Emily O'Day

This activity offers CE credits for:
1. Physicians (CME)
2. Other

To understand the changes to the criteria for persistent complex bereavement disorder in DSM-5 as well as risk factors and clinical management considerations of pathological reactions to the death of a loved one.

At the end of this CE activity, participants should be able to:

• Discuss DSM-5 criteria for persistent complex bereavement disorder

• Assess pathological entities of pathological reactions to the death of a loved one

• Describe clinical management of pathological reactions to the death of a loved one

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

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 ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Eric Bui, MD, PhD, reports that he is the recipient of a grant from the Osher Center for Integrative Medicine.

Mary C. Zeng, MD, has no disclosures to report.

Emily O’Day has no disclosures to report.

Sidney Zisook, MD, (peer/content reviewer) has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

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Bereavement is a universal marker of the human condition. In an attempt to conceptualize grief and understand the emotional process underlying loss, psychological reactions to bereavement have been described since antiquity. In 

, Homer (circa 1260 to 1240 BC) wrote about Achilles, who lost his friend Patroclus:

But Achilles went on grieving for his friend, whom he could not banish from his mind, and all-conquering sleep refused to visit him. He tossed to one side and the other, thinking always of his loss, of Patroclus’s manliness and spirit . . . of fights with the enemy and adventures on unfriendly seas. As memories crowded in on him, the warm tears poured down his cheeks.

Although grief-the emotional, cognitive, and behavioral response to bereavement-is a highly individualized process, it is experienced by virtually everyone at some point in his or her life. Consequently, because grief is both a ubiquitous and a unique psychological process, mental health professionals often find themselves in a dilemma, drawn between the need to alleviate an individual’s distress and impairment and the danger of overly “pathologizing” grief.

Although many bereaved individuals have ordinary grief reactions and continue to lead active and fulfilling lives, it is increasingly recognized that many persons experience manifestations of pathological grief that cause significant distress and impairment in their daily lives. Bereavement is linked to increased morbidity and mortality from medical illnesses, including cardiovascular disease, and prolonged grief reactions are associated with distress, impairment, and increased risk of suicide.

Accumulating empirical evidence has moved the field toward consideration of certain grief reactions as psychiatric conditions. Prolonged and complicated grief reactions were operationalized as persistent complex bereavement disorder (PCBD) in DSM-5, which enabled researchers and clinicians to further examine this construct using a common diagnostic language. The bereavement exclusion in the diagnostic criteria for MDD, which existed from DSM-III through DSM-IV-TR and systematically excluded bereaved individuals from a depression diagnosis unless specific additional criteria were met (eg, duration of 2 months or more), was also removed from DSM-5. These changes point to an increasing recognition of pathological grief reactions as well as a heightened need for accurate clinical diagnosis and treatment of such debilitating responses.

Clinical entities of pathological reactions

While prolonged or complicated grief, which was introduced as PCBD in DSM-5, is a bereavement-specific psychopathological reaction, the death of a loved one is a major life stressor and may precipitate or exacerbate one of several psychiatric conditions. These syndromes may or may not be specific to grief alone; they include acute stress disorder (ASD), PTSD, and MDD, in addition to PCBD. The Table provides a summary of bereavement-related conditions, their main symptoms, and the time frame in which these conditions can be diagnosed.

PCBD is a severe, impairing, bereavement-specific condition that was provisionally included in DSM-5 as a subtype of other specified trauma- and stressor-related disorders; this corresponds to a clinical presentation not meeting criteria for any other trauma- or stressor-related disorder. Explicit diagnostic criteria for PCBD are listed under “Conditions for Further Study” in DSM-5.

PCBD -also called prolonged grief disorder or complicated grief in earlier research (with slightly different diagnostic criteria) -has been reliably identified in clinical and epidemiologic studies, and it has been shown to be distinct from mood, anxiety, and other trauma-related disorders despite some symptom overlap. The core symptoms of PCBD differ from those of MDD, PTSD, or anxiety.

Mood and anxiety disorders frequently co-occur among clinical populations with PCBD. However, PCBD contributes to suicidality, morbidity, and reduced quality of life above and beyond the effects of comorbid anxiety or mood disorders.

A DSM-5 diagnosis of PCBD requires the presence of symptoms for 12 months or longer following the death of a family member or friend (6 months or longer in the case of children). At least one core symptom must be present on most days to a clinically significant degree, including:

• Persistent yearning or longing for the deceased

• Intense sorrow and emotional pain in response to the death

• Preoccupation with the circumstances of the death

In addition, one must demonstrate at least 6 associated symptoms, on most days to a clinically significant degree, across 2 clusters: reactive distress to the death and social/identity disruption. As with other DSM-5 disorders, the symptoms must interfere with the person’s normal routine or cause marked distress. An additional stipulation is that presenting symptoms are out of proportion to or inconsistent with cultural, religious, or age-appropriate norms.

