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Healing Emotions After Loss (HEAL):
Western Psychiatric
Institute and Clinic of UPMC
3811 O’Hara St.
Pittsburgh, PA 15213
Phone: 1-877-624-4100
Charles F. Reynolds III, MD; Jacqueline Stack, MSN; Jill Houle, BS
Introduction
Grief can be excruciatingly painful. As John Bowlby wrote in Loss (1980)1: “The loss
of a loved person is one of the most intensely painful experiences any human can suffer.
Nothing but the return of the lost person can bring true comfort; should what weprovide fall short of that, it is felt almost as an insult.” In this article, we reviewcontemporary understanding of normal acute and integrated grief and its difference from complicated, or prolonged, grief. Included also are strategies for screening and diagnosis of complicated grief, together with a review of the evidence supporting psychotherapeutic and pharmacologic interventions for alleviating the anguish of complicated grief. Finally, we describe current NIMH-sponsored research to enhance the evidence base for treating complicated grief.
Normal Acute Grief
Bereavement is like an earthquake, shaking the foundations of a person’s life and triggering a full-blown separation response in adults. Acute grief is a mix of trauma and separation response. Acute grief can be and usually is present most of the day, everyday, for up to six months. The experience of acute grief embodies a sense ofprotest, a struggle to accept the death, and an intense yearning and longing to be with the person (possibly even a wish to die to be with the deceased loved one).
Bereaved people report frequent thoughts or images of the deceased, and a strongdesire to reminisce and spend time with memorabilia, often at the expense of interestand engagement in ongoing life.
Pangs of deep sadness or remorse, and episodes of crying or sobbing, are typically interspersed with periods of respite and even positive emotions. A steady stream of thoughts or images of the deceased may be vivid or even entail hallucinatory experiences of seeing or hearing the deceased person. Somatic distress expresses itselfwith uncontrollable sighing, digestive symptoms, loss of appetite, dry mouth, feelingsof hollowness, sleep disturbance, fatigue, exhaustion, restlessness, and difficulty www.UPMCPhysicianResources.com/Psychiatry
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initiating and maintaining organized activities. Feeling Complicated grief differs from normal grief disconnected from the world or other people, indifferent, because of complicating thoughts, feelings, and and not interested or irritable with others, all evidence behaviors that derail the progress of adjustment.
the shutdown of normal exploratory behaviors.
For example, the person with prolonged ormaladaptive grief continues to ruminate about how Integrated Grief
the person died, how the loss could have been Acute grief usually changes over time, evolving as prevented, and who is to blame. He or she may information about the death is processed. The bereaved engage in excessive avoidance of activities or situations person is able to accept the finality and consequences that arouse intense emotions related to the loss.
of the death, reconfiguring the relationship with the Ineffective emotion regulation with over- or under- deceased, and revising goals and plans for ongoing life.
engagement is common. The bereaved person feels As grief is integrated, the bereaved person no sense of progress, working through grief, or experiences a rebirth of interest and pleasure in beginning to adjust to the finality and consequences ongoing activities and other people, rediscovering a of the death. With the prolongation of acute grief capacity for joy and satisfaction. While a sense of comes a sense of hopelessness that it can ever recede.
connectedness to the deceased remains, feelings of Screening for Complicated Grief:
yearning, sorrow, and loneliness gradually become The Brief Grief Questionnaire
less intense, no longer occupying center stage.
When grief is integrated into the life of the The Brief Grief Questionnaire (see page 3) allows
bereaved, it becomes a permanent background state a short (about three minutes) screening for the that changes in quality and importance over time.
presence of complicated grief, with scores of 5 or With acceptance of the death come renewed interest higher constituting a screen-positive interview. The and engagement in ongoing life, with a mix of BGQ can be administered over the telephone. Screen emotions, usually positive, and with thoughts of the positivity indicates a need for a diagnostic workup, deceased accessible but not preoccupying.
which should be conducted face to face. It is often Feelings of emotional loneliness may nonetheless difficult for those with complicated grief to take the persist. Sadness and longing tend to be in the step of asking for help. Stigma, fear, and avoidance of background but still present. Thoughts and memories painful affects may inhibit help-seeking and require of the deceased person are accessible and bittersweet great courage, and encouragement, to overcome.
