It is clear from the above discussion that the manifestations of grief are manifold. Yet, if all of these variations can be seen as normal reactions to the loss of an intimate, then how is the pathological differentiated from the normal? First, this is done on the basis of the severity of the symptoms (their intensity and/or frequency). Second, duration is a factor. In normal grief there is a gradual reduction in symptoms, acceptance of the death, and reinvestment in new activities and relationships; when this process is prolonged, there is reason for concern. Third, to be considered a disorder, the symptoms must cause a clinically significant disruption in the bereaved individual's social, occupational, or other important domains of functioning. Finally, some symptoms are more rare and are found predominantly in pathologic forms of grief. The most common bereavement-related psychiatric disorders are considered below.
Major depression. When persistent and intense, the depressive symptoms present in normal grief can lead to a diagnosis of major depressive disorder. In addition to these symptoms, Jacobs and Paula Clayton have found that those suffering from major depressive disorder following a loss may experience hopelessness, worthlessness, low self-esteem, guilt, a slowing of movement, and thoughts of suicide. Since these symptoms are uncommon in bereaved people who are not clinically depressed, they seem to be key markers of depression following a significant loss. Studies have found that between 12 and 32 percent of widowed people are depressed in the first six months following the loss. A study by Carolyn Turvey and others found the rate of syndromal depression in the recently widowed to be nine times higher than that in married individuals. Furthermore, two years after the loss, the bereaved subjects were still more likely to be depressed than those who were married. Other studies have found that between 5 and 10 percent of widowed people are continuously or "chronically" depressed for at least two years following the loss.
Post-traumatic stress disorder, anxiety disorders. A death that is perceived as particularly violent or unexpected may result in clinically significant levels of what has been described as "traumatic distress." Those experiencing these symptoms (e.g., reexperiencing the traumatic event with intrusive thoughts; avoidance and numbness in reaction to the trauma; hypervigilance or hyperarousal at cues related to the exposure) at high intensities and frequencies generally meet diagnostic criteria for posttraumatic stress disorder (PTSD) and/or other anxiety disorders. More research is needed to determine whether the likelihood of developing PTSD following loss depends on the nature of the death (e.g., whether it occurred in a violent or unexpected manner) because available evidence on this is mixed. PTSD is less common than depression in the context of bereavement.
In addition to PTSD, other anxiety disorders are related to some symptoms of traumatic distress. Studies have found that up to one in four recently bereaved people may meet criteria for some anxiety disorder within two months of the loss. However, Paul Surtees found that these anxiety disorders rarely appear without concurrent depression, and resolve more quickly over time.
Traumatic grief. Until recently, there had been no diagnostic classification for people suffering from bereavement-specific symptoms, such as those associated with extreme separation anxiety (e.g., yearning and searching for the lost person). Motivated by the apparent need for such a diagnosis, a group of experts in the areas of bereavement and trauma convened in 1997 to examine this issue. The workshop reviewed a series of studies of independent samples of bereaved people and found that elements of separation distress and traumatic distress form a single cluster, and that this cluster is distinct from depressive and anxiety symptom clusters. This means that people who experience severe symptoms of separation distress also tend to suffer from certain symptoms of traumatic distress. In addition, this single cluster of traumatic and separation distress symptoms was found to persist for months or years in a significant minority of bereaved subjects.
Furthermore, these symptoms, unlike depressive symptoms, did not respond to interpersonal psychotherapy, either alone or in combination with the tricyclic antidepressant nortriptyline. Finally, these symptoms predicted substantial morbidity (e.g., suicidal thoughts, hypertension, increased smoking) over and above the level predicted by depressive symptoms. The evidence reviewed indicated that aspects of separation distress and traumatic distress seem to constitute a single, distinct disorder that merits its own set of diagnostic criteria. The panel participants discussed the symptoms that should be included in a diagnosis and, ultimately, proposed a consensus set of criteria for the disorder, which they called traumatic grief (see Table 1).
A diagnosis of traumatic grief requires meeting both criterion A (separation distress) and criterion B (bereavement-specific traumatization occurring as a result of the loss). Preliminary studies indicate that people experiencing a majority of criterion B symptoms to a marked and persistent degree can be said to meet this criterion. A 1999 study in the British Journal of Psychiatry found that four out of the eight criterion B symptoms tested were required for a highly specific (excluding those without the disorder) and sensitive (including those with the disorder) diagnosis of traumatic grief. Criterion C, specifying a minimum duration of two months, and criterion D, requiring clinically significant impairment, may serve to further differentiate the disorder from a normal, or uncomplicated, grief response. However, additional research is necessary to determine the optimal mix of symptoms, duration, and impairment required for a diagnosis. Studies have found that between 10 and 20 percent of widowed people who have lost their spouse within six months meet criteria for traumatic grief.
Comorbidity. Psychiatric comorbidity (i.e., the presence of multiple disorders) is common following bereavement. In a study by Gabriel Silverman and colleagues (2000), traumatic grief, PTSD, and major depressive episode were found to overlap with each other to similar degrees. Of those with traumatic grief, 47 percent also received a diagnosis of major depressive episode, 33 percent met criteria for PTSD, and 40 percent had traumatic grief alone (these percentages sum to over 100 because 20 percent of those with traumatic grief received all three diagnoses).
Traumatic grief has also been found to predict lower energy levels; lower levels of social functioning; higher rates of hospitalization and physical health events, such as heart attack, cancer, and stroke; lower self-esteem; changes in sleeping and eating habits; and heightened levels of thoughts of suicide.
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