). This finding suggests that a substantial number of mourners experience a relatively brief period of dysphoric emotions and that these individuals generally have a benign course. Thus there is little evidence for the need for "grief work" in order to come to terms with the death of a loved one.

other data challenge the idea that detachment from the deceased (i.e., "letting go") is the optimal outcome (Field, Nichols, Holen, & Horowitz, 1999; Reisman, 2001; Russac, Steighner, & Canto, 2001). Instead, the relationship to the loved one is often a permanent, ongoing one, in which the deceased person continues to influence the life and the thinking of the bereaved. The relationship being characterized by an ambivalent, avoidant attachment style is associated with a better, not a worse, grief outcome (Bonanno, Notarius, Gunzerath, Keltner, & Horowitz, 1998), whereas closer, more satisfying relationships often produce more grief. The syndrome of complicated grief, therefore, is more likely to happen when there has been a very positive relationship to the deceased, rather than a troubled or ambivalent relationship (Prigerson et al. 1997b; van Doorn, Kasl, Beery, Jacobs, & prigerson, 1998). These findings have important implications for understanding risk and for designing a treatment approach for CG.

The field has been slow to specify criteria for abnormal grief reactions, in spite of the fact that pathological grief is well described in the clinical literature (Bowlby, 1973; Lindemann, 1944; Parkes, 1998; Raphael & Martinek, 1997). Additionally, lack of consensus regarding the best name for a pathological grief reaction is a problem in both the clinical and research literature. In this chapter, we utilize the term "Complicated Grief' to refer to the syndrome described by Horowitz (Horowitz et al., 1997) and Prigerson (Prigerson et al. 1999). Analogous to the situation that existed for a trauma-related syndrome a few decades ago, clinical descriptions abound, but diagnostic criteria have not been agreed upon. This means that CG is not widely recognized and no proven efficacious treatment yet exists for this condition. As several authors have noted (Middleton & Raphael, 1987; Sireling, Cohen, & Marks, 1988), the absence of criteria is an important obstacle to the development and testing of efficacious treatment. There is a growing movement to redress this problem.

The ability to identify reliably those bereaved individuals with clinically significant grief-related symptoms was made possible by the creation of the Inventory of Complicated Grief (ICG; Prigerson et al., 1995b). A score exceeding 25 on the ICG 6 months after a loss predicts poor mental and physical outcomes at 18 months (Prigerson et al., 1997a). Diagnostic criteria for a clinically significant grief syndrome of complicated grief were proposed by Horowitz et al. (1997) and later by Prigerson et al. (1999). Prigerson et al. designated the syndrome "complicated grief' because of the similarity of symptoms to PTSD. Symptoms on the ICG, listed in Table 12.1, include an inability to accept the death, intense yearning and longing for the deceased, bitterness and anger about the death, intrusive images of the dying person, avoidance of reminders of the loss, and a general inability to function effectively.

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