but no longer dominant. Occasional hallucinatory Based upon a literature review and the factor experiences of the deceased may occur. Surges of analysis noted on page 3, we have conducted a factor grief in response to calendar days or other periodic analysis of ICG responses in 288 participants in reminders of the loss may wash over the survivor.
previous NIH-sponsored studies.4 We observed asix-factor solution: (1) yearning, with preoccupation Progress Interrupted: Complicated Grief
with the deceased; (2) shock and disbelief; (3) anger In about 10 percent of people, the normal and bitterness; (4) estrangement from others; (5) healthy progression of grief can be derailed (“com- hallucinations of the deceased; and (6) behavior plicated”), with prolongation of intense symptoms change. We have used the six factors in our proposed diagnostic criteria for complicated grief (see page 4).
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Question
Not at all
Somewhat
trouble accepting the death of a loved one? 2. How much does your grief interfere with 3. How much are you having images or thoughts of your loved one when he or she died or other thoughts about the death that really bother you? 4. Are there things that you used to do when your loved one was alive that you don’t feel comfortable doing more, that you avoid? How much are you 5. How much are you feeling cut off or distant from other people since your loved one died, even people you used to be close to, like family or friends? Identifying Complicated Grief: The Inventory of Complicated Grief (ICG)
The Inventory of Complicated Grief (ICG) is a self-report instrument that allows for the dimensional assessment of the severity of CG symptoms.2;3 Scores of 30 or higher (over a range of 0 to 76) indicate ahigh likelihood that the syndrome is present. Each of the 19 items is rated 0 (not at all) to 4 (severe).
1. Preoccupation with the person who died 2. Memories of the person who died are upsetting 5. Drawn to places and things associated with the 14. Hearing the voice of the person who died 16. Feeling it is unfair to live when the www.UPMCPhysicianResources.com/Psychiatry
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Diagnosis of Complicated Grief
emotional or physiological reactivity to the memoriesof the person who died or to reminders of the loss; We have proposed the following criteria for (8) change in behavior due to excessive avoidance or diagnosing of the syndrome of Complicated Grief.4 the opposite, excessive proximity seeking.
The DSM-5 Taskforce of the American Psychiatric > The duration of symptoms and impairment is
Association is currently reviewing these and similar diagnostic criteria for “Maladaptive Bereavement > The symptoms cause clinically significant distress
Disorder,” as a potentially new adjustment disorder.5 or impairment in social, occupational, or other impor- Proposed Criteria for Complicated Grief
tant areas of functioning, where impairment is not better explained as a culturally appropriate response.
The person has been bereaved, i.e., experienced the death of a loved one, for at least six months.
> At least one of the following symptoms of
Special Case: Suicide Bereavement Versus
persistent intense acute grief has been present for a Other Bereavement
period longer than is expected by others in the Persons who have lost a loved one to suicide may person’s social or cultural environment: (1) persistent, be at higher risk for complicated grief than those intense longing for the person who died; (2) with other kinds of bereavement. Prominent themes frequent intense feelings of loneliness or that life is in suicide bereavement encompass difficulty with empty or meaningless without the person who died; meaning-making, guilt, shame, and blame (“What did (3) recurrent thoughts that it is unfair, meaningless, I do wrong?”) and feelings of rejection, abandon- or unbearable to have to live when a loved one has ment, and anger (“How could you do this to me?”).6 died, or a recurrent urge to die in order to find or Suicide survivors often find it helpful to talk with to join the deceased; (4) frequent, preoccupying other survivors and with family and friends who listen thoughts about the person who died, i.e., thoughts and don’t judge. Attending events such as the annual or images of the person intrude on usual activities walks sponsored by the American Foundation for Suicide Prevention, support groups, and participation > At least two of the following symptoms have
in communities of faith may help in meaning-making.
