Concept and Nosological status of

Pathological Grief Reaction

 Grief is the price of love. It is the ‘cost of
commitment’
Bereavement: Studies of Grief in Adult
Life (Parkes, 1986).
 “Grief is the physical, emotional, somatic,
cognitive and spiritual response to actual or
threatened loss of a person, thing or place
to which we are emotionally attached. We
grieve because we are biologically willed to
attach.” (John Bowlby)
 Grief is the affective or emotional
response to a significant loss or series
of losses.

 It is a normal and universal response to

loss or separation.
 Bereavement is the loss of a loved person
through death
 Grief is the involuntary emotional and
related behavioural reaction to that loss
 Expression of grief is often based on
culture
 Mourning is the voluntary social
expression of the loss.
(Committee on Health Consequences of the
Stress of Bereavement; Mitchell & House,
2000)
Features of grief
 Feelings/ Emotions/ Psychological :

 Physical Sx

 Cognitions

 Behaviours
Feelings/ Emotions/ Psychological :

 Numbness  Yearning
 Shock  Relief
 Anger/ Hostility  Acceptance
 Anxiety  Sadness
 Loneliness  Tearfulness
 Guilt  Depressive
 Fatigue feelings
 Sense of
depersonalization
Physical Sx:

 Tightness in the  Weakness in the

chest muscles
 Shortness of Breath  Lack of energy
 Lack of Energy  Dry mouth
 Panic Attack-like  Low appetite
symptoms
 Low sex drive
 Tightness in the
throat  Sleep disturbances
 Oversensitivity to  Hollowness in the
noise stomach
Cognitions:

 Disbelief
 Confusion
 Sense of Presence
 Lack of Concentration
 Preoccupation
Behaviors:

 Social withdrawal
 Avoiding reminder of deceased
 Searching & calling out
 Disheveled appearence
 Sighing
 Restless overactivity
 Crying
 Visiting places or carrying objects that remind
the survivor of the deceased
 Treasuring objects that belonged to the
deceased
Concepts of pathological grief:

 Lie in a continuum
(Normal/Continuing/Disenfranchised/pathologica
l Grief)
 Individual, sociocultural determinants are
important
 Differentiated on the basis of statistical
approaches, duration, intensity,
symptomatology, dysfunction and
equivalence with other disorders.
Concepts of pathological grief:

 Continuing grief: Lies in grief-

pathological grief continuum.
 Normal and not dysfunctional.
 Feeling like the loss of a body part, a
constant empty space, continuing
emotional dullness or shadow grief,
 Anniversary reactions
Concepts of pathological grief:

 Disenfranchasised Grief: Grief that

persons experience when they incur a loss
that can not be openly acknowledged or is
not socially supported.
 Relationship is not recognized: non-
traditional relationships, “non-essential”
relationships.
 Griever is not recognized: young, old,
persons with mental disabilities.
Concepts of pathological grief:

 Pathological/ traumatic/ complicated

interchangeably used
 Lack of consensus in definition
 Definitions
 Pathological grief : “Where grief for a
particular individual, in a particular culture,
appears to deviate from the expected
course in such a way that it is associated
with excessive or prolonged psychological
or physical morbidity, it may be labelled as
pathological.” (Middleton , 1993)
Concepts of pathological grief:

 Complicated grief : “The failure to

return to pre-loss levels of performance
or states of emotional well-being”. Two
issues unfold in this definition. :
unresolved grief & functional
impairment. ( Prigerson et al., 1995)
Classification:
 Chronic grief—the failure to resolve all
adverse bereavement-related symptoms
within 6 months
 Inhibited grief—the absence of expected
grief symptoms
 Delayed grief—the avoidance of painful
symptoms within the first 2 weeks of a loss
followed by a typical grief reaction
(Parkes, 1965)
Classification:
 Bowlby: Chronic mourning/ Prolonged absence of
grieving

 Bellisky and Jacobs (1986): Distorted grief / Delayed

grief

 Worden (1982):
 Chronic grief : solely based on duration
 Exaggerated grief: Based on intensity
 Delayed grief: Immediate reaction not
commensurate; experienced more fully later
 Masked grief: Behavioural manifestations present,
not recognized
Classification:
 Rando (1992): Complicated mourning
 Absent
 Delayed Problems in expression
 Inhibited