Individuals who have lost a loved one often experience the most distressing grief symptoms in the early period after the loss, but DSM-5 requires that these symptoms persist for a substantial duration (12 months) to qualify for the bereavement-specific diagnosis of PCBD. In addition, PCBD is highly comorbid with MDD and PTSD, and it is likely that individuals with MDD or PTSD who have recently lost a loved one would also exhibit core symptoms of grief. Thus, while grief may not be considered a diagnosable (or treatable) condition in the early period after a death, a bereaved individual may still meet diagnostic criteria for another comorbid condition. It is therefore important, even in the first few months after a death, to screen for psychiatric symptoms that may have occurred as a result of the loss.

Risk factors for PCBD can be subdivided into pre-loss factors, loss-related factors, and post-loss factors. Pre-loss risk factors include prior personal or family history of psychiatric illness, female sex, and cognitive decline. Loss-related risk factors include the type of loss (eg, loss of a spouse or child, loss associated with stigma such as a death from suicide), the (subjectively perceived) suddenness of the loss, and the immediate psychological response to the loss, including peri-loss dissociative reactions. Finally, post-loss risk factors include negative coping strategies (eg, avoidance, alcohol use); lack of social support; and negative consequences of the loss, such as severe financial difficulties.

Note that the risk factors for PCBD are similar to those for other bereavement-related conditions, including MDD and PTSD, which suggests that all of these conditions share some common pathophysiological processes. In practice, this means that screening for risk factors may be helpful in identifying individuals at risk for any bereavement-related condition.

ASD and PTSD occur as a result of exposure to a traumatic event. According to DSM-5, traumatic events include direct exposure to a life-threatening event (ie, being a direct victim of the trauma or witnessing it), as well as learning that it occurred to someone close. The death of a loved one thus qualifies as a traumatic event and, unsurprisingly, ASD and PTSD can occur after bereavement.

Limited research has been conducted specifically on bereavement-related ASD or PTSD. PCBD is highly comorbid with PTSD: 48% of individuals who meet diagnostic criteria for PCBD also meet current diagnostic criteria for PTSD. A diagnosis of ASD requires, in addition to a trauma exposure, the presence of at least 9 out of 14 symptoms of dissociation, re-experiencing, hyperarousal, or avoidance, for at least 3 days to a maximum of 4 weeks. A PTSD diagnosis requires, in addition to a trauma exposure, the presence of 4 clusters of symptoms, including re-experiencing, avoidance, negative alterations in mood and cognitions, and hyperarousal, lasting at least 1 month. ASD and PTSD may result from the death of a loved one and should be screened for in individuals who have recently lost a loved one, even when the timing of symptoms in relation to that loss precludes the diagnosis of PCBD.

From DSM-III through DSM-IV-TR, MDD diagnostic criteria included a bereavement exclusion criterion. In DSM-IV-TR, this prevented the diagnosis of MDD in the first 2 months following a loss unless the bereaved individual’s depressive symptoms met certain severity requirements (ie, the episode had to be characterized by marked functional impairment, preoccupation with worthlessness, suicidality, psychosis, or psychomotor retardation).

However, recent studies have found no substantial differences between bereavement-related depressive syndromes and non–bereavement-related depressive syndromes in terms of clinical characteristics and treatment response, which suggests that the bereavement exclusion prevented some individuals from receiving the care they needed.

 The bereavement exclusion was dropped in DSM-5, and the death of a loved one no longer precludes the diagnosis of MDD as long as the usual criteria for depression are met. Because of the risk of “medicalizing” normal grief reactions, DSM-5 includes a note urging providers to exercise clinical judgment in distinguishing between bereavement and depression, and to take into account individual as well as cultural factors when making a diagnosis.

Several clinical factors may help distinguish between bereavement and MDD. While a depressed mood is frequently present in both bereavement and depression, that mood is more persistent and more associated with anhedonia in the case of depression. In normal grief, feelings of loss, low mood, and sadness are more likely to occur in waves with a relatively preserved ability to experience positive emotion. Also, in grief, symptomatic thoughts and behaviors tend to be specifically associated with the loved one (eg, self-critical ideation related to perceived failings toward the decreased with otherwise preserved self-esteem, thoughts of death in order to “join” the deceased), whereas in depression they are more generalized (eg, self-loathing, suicidal ideation related to feelings of worthlessness or hopelessness). If clinicians feel that normal bereavement rather than MDD (or another psychiatric diagnosis) is more fitting in the context of the loss of a loved one, they may apply the code “V62.82 Uncomplicated Bereavement.”

