Academic journal article American Journal of Psychotherapy

Abnormal Grief: Should We Consider a More Patient-Centered Approach?

Academic journal article American Journal of Psychotherapy

Abnormal Grief: Should We Consider a More Patient-Centered Approach?

Article excerpt

INTRODUCTION

The loss of a significant other is a highly stressful interpersonal event (Holmes & Rahe, 1967; Osterweis, 1984) accompanied by psychological pain. This pain, felt during any normal grieving process, can be marked by the desire to reunite with the deceased, a feeling of emptiness, and depressive symptoms, such as sadness, loss of interest and pleasure, fatigue, loss of appetite, sleep disturbance, and loss of concentration (Clayton, Desmarais, & Winokur, 1968). The evolution of grief is usually benign, with a progressive decrease in psychological pain and a recommitment to life within six months (Clayton et al., 1968; Clayton, Halikas, & Maurice, 1972; Holman, Perisho, Edwards, & Mlakar, 2010; Horwitz, 2007; Zisook & Shuchter, 1991a). Not to pathologize bereavement, which is a natural life event, the DSM-IV allowed the diagnosis of major depressive disorder (MDD) in bereavement only when the criteria for MDD persisted more than two months or presented characteristics that were more intense or more debilitating than those usually observed in bereavement. In this case, DSM-IV offered the term grief-related major depression (GRMD). The DSM-IV did not recognize complicated grief (CG) as a nosological entity; the DSM-5 proposed such a diagnosis, but in the end relegated it to the category of "Condition for Future Study" under the name "persistent complex bereavement disorder" (APA, 1994, 2014).

The DSM-5 considers bereavement akin to any other stressor likely to trigger MDD, and permits making the diagnosis once the criteria of MDD are met within two weeks after the loss. To help physicians not conflate grief and MDD, the DSM-5 explains (however insufficiently) the differences between GRMD and grief. It only takes into consideration the symptom profile differences, neglecting the personal factors that make a bereaved individual vulnerable to grief.

Various therapies have been offered to help, support, and treat patients experiencing abnormal grief (Jacobs, Nelson, & Zisook, 1987; Prigerson & Jacobs, 2001; K. Shear, Frank, Houck, & Reynolds, 2005; Wetherell, 2012; Zygmont et al., 1998). Antidepressant pharmacotherapy seems to help reduce CG symptoms (Zygmont et al., 1998). Grief-related major depression also responds to antidepressants, decreasing depressive symptoms without improving the grieving process (Jacobs et al., 1987; Wetherell, 2012). Whereas pharmacological treatments seem just to reduce symptom severity, various psychotherapeutic approaches have shown efficacy in treating CG and GRMD. Interpersonal psychotherapy (IPT) has been recognized as an efficient treatment for GRMD (Klerman, 1984; Weissman, 2000). Interpersonal psychotherapy helps the patient experience a normal grief process: feeling and expressing sadness and other emotions linked to bereavement, letting go of the deceased, and re-establishing social contacts (Klerman, 1984; Weissman, 2000). The more recently developed complicated grief treatment (CGT) uses cognitive behavioral as well as interpersonal methods. In one head-to-head study it yielded a better response to treatment than IPT in treating CG (Shear et al., 2005).

Research demonstrates that the personal history of a grieving person, the nature of the person's relationship with the deceased, and the nature of the loss affect the evolution of bereavement (Anderson, Arnold, Angus, & Bryce, 2008; Chiu et al., 2010; Dodd et al., 2008; Johannesson et al., 2009; Johnson, Zhang, Greer, & Prigerson, 2007; Keesee, Currier, & Neimeyer, 2008; Meert, Thurston, & Thomas, 2001; Nelson et al., 2010; Neria et al., 2007; Pfefferbaum et al., 2001; Robinson & Marwit, 2006; Shear & Shair, 2005; Shear, Jackson, Essock, Donahue, & Felton, 2006; Siegel, Hayes, Vanderwerker, Loseth, & Prigerson, 2008; Simon et al., 2005; Simon et al., 2007; Tomarken et al., 2008; van Doorn, Kasl, Beery, Jacobs, & Prigerson, 1998; Vanderwerker, Jacobs, Parkes, & Prigerson, 2006; Wiese et al. …

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