 Distorted (angry/ guilty) Syndrome with

 Conflicted skewed aspects
 Unanticipated

 Chronic Problems in ending

Principles and Methods for
distinction between normal and
pathological grief
 Principle: Statistical approaches.
 Methods: Cluster and factor analysis,
latent class model analyses and signal
detection procedures (Horowitz et al.,
1997; Middleton et al., 1996; Prigerson, et
al., 1996)
 Critique: Functional & Statistical
abnormality do not necessarily go hand in
hand
 Principle: Duration
 Methods: Too short/ too long (Middleton et
al., 1996, Bonnano et al., 2001)
 Critique: Better consensus about “too
long” than “too short”, Cultural Factors
Principle: Intensity
Methods: Scoring on Grief inventories
(Prigerson et al., 1995; Sanders et al.,
1985/1991)
Critique: Possibility of avoidance /delay/
inhibition as confounding factor
 Assessment problems
 Normal score does not preclude
complications/ need for interventions
 Principle: Differential symptomatology
 Methods: Combined with statistical
approach (Middleton et al., 1993 Prigerson
et al., 1995;)
 Critique: Inadequate empirical support
o Principle: Dysfunction
o Methods: Major/ prolonged dysfunction
(Wakefield 1992 Horowitz et al., 1997)
o Critique: Dysfunction may represent an
adaptive reaction to loss
 Principle: Equivalence with other
disorders
 Methods: Application of criteria for
depression, PTSD (Stroebe et al., 2000)
 Critique: Championed by supporters of
current nosology
Pathological Grief : Risk Factors
Factors related to deceased / death
circumstances:
 Death of a spouse or child
 Death of a parent (particularly in early
childhood or adolescence)
 Sudden, unexpected, and untimely deaths
(associated with horrific circumstances)
 Multiple deaths (particularly disasters)
 Deaths by suicide / murder
Factors in the survivor
 Low self-esteem /  Insecure
low trust in others attachment to
 Previous psychiatric parents in
disorder childhood (learned
 Previous suicidal fear and learned
threats or attempts
(personality
helplessness)
variables)  Poor social support
 Dependent or  Low SES
interdependent
attachment to  Concurrent life
deceased person events
 Female gender  Ambivalent
attachment to
deceased person
Factors influencing co-morbidity:
 Intense grief
 Early psychiatric symptoms as part of grief
 Early age
 Gender (specific effects)
 Past psychiatric history
 Neuroticism
 Unemployment
Factors influencing mortality:
 Premorbid health
 Psychiatric comorbidity
 Duration of bereavement response
 Male gender (widowers)
 Young age
 Failure to remarry (in men)
Proposed Criteria for Complicated
Grief Disorder
A. Event criterion / prolonged response
criterion
 Bereavement (loss of a spouse, other
relative, or intimate partner) at least 14
months ago (I2 months is avoided due to
anniversary reaction)
B. Signs and symptoms criteria
Intrusive symptoms
 Unbidden memories or intrusive fantasies
related to the lost relationship
 Strong spells or pangs of severe emotion
related to the lost relationship
 Distressingly strong yearnings or wishes
that the deceased were there
Signs of avoidance and failure to adapt
 Feelings of being far too much alone or
personally empty
 Excessively staying away from people,
places, or activities reminding of the
deceased
 Unusual levels of sleep disturbance
 Loss of interest in work, social, caretaking,
or recreational activities to a maladaptive
degree
Proposed Criteria for Traumatic
Grief :
Criterion A
 I. The person has experienced the death of a significant
loved one
 2. The response involves intrusive, distressing
preoccupation with the deceased person (eg, yearning,
longing, and searching)
 Criterion B
 In response to the death, the following symptom(s)
is/are marked and persistent
 I. Frequent efforts to avoid reminders of the deceased
(eg, thoughts, feelings, activities, people, places)
 2. Purposelessness or feelings of futility about the future
 3. Subjective sense of numbness, detachment, or
absence of emotional responsiveness
 4. Feeling stunned, dazed, or shocked
 5. Difficulty acknowledging the death (eg, disbelief)
 6. Feeling that life is empty and meaningless
 7. Difficulty imagining a fulfilling life without the
deceased
 8. Feeling that part of oneself has died
 9. Shattered world view (eg, lost sense of security, trust.
control)
 10. Assumes symptoms or harmful behaviors of, or
related to, the deceased person
 11. Excessive irritability, bitterness, or anger related to
the death
 Criterion C
 Duration at least 2 months
 Criterion D
 Significant sociooccupational dysfunction
COMPLICATIONS OF
PATHOLOGICAL GRIEF
Medical
 Increased Mortality: heart disease, cancer,
more significant for violent causes (93%)
and suicide (242% increase)
 Increased Morbidity: more doctor visits
(60%)
 Neuroendocrine effects
 Psychosomatic disorders

 Psychiatric
 Depression (with or without suicide risk)
 Anxiety or panic disorders
 PTSD
 Substance use disorders
Social complications

