Dear Editor,

The grief reaction developing after the death of a beloved one contains elements of separation as well as of stress; in addition to intense sorrow and longing, it is characterized by mental occupation with the deceased. It is said that with time the intensity decreases, while the person accepts the certainty of the loss and its results and leaves its place to hopes and plans directed towards the future (1).

A presentation where signs of grief are particularly severe, of a longer duration than expected according to social values, and lead to a breakdown of functionality is known as “Complicated Grief (CG)”. The process of grief can be affected by the modality of death and its consequences, the quality of the relation with the lost person, and personal factors. Similar to acute grief, CG counts chronic, intense feelings of sadness and longing among its main sensations. These feelings can be accompanied by inability to accept death, ruminations about the deceased and death, behaviors avoiding objects reminiscent of the loss, and feelings of numbness and alienation (1,2).

As is known, in DSM-IV “Grief” is presented with an emphasis on a differential diagnosis against major depressive episode (3). As a result of researchers’ efforts to demonstrate the specific symptom pattern, risk factors, clinical characteristics, and course and outcomes of CG, showing its categorical difference from post-traumatic stress disorder, major depressive disorder, and adjustment disorder (4,5), in DSM-5 CG was placed in the section “Conditions for further study” as “Persistent complex bereavement disorder” (6).

With a prevalence of 3.7% in the general population, CG is a common disorder. Female sex, low income level, advanced age, death of a child or spouse, and death from cancer have been described as risk factors (7). CG is associated with psychiatric symptoms such as sleeping disorder, psychoactive substance abuse, and suicidal ideation, as well as diseases like anomalies of the immune system, hemodynamic alterations, increase of cardiovascular diseases, and cancer risk (8).

Studies have pointed out the importance for clinicians diagnosing CG to ask straightforward questions sensitively and empathetically (1). In addition, to facilitate assessment, the usefulness of the “Brief Grief Questionnaire” (9) and the “Inventory of Complicated Grief” (10) has been indicated.

In the treatment of CG, psychotherapy is used in the first place. Which psychotherapeutic approach is applicable to the bereaved, irrespective of the method, depends on differences and choices relative to the individual person and the relation with the deceased. In the literature, we find studies using Cognitive Behavior Therapy (CBT) (11,12) and Interpersonal Relation Therapy (IRT) (13). Based on attachment theory, Shear et al. (1,2,14) suggested the method of “Complicated grief treatment” (CGT), composed of IRT, CBT, and motivational interviewing techniques, as a short-term approach (a total of 16 sessions once per week) to address the depressive (sorrow, feelings of guilt, social withdrawal) and traumatic signs (intrusive thoughts and images, avoidance behavior) seen in CG. Core elements of this method include discussing loss, grief, adaptation and complications, self-observation and examination, bonding with others, formulating aspirational goals, and confronting evaded situations, recounting the story of death, reviewing positive and negative memories of the deceased, and entering into an imaginary conversation with the dead person in order to be able to accept death and confront pain (1). Some studies show that CGT is more effective than other therapeutic methods. In one study comparing CGT with IRT, the response rate was 51.0% compared to 28.0% (2), in another study 70.5% compared to 32.0% (14).

We want to alert our readers to a condition that has been shown to be frequently missed by clinicians (9). We also believe that the psychotherapy of grief, a universal and inevitable reality, is a challenging and consuming journey for the therapist, for which CGT as a structured roadmap will be beneficial.

REFERENCES

1.Shear MK. Clinical practice. Complicated grief. N Engl J Med 2015; 372:153-160. [CrossRef]

2.Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA 2005; 293:2601-2608. [CrossRef]

3.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Koroglu E (Translation editor), Ankara: Hekimler Yayin Birligi, 1998, 944. (Turkish)

4.Lichtenthal WG, Cruess DG, Prigerson HG. A case for establishing complicated grief as distinct mental disorder in DSM-V. Clin Psychol Rev 2004; 24:637-662. [CrossRef]

5.Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Reynolds C, Lebowitz B, Sung S, Ghesquiere A, Gorscak B, Clayton P, Ito M, Nakajima S, Konishi T, Melhem N, Meert K, Schiff M, O’Connor MF, First M, Sareen J, Bolton J, Skritskaya N, Mancini AD, Keshaviah A. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety 2011; 28:103-117. [CrossRef]

6.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Koroglu E (Translation editor), Ankara: Hekimler Yayin Birligi, 2014,1094-1098. (Turkish)

7.Kersting A, Brahler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord 2011; 131:339-343. [CrossRef]

8.Buckley T, Sunari D, Marshall A, Bartrop R, McKinley S, Tofler G. Physiological correlates of bereavement and the impact of bereavement interventions. Dialogues Clin Neurosci 2012; 14:129-139.

9.Ito M, Nakajima S, Fujisawa D, Miyashita M, Kim Y, Shear MK, Ghesquiere A, Wall MM. Brief measure for screening complicated grief: reliability and discriminant validity. PLoS One 2012; 7:e31209. [CrossRef]

10.Prigerson HG, Maciejewski PK, Reynolds CF 3rd, Bierhals AJ, Newsom JT, Fasiczka A, Frank E, Doman J, Miller M. Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res 1995; 59:65-79. [CrossRef]

11.Wagner B, Knaevelsrud C, Maercker A. Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Stud 2006; 30:429-453. [CrossRef]

12.Boelen PA, de Keijser J, van den Hout MA, van den Bout J. Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 2007; 75:277-284. [CrossRef]

13.Jacobs S, Prigerson H. Psychotherapy of traumatic grief: a review of evidence for psychotherapeutic treatments. Death Stud 2000; 24:479-495. [CrossRef]

14.Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A. Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry 2014; 71:1287-1295. [CrossRef]