Clinical management of pathological reactions

The loss of a loved one is a potentially traumatic experience that can shake a person’s life. In addition to the psychotherapeutic and pharmacotherapeutic modalities of treatment detailed below, trauma-informed approaches and interventions should be kept in mind. Psychosocial management of bereavement parallels that for trauma exposure, and relies on providing safety, preventing negative coping strategies, and increasing social support.

 The preponderance of evidence supports the efficacy of psychotherapy in the treatment of PCBD and pathological grief. Complicated grief treatment (CGT) is a manualized, bereavement-focused individual therapy that has consistently shown efficacy in the treatment of pathological grief reactions.

 Response rates in severely ill, chronically grieving populations range from 51% to 82.5% across 3 randomized controlled trials.

 CGT includes elements of both loss-focused and restoration-focused components, with 4 phases of treatment that encompass patient history and grief experience, exposure-based procedures and situation revisiting, and maintained focus on personal goals (eg, improving self-regulation of emotional distress, identifying coping strategies, building social connections) throughout sessions. One limitation to this treatment is the lack of wide availability of CGT, although Dr. Shear’s group has recently invested efforts in disseminating it (see website of the Center for Complicated Grief, 

Cognitive behavioral therapy (CBT) has shown some efficacy compared with supportive therapy and wait-list controls.

 CBT with an exposure component was more efficacious than one without.

 Although these data are promising, it is noteworthy that CBT seems to yield lower response rates than CGT.

Other grief-focused psychotherapeutic approaches have been developed and tested in small trials, with preliminary support for their efficacy. For example, narrative therapy has been shown to significantly reduce complicated grief, depressive symptoms, and traumatic symptoms.

 There are few data on pharmacological treatment of PCBD. Findings from a well-powered, multisite, randomized, controlled trial suggest that SSRIs are not efficacious in treating PCBD.

 In this study of 359 bereaved adults, the response to citalopram did not differ significantly from the response to placebo at week 12 (46% vs 38%) or at week 20 (69% vs 55%). However, citalopram as an adjunct to CGT showed significant efficacy on depressive symptoms, despite a lack of efficacy on grief symptom severity.

In the case of bereaved individuals who meet the criteria for ASD or PTSD, specific treatment for these conditions can be proposed. There is a paucity of data on the treatment of bereavement-related ASD and PTSD. In the absence of such data, there is no support for any specific approach that would differ from general treatment guidelines for ASD or PTSD. First-line pharmacotherapy for PTSD relies on SSRIs, including FDA-approved sertraline, paroxetine, and fluoxetine; first-line psychotherapies include trauma-focused treatments such as prolonged exposure and cognitive processing therapy.

Limited data are available on the treatment of bereavement-related depression. The only randomized controlled trial available, conducted in older adults, suggests the efficacy of nortriptyline.

 Given the lack of replication of these findings, and the unfavorable adverse effect profile of TCAs, bereavement-related MDD should be treated according to general guidelines for MDD.

The severity of distress and disruption in the first days after a loss may raise the question of whether to prescribe a fast-acting medication such as a benzodiazepine for more rapid symptom relief. Despite high rates of benzodiazepine prescriptions that may last for up to a year after the loss, few studies have evaluated the efficacy of such an approach. To date, no empirical evidence supports the primary efficacy of benzodiazepines for the treatment of PCBD, bereavement-related depression, or bereavement-related PTSD. In fact, data suggest that benzodiazepines may be associated with poorer outcomes in PCBD and PTSD, probably because of their impairing effect on learning processes.

 Given worse outcomes and possible long-term prescription dependence, caution is warranted when prescribing benzodiazepines in the initial period after a loss -with ongoing surveillance for potential medication misuse.

Recent advances have increased the recognition of pathological grief reactions as potentially requiring treatment. Although PCBD has not quite made it into the official list of DSM-5 diagnoses despite a wealth of empirical data that support its validity, its inclusion as a “Condition Under Study” should accelerate research. While CGT has emerged as the psychotherapy of choice for this condition, no empirical data support the use of pharmacotherapy in the absence of comorbid depression or PTSD.

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Dr. Bui is Assistant Professor of Psychiatry, Harvard Medical School, and Associate Director for Research, Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston, MA; Dr. Zeng is Clinical Fellow in Psychiatry, Massachusetts General Hospital; Ms O’Day is Clinical Research Coordinator, Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital.

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 Silverman GK, Jacobs SC, Kasl SV, et al. Quality of life impairments associated with diagnostic criteria for traumatic grief. 

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Articles

An in-depth CME on DSM-5 criteria for persistent complex bereavement disorder and the clinical management of pathological reactions to the death of a loved one.

Author | Emily O'Day

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Bereavement, Grief, and Depression: Clinical Update and Implications