 Social withdrawal & isolation

 Role disruptions
 Difficulties with new relationships
 Unemployment, financial hardships
NOSOLOGICAL STATUS OF
PATHOLOGICAL GRIEF:
 CURRENT NOSOLOGICAL STATUS of
Bereavement
 Not given status of a disorder in either ICD-
10 or DSM-IV
 Coded in ICD-10 as Z63.4 and in DSM-IV
as V62.82.
 V code: Focus of clinical attention ;
exclusion criteria in MDD and adjustment
disorder
 Z63 Other problems related to primary
support group, including family
circumstances
 Not exclusion criteria in depressive
disorder, adjustment disorder, PTSD in
ICD
 In DSM-IV depression is diagnosed if
persists for more than two months or
includes marked functional impairment,
morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms, or
psychomotor retardation

(Stroebe et al, 2000)

HISTORY AND EVOLUTION OF
PATHOLOGICAL GRIEF
 References aplenty in history and mythology
 1944- Erich Lindeman’s Study
 1969- Elizabeth Kubler Ross and the stages of
grief
 1977- ICD-9 ( 309.0) Adjutment dis- Brief
depressive reaction subtype- Grief reaction
 1987- DSM-III R new category of
Uncomplicated Bereavement suggesting that
bereavement- related depression is a normal
reaction.
 1994- DSM-IV Bereavement no longer
excluded as potential stressor for PTSD
 Uncomplicated Bereavement excluded
from diagnostic features of MDD and
PTSD; placed under V code (may be a
focus of clinical attention)
 1997: Horrowitz and colleagues proposed
criteria for Complicated Grief
 1999: Expert consensus group (Prigerson
and colleagues) proposed criteria for
Traumatic Grief
VALIDITY OF PATHOLOGICAL GRIEF AS
A NOSOLOGICAL ENTITY
 1) Clinical description (including symptom
profiles, demographic characteristics, and
typical precipitants)
 2) Laboratory studies (endocrinal,
immunological)
 3) Delimitation from other disorders
(depression, adjustment disorder, anxiety and
PTSD)
 4) Follow-up studies
 5) Family studies.
Laboratory studies :
 Raised urinary cortisol excretion rates, non-
suppression on DST, blunted ACTH responses
to CRH stimulation, reduced immune activity
(natural killer cell, mitogen response) are non-
specific, inconsistent and probably mediated by
associated depression/ anxiety
 No sleep changes in absence of co-morbid
depression (McDermott et al , 1997)
 Exposure to chronic social stress associated
with long-term selective reductions in
serotonergic activity in the PFC. This may
underlie the association in human beings
between conditions such as pathological grief.
(Bonnano et al, 2001;Fontennot et al, 1995)
Delimitation from other disorders
 Pathological Grief and PTSD
 Similarities
 They reflect symptoms of both separation distress
and traumatic distress
 Model of CG based on stress response theory
proposed by Horrowitz , replicated .
 Phenomenologically both have reexperiencing
(intrusive thoughts about the deceased),
avoidance (avoidance of reminders about the
deceased), and numbness
 High “co-morbidity” of PTSD and chronic grief
following violent deaths
 SSRIs used in the treatment of both
(Prigerson, Maciejewski, et al., 1995; Langner et
al, 2004).
Differences:

Points PG PTSD
Distinct Universal Beyond scope of normal
precipitating experience
Events Helplessness Fear and horror
Intensity depends on Intensity depends on
relation with deceased impact of trauma

Phenomenology Separation anxiety Anxious about threat

More sadness, yearning Sadness less
and pining
Intrusions comforting Intrusions distressing
Avoidance uncommon Avoidance common
Hypervigilance: Low Hypervigilance: High
specificity specificity
Differences:

Points PG PTSD
Aetiology / Risk Factors Insecure attachment with Intensity of trauma; severity
deceased (Ch) Childhood of threat (Ch)
adversities (Widow) Adult traumas (Widow)

Clinical Normal sleep EEG (non- Abnormal sleep EEG

depressed )
correlates
63% PG not PTSD
Focus of Reconstructing life without Re-establishing safety in
a loved one the world
intervention
Treatment response Need to resolve attachment Need to emotionally
issues. habituate to fearful
Therapy addresses responses
meaning of loss/ integrated Exposure is more important
approach (not exposure
alone)
Pathological Grief and Depression

Similarities:
 Overlapping symptoms
 May be diagnosed in ICD / DSM (> 2
months)
 Depression model of grief : continued
depressive symptom
(Clayton)
 Bereavement-depression one of empirical
factors in grief
(Prigerson et al., 1995)
Differences:
Points PG Depression
Distinctive Yearning , hallucinations Dysphoria often independent
Phenomenology involving deceased, of deceased
preoccupation with Preoccupation with
deceased worthlessness
Intrusion, avoidance, Suicidal ideas / guilt disjointed
failure to adapt from deceased
Not all meet MDD criteria Marked psychomotor
retardation
Distinctive Close, security- None were predictors of
Risk Factors enhancing relationship depression
Insecure attachment
styles: Excessive
dependency, compulsive-
caregiving, and defensive
separation
Differences:
Points PG Depression