been present for at least a month: (1) frequent,troubling rumination about circumstances or conse- Psychotherapeutic Treatment of
quences of the death, e.g., concerns about how or Complicated Grief
why the person died, or about not being able tomanage without the loved one, or thoughts of having The guiding principles of Complicated Grief let the deceased person down; (2) recurrent feelings Therapy (CGT) are that grief and mourning are of disbelief or inability to accept the death; (3) natural, instinctive responses that find their own persistent feelings of being shocked, stunned, healing pathway.3 Complications derive from circum- dazed, or emotionally numb since the death; (4) stances or consequences of the death. Treatment of recurrent feelings of anger or bitterness since the complicated grief can be achieved by addressing the death; (5) persistent difficulty trusting or caring about complications and facilitating the natural mourning other people or feeling intensely envious of others process. CGT revitalizes natural healing. It is both who have not experienced a similar loss; (6) fre- loss-focused (grief monitoring, imaginal revisiting, quently experiencing pain or other symptoms that situational revisiting, memories and pictures, and the deceased person had, or hearing the voice of or imaginal conversation), and restoration-focused seeing the deceased person; (7) experiencing intense (personal goals and self-care, re-engagement with www.UPMCPhysicianResources.com/Psychiatry
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significant others, and situational revisiting). CGT is antidepressant medication (more than 50 percent), a targeted psychotherapy combining strategies from although the evidence supporting this practice is Interpersonal Therapy, Cognitive-Behavioral Therapy scant. However, it is particularly intriguing that (especially CBT-based exposure strategies), and CG therapy appears to work best when combined with antidepressants, recalling a similar finding in the The one published randomized clinical trial of CG treatment of bereavement depression9 that the highest treatment3 compared Complicated Grief Therapy response rates were observed with combination (CGT) and Interpersonal Therapy (IPT) for depres- sion. Participants in the trial were at least six months Given the absence of any controlled medication post-loss, bereaved of any close friend or relative, and studies for complicated grief, these observations with ICG scores of 30 or higher. Participants were provided the scientific and clinical rationale for a randomly assigned to CGT (n = 49) or IPT (n = 46) large clinical study of optimal care: “HEAL” and offered 16 sessions of weekly treatment, over a (Healing Emotions After Loss) sponsored by the period of up to 20 weeks. In intent-to-treat analyses, National Institute of Mental Health and the American Foundation for Suicide Prevention. HEAL Improvement scores of 1 or 2) were 51 percent in is a multisite collaboration (M. Katherine Shear, CGT versus 28 percent in IPT (chi-squared = 5.07, df MD, and Naihua Duan, PhD, Columbia University; = 1, p = .02), generating a number needed to treat of 4. Thus, CGT was found to be effective, with a Hospital/Harvard University; Charles F. Reynolds moderately large clinical effect size; however, half of III, MD, University of Pittsburgh/UPMC; and participants did not respond, raising the question as to Sidney Zisook, MD, University of California, San the place of pharmacotherapy for complicated grief.
Diego) with three aims: (1) to obtain the first Pharmacotherapy of Complicated Grief
randomized controlled data about the effectiveness Post hoc analyses of the 2005 CGT trial revealed of an antidepressant (citalopram) versus placebo for that CGT was more effective when administered with the treatment of complicated grief; (2) to determine naturalistically prescribed antidepressant pharma- whether citalopram improves the effectiveness of cotherapy.7 Antidepressant use also was associated CGT for complicated grief; and (3) to determine with a significantly lower attrition rate from CGT.
