Physician Focus: Complicated Grief
By Naomi M. Simon, M.D., M.Sc.
The death of a loved one – certainly one of the most stressful experiences that any person will ever endure – affects all of us at one time or another. Most people after a loss will undergo an intense period of acute grief, measured in days, weeks, or months. Usually grief evolves over time, and people eventually adapt to the loss and find a satisfying life without their loved one.
Some people, however, find it more difficult to move forward after a loss. These individuals may develop what is called complicated grief, a condition defined as severe and persistent grief that lasts for 12 months or more, though the time can vary from person to person. Essentially, the bereaved person becomes stuck in a persistent, intense, and impairing acute grief, as if the loss just occurred.
The symptoms of complicated grief include such characteristics as an intense longing for the deceased, a preoccupation with or trouble accepting the finality of the death, difficulty returning to normal or previously shared activities, and a lost sense of purpose. Complicated grief is a serious and potentially debilitating condition. It can impair daily functioning and quality of life and increase the risk of physical or mental illness. Its most worrisome symptom is hopelessness, or a feeling that life is not worth living, raising the chance of suicide.
While it appears more common among women than men, complicated grief can occur at any age and to any person. It affects about seven of every one hundred people who experience the loss of an important person in their life, though certain risk factors can increase that number.
Individuals suffering from depression, anxiety or mood disorders prior to the death, for example, may be more susceptible to the condition, and some research indicates that among those individuals the rate may be as high as one out of every four exposed to an important loss. The type of loss can also raise the risk: for example, the loss of a child may be more likely to trigger complicated grief.
The circumstances of a person’s death can also add to the severity of the grief. People may spend a lot of time focusing on the ‘what if’ – ‘if only I had called the doctor a day earlier’ or ‘if only I had encouraged my loved one harder not to smoke.’ This kind of thinking results in the person assuming blame for the death. Caregivers or those who lost a loved one to suicide may be especially susceptible to these feelings, believing that they had some responsibility for the death.
Complicated grief can be thought of in the way we think about a medical complication that hinders the healing process. With complicated grief, difficulties interfere with grief progressing along the usual pathway to a more background state.
It is important to recognize that there is no single way to grieve; everyone does so in their own way, and because we can never bring our loved one back, in some way people grieve forever. That is what differentiates loss and grief from other types of stressful experiences like a trauma: where the trauma is over, the loss is permanent.
Complicated grief should also be distinguished from depression, which is marked by a pervasive and persistent sadness that is not specific to the loss of a loved one as complicated grief is.
The good news is that complicated grief is a treatable condition. Primary care providers, psychiatric or psychological counselors, or clergy can be helpful, and grief support groups may be available in some communities. Cultural, religious, and family traditions can also provide comfort after a death.
Growing research evidence supports that for complicated grief, focused time-limited psychotherapy approaches are effective. These therapies help people process the meaning and finality of the loss and return to activities. While some sadness about the loss remains for most bereaved people, treating complicated grief can help people find a satisfying place in the world without their loved one and to recognize that grief is not the only way to honor and be connected to that person. Some treatments may also include medications.
Naomi M. Simon, M.D., M.Sc., a board-certified psychiatrist, is Director of the Complicated Grief Program and Director of the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital in Boston. Physician Focus is a public service of the Massachusetts Medical Society. Readers should use their own judgment when seeking medical care and consult with their physician for treatment. Send comments to PhysicianFocus@mms.org
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