Clinical Normal sleep EEG (non- Abnormal sleep EEG

depressed )
correlates
50-79% not MDD

Course & Outcome More severe and stable Typically remits

Treatment response Core grief symptoms not Response better to

reduced with TCA traditional antidepressive
treatment
Lower effect size in ( both drugs /
psychotherapy trials psychotherapy)
Pathological Grief (PG) &
Adjustment Disorders (AD)
 Similarities:
○ Development of emotional or behavioral
symptoms in response to an identifiable
stressor(s) occurring within 1 month (ICD)
to 3 months (DSM) of the onset of the
stressor(s)
○ Captures the essence of pathological grief
○ In ICD-10 cases of PG which do not meet
diagnosis of MDD, PTSD or anxiety
disorders will qualify for AD.
Problems of diagnosing PG as AD:
 DSM-IV rules out AD in cases of
bereavement (Criterion D)
 there is empirical evidence demonstrating
CG is composed of specific clinical
symptoms rendering the broad description of
AD inexact (Prigerson, Frank, et al., 1995)
 AD is time-limited ; fails to record chronic
grief
 Non-specific & inadequate to problems of
either research or clinical work
Follow-up studies (for evidence
of diagnostic stability)
 There were large numbers of bereaved
people with risk factors, frequent failure to
adhere to the proposed programme, and a
high number of cases of lengthy and delayed
grief. (Gonzalez et al, 2001)
 After suicide of their psychotherapist, several
patiets continued to discuss the event with
friends, had persistent feelings of depression
and abandonment, and continued to deny the
death as a suicide even after 1 year
(Reynolds et al, 1997)
 Follow up studies after abortion: women (about 20%)
report a high importance of their abortion, painful feelings
in seeing pregnant women and babies and fears of
another abortion even after 13 months. a high level of
negative feelings during the pregnancy leading to the loss,
extensive preparations for the expected baby, an unsettled
vocational and family situation and intensive strains and
despair immediately thereafter. the embryo is represented
early in fantasies and dreams as a child. Mourning is still
present 24 months after the abortion. (Deckardt et al,
1994; Beutel et al, 1993)
 Suicide-bereaved (SB) children were more likely to
experience anxiety, anger, and shame & were more likely
to have preexisting behavioral problems and more
behavioral and anxiety symptoms in the first 2 years.
(Cerel et al, 1999)
Advantages of Separate
Nosological Entity
 Reduced mental health morbidity
 Pathological grief linked to increased
risk for many psychiatric complications,
including suicide
 Reduced physical health morbidity
 Improvement in assessment of CG
Advantages of Separate
Nosological Entity
 Stimulate research: Controlled studies
of CG leading to better scientific
understanding of its phenomenology
and underlying risk factors.
 Improvement in specific treatment of CG
 Prevent costs of not treating CG
 Health insurance coverage

Disadvantages of Separate
Nosological Entity
 Normal grief may be “pathologized”
 Individual and cultural variability blurr the boundaries
of pathological grief
 Increased costs to create interventions as more
individuals with the disorder are detected.
 Informal social support networks are weakened
because of the overinvolvement of the mental health
profession.
 Subsequent refinement of the criteria would cease
after the establishment of CG as a formal diagnosis
 (Stroebe et al., 2000; Frank et al., 1997; Prigerson,
Frank, et al., 1995).
RESEARCH LIMITATIONS:

 Non-representative study samples:

different recruitment methods
 Cultural and societal differences
 Few long term studies
 Most studies targeted mid to late life
participants
 Hypothetical assumptions/ theoretical
models not validated empirically
Bonnano et al, 2001; Stoebe et al,
2000
RESEARCH LIMITATIONS:
 Excessive theoretical heterogeneity
 Marked between-study variation
 Inadequate reporting of intervention
procedures
 Few published replication studies
 Methodological flaws of study design.

(Forte et al, 2004)

CONCLUSIONS
 Pathological grief is, by definition, a mental
disorder, since pathology describes
abnormal or diseased conditions in
organisms

 Problem areas include the definition of

pathological grief, the diversity in
conceptualizations, the problem of
distinguishing normal from pathological
grief, and the complexity of relationships
with other psychiatric disorders
CONCLUSIONS
 Enduring dysfunctional forms of grief are not
uncommon and lead to significant medical,
psychiatric and social complications including
increased mortality.

 Need for greater accuracy in describing grief as

pathology, further establishment of the validity
(empirically) of the syndromes that have been
associated with pathology, although recently
researchers have proposed criteria for
consideration in future diagnostic manuals.
CONCLUSIONS
 Pathologizing normal grief or discounting
the function and value of grief as a normal
emotional process must be avoided.

 Including pathological grief in diagnostic

systems may help patients gain easier
access to health care and financial aid
programs and would acknowledge
pathological grief as a problem that
warrants professional attention.
THANK YOU