what the best treatment option is (antidepressant In an open pilot study, Simon et al.8 treated four patients in a 10-week treatment with escitalopram. All HEAL uses a 2 x 2 factorial design, with random four patients showed a robust response with a mean assignment of 440 participants (including at least reduction in ICG scores from 34.5 (SD = 6.0) to 8.3 40 suicide survivors with complicated grief) to one (SD = 3) (paired t = 8.97, df = 3, p = .001). Overall, of four treatment arms, each lasting 16 to 20 weeks: subjects decreased from markedly ill to borderline ill (1) citalopram + clinical management; (2) placebo + on average Clinical Global Impression-Improvement clinical management; (3) citalopram + complicated grief therapy; or (4) placebo + complicated grieftherapy. Pharmacotherapy allows flexible, gradual Ongoing Work to Expand Evidence-Based
dose increase from 10mg/day to 60 mg/day over 16 Interventions for Complicated Grief
weeks. The rationale for using a selective serotonin The observations from these studies indicated reuptake inhibitor (SSRI) is that SSRI pharmaco- that many people with Complicated Grief receive therapy has been shown to be effective for symptoms www.UPMCPhysicianResources.com/Psychiatry
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of anxiety and depression (which are highly comorbid shop in stores or visit restaurants which they used to in complicated grief) and may also relieve the vol- frequent; at the same time she felt drawn to the area ume and pressure of ruminative preoccupations with where her father spent a lot of time gardening.
EGD would spend a good deal of time daydreaming Inclusion criteria for HEAL allow a broad age about her father and reported frequent and intense range (18 to 95) for those having experienced the pangs of grief, of yearning to be with him, with death of a loved one at least six months ago, with thoughts of her own death and a wish never to wake complicated grief as their primary diagnosis, and an up. On the Inventory of Complicated Grief, her Inventory of Complicated Grief (ICG) score of 30 most strongly endorsed symptoms include longing or higher. Exclusion criteria include a history of for her father, disbelief over what happened, difficulty schizophrenia, bipolar, or substance abuse/dependence trusting other people since the death and feeling disorder; a Montreal Cognitive Assessment (MOCA) distant from others, and feeling that life is empty score of 21 or lower; active homicide or suicide and lonely much of the time. The patient’s clinical risk; prior failed treatment with citalopram or presentation met the proposed diagnostic criteria escitalopram; or acute/unstable medical illness.
for complicated grief. In addition, on SCID inter-view, she coded positive for current major depressive episode. Further medical workup, including sleep Prolonged, complicated grief entails suffering, studies, disclosed untreated sleep apnea of moderate distress, and disability. The experience of complicated severity. At baseline, the patient’s Clinical Global grief is one of protracted yearning for the deceased, Impression-Severity score was 6, indicating a severe difficulty accepting the death, estrangement from level of distress and impairment. Her Inventory of others, absence of joy in living, and finally, behavioral Complicated Grief Score was 48, indicative of fully changes driven by avoidance of painful affects and syndromal complicated grief. Her QIDS depression reminders. There are promising approaches to psy- score was 21, consistent with current, moderately chotherapeutic and pharmacologic interventions, with combined treatment showing the most promise.
Treatment in the HEAL protocol: EGD was
Research into complicated grief is still a young randomly assigned to receive a course of Complicated science, however, with important nosologic and Grief Therapy combined with double-blind pharma- intervention research still needed to fully under- cotherapy (either citalopram or placebo) for 16 stand pathogenosis and optimal treatment strategies.
weeks. At the same time, she began treatment with The attached case vignette illustrates the clinical CPAP (continuous positive airway pressure) for her presentation and treatment of complicated grief breathing-related sleep disorder (obstructive sleep being provided in the HEAL Study at Pittsburgh.
apnea). During the course of treatment, she had amotor vehicle accident after falling asleep while driv- Complicated Grief Case Vignette
ing; as a result, we delivered her protocol treatment Clinical presentation: EGD was 50 at the time
at her home (so that she would not have to drive) and of entry into HEAL, presenting with symptoms of over the telephone. She readily engaged in CGT depression, anxiety, and complicated grief related to despite finding the re-exposure components of treat- the death of her father from cancer approximately ment to be painful. She also was adherent to CPAP two years ago. EGD described difficulty accepting and to pharmacotherapy. Her dose of citalopram/ the death of her father, with whom she “always did placebo was gradually increased in 20 mg increments everything together.” She reported being unable to to 60 mg/day over the first eight weeks of treatment.
