Abnormal Grief

Evidence summary

A subset of people experience extreme and disabling grief. [1,2] There has been considerable debate about how and when grief should be identified as abnormal. Intense debates over issues related to abnormal grief in the last few decades have resulted in a range of different and conflicting terminologies.

The most common terms used in clinical practice are 'complicated grief' and 'prolonged grief disorder'. [3] Both are used to describe extreme and abnormal grief, characterised by a yearning and longing for the deceased that impacts negatively on a person’s relationships, employment and life. [1,4] The release of DSM-5 in 2014 introduced another term, Persistent Complex Bereavement-Related Disorder (PCBRD), and highlighted a need for further research. [5-9]

The following circumstances can potentially increase the risk of abnormal grief: [10,11]

Death-Related:

• perception of the death as traumatic and/or sudden
• witnessing extreme distress
• death of a child is often associated with lasting and intense grief. [12]
  
  

Factors About the Bereaved Person:

• past history of depression can increase the risk of abnormal grief
• coexisting stressors such as financial difficulties can intensify grief
• pre-bereavement depression may be associated with escalation of depression in bereavement
• widowers and mothers tend to express more intense grief
• abnormal grief is more likely having experienced multiple losses
• childhood loss of parent can lead to abnormal grief later in life [13,14] (however, quality of remaining parental care and child’s personality contribute as predictors of outcome)
• insecure attachment style, childhood abuse and serious neglect, childhood separation anxiety can increase the risk of abnormal grief.

However, whilst it has been shown that treatment interventions can diminish the symptoms of abnormal grief, as yet high level evidence has not shown preventive interventions to be effective, [15] although promising approaches are developing. [3,16]

Tools which measure grief responses have reported good reliability and validity - however their feasibility for use in the Australian palliative care setting is yet to be established [17] and there is also no clear consensus about how screening and assessment of bereavement risk should be performed by palliative care services. [18] A recent Australian report examining services and needs of people experiencing complicated grief examined the available screening tools and while the Bereavement Risk Index (BRI) tool is acknowledged as being commonly used there is limited evidence to support its validation. [19] Specific assessment tools have been proposed for parental bereavement in the PICU. [20]

Cognitive behavioural therapy-based interventions are being studied in bereavement and appear to show evidence of benefit. [21] Provision of bereavement support by volunteers may be effective. [22] Pharmacological treatment of depression may possibly be beneficial for symptoms of depression in bereavement [23] but the interrelationship of grief and depression is controversial, and has been the subject of considerable debate recently. [5]

Transitional hospital-based services for bereaved parents have been shown to be of benefit following the loss of a child. [24]

Children’s grief camps have been shown to be a beneficial strategy for children who are bereaved. [25] Interventions for bereaved children and adolescents were more effective when those who were more symptomatic were targeted. Modalities that showed some evidence of benefit included music therapy, grief-focused school based brief psychotherapy and group based therapy. [26,27]