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EGD improved steadily; by the end of the 16-week Follow-up: EGD returned to her referring primary
protocol, her Inventory of Complicated Grief score care physician with a recommendation from us to had fallen from 48 to 8. On the Clinical Global continue maintenance citalopram 60 mg daily and Impression – Improvement scale, she was rated at 2, to have further adjustment of her CPAP to maximize “much improved”, with an overall severity rating of 3 therapeutic benefit. We contacted EGD six months (“mildly” ill), down from the baseline score of 6. Her after the end of her protocol participation; follow-up QIDS depression score had decreased from 21 to scores on the Inventory of Complicated Grief and 10, with residual symptoms mostly related to sleep Clinical Global Impression Severity scales indicated disturbance and daytime fatigue probably secondary continued maintenance of improvement achieved Acknowledgments
M. Katherine Shear, MD (Columbia), Naihua Duan, PhD (Columbia), Naomi Simon, MD (Massachusetts General Hospital), Sidney Zisook, MD and Barry D. Lebowitz, PhD (University of
California, San Diego), with whom Dr. Reynolds is collaborating in a randomized clinical trial of the
treatment of complicated grief (HEAL), sponsored by the National Institute of Mental Health
(NIMH) and the AFSP. This article summarizes key points of an AFSP-sponsored webinar broadcast
November 17, 2010 (http//:www.afsp.org).
Contact information for clinicians interested in making referrals to the study or for those wishing
to self-refer follows: (1) Boston (Nicole LeBlanc; 617-726-4585; njleblanc@partners.org; website:
www.bostongrief.com); (2) New York (Rachel Fox; 212-851-2107; sw-cgte@columbia.edu; (3) Pitts-
burgh (Jill Houle; 412-246-6006; houleja@ upmc.edu; website: www.healstudy.org; and (4) San Diego
(Ilanit Young; 858-552-7598; ityoung@vapop.ucsd.edu; website: http://psychiatry.ucsd.edu/heal.html.
References
2. H.G. Prigerson, P.K. Maciejewski, C.F. Reynolds, A.J. Bierhals, J.T. Newsom, A. Fasiczka, E. Frank, and J. Doman, “Inventory of complicated grief: A scale to measure maladaptive symptoms of loss,” Psychiatry Research 59 (1995) 65-79.
3. M. K. Shear, E. Frank, P.R. Houck, and C.F. Reynolds, “Treatment of complicated grief: A randomized controlled trial,” The Journal of the American Medical Association 293 (2005) 2601-8.
4. K. Shear, N. Simon, S. Zisook, R. Neimeyer, N. Duan, C.F. Reynolds, B. Lebowitz, S. Sung, A. Ghesquiere, B. Gorsack, P. Clayton, M. Ito, S.
Nakajima, T. Konishi, N. Melhem, K. Meert, M. Schiff, M.F. O’Connor, M. First, J. Sareen, J. Bolton, N. Skritskaya, A. Mancini, M. Wall, and A.
Keshaviah, “Complicated grief and related bereavement issues for DSM-5,” Depression and Anxiety (2010). Ref Type: In Press 5. S. Zisook, N.M. Simon, C.F. Reynolds III, R. Pies, B. Lebowitz, I.T. Young, J. Madowitz, and M.K. Shear, “Bereavement, complicated grief, and DSM, part 2: complicated grief,” Journal of Clinical Psychiatry 71 (2010) 1097-8.
6. J.R. Jordan, “Bereavement after Suicide,” Psychiatric Annals 38 (2008) 679-85.
7. N.M. Simon, M.K. Shear, A. Fagiolini, E. Frank, A. Zalta, E.H. Thompson, C.F. Reynolds, and R. Silowash, “Impact of concurrent naturalistic pharmacotherapy on psychotherapy of complicated grief,” Psychiatry Research 159 (2008) 31-6.
8. N.M. Simon, E.H. Thompson, M.H. Pollack, and M.K. Shear, “Complicated grief: a case series using escitalopram,” American Journal of 9. C.F. Reynolds, M.D. Miller, R.E. Pasternak, E.Frank, J.M. Perel, C. Cornes, P.R. Houck, S. Mazumdar, M.A. Dew, and D.J. Kupfer, “Treatment of bereavement-related major depressive episodes in later life: A controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy,” American Journal of Psychiatry 156 (1999) 202-8.
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