Complicated Grief


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Mary-Frances O'Connor and Washington Post staff writer Rob Stein were online Monday, Aug. 4 at 11 a.m. ET to discuss a new study that may validate a psychological syndrome known as "complicated grief," an unrelenting form of mourning that affects an estimated 10 to 20 percent of people who have lost someone close to them.

Read the Washington Post's Science Page story:
Rob Stein: Hello everyone. Thanks so much for joining us today to discuss this very interesting new research on grief. Joining me today is Mary-Frances O'Connor [formerly] from the University of California at Los Angeles, who led the new study. I see we already have some questions waiting for us. So let's get started.
Mary-Frances O'Connor: Thanks, Rob. It was a great article and I look forward to bringing this discussion to folks out there.
Pittsburgh, Pa.: Thank you for the article. I lost my 2-year-old nephew last year, and I have been unable to move on. Although the initial stage of shock and grief has faded, I find myself dwelling on his final days, his final time in the hospital, the last time I saw him before he got sick, etc. When I read your article,
I felt an "aha!" moment about the reward sensation. NOT thinking about my little guy is worse than thinking about him, as painful as it is to do so. I am planning on taking the article to my therapist and psychiatrist. I often find myself yearning to talk to someone about those final days, and in particular, about what it was like when he died. (I was in the room with his parents.) I refrain from doing so because it's painful for me to talk about, as much as I want to do it, and it's painful for the other person to hear. Your article makes me think it's something I need to do, however.

I was wondering if there was any other advice on dealing with this kind of complicated grief. I'm already on anti-anxiety medication for panic attacks and generalized anxiety disorder, all of which got worse after his death, so I doubt I can switch to a different kind of medication. Thanks in advance.

Mary-Frances O'Connor: I'm sorry to hear about your loss. I would say that research on treatment for complicated grief has clarified that for folks who have found it difficult to adapt, talking about the aspect that is most difficult for them is very therapeutic. Many of us don't talk about it with our circle of friends, often because we get the social signal that they don't want to talk about it. That is good reason to talk about it with a professional. It is also very useful to focus on goals for your life now, after the loss, that are rewarding. These may include finding something you can do that memorializes him (a contribution, volunteering, writing something, etc).
Munich, Germany: How do you diagnose and discriminate between complicated grief and depression? Also, if a person suffers from complicated grief, is he or she more likely to suffer from depression?

Mary-Frances O'Connor: There are several questions that people have about the difference (and similarity) between complicated grief and depression. They are different, with different symptoms. However, about 1/3 of people with complicated grief also have depression (just like you can have depression and anxiety). In the study that I did, I specifically interviewed the participants to determine if they had depression, and I excluded anyone who did. So the brain activation that I report on is just from complicated grief.

So, what is the difference? Scientific research has shown that in depression there is a sad mood about everything (and it is often felt to be all one's fault), but with complicated grief, the sadness centers just on the deceased (and so does any guilt). In depression, there is also often a loss of interest or pleasure in things, where as with complicated grief, there is still pleasure from thinking about the person who has died. Complicated grief also has intrusive images and thoughts about the deceased that come unexpectedly, which is not the case with depression.
Washington, D.C.: I've noticed that sometimes when a spouse dies, the other dies shortly thereafter, could that be part of the syndrome?

Mary-Frances O'Connor: This is an excellent question. One of the main reasons that I began studying grief is that those who experience a death are at higher risk of dying themselves. This is even true after you account for suicide and accidents. It is a very small, but very consistent finding. A review in the British medical journal "The Lancet" found that it is roughly a little less than twice as high a risk. There is evidence that those with complicated grief have an even higher risk of being diagnosed with a new illness after the death of a loved one. This is one of the hard facts that makes me think it isn't just "all in people's heads".
Bozeman, Mont.: I am unfamiliar with the concept of "complicated grief." Nevertheless, I am at times overwhelmed with sadness regarding the loss of my father, which was over four years ago. Generally when this occurs, I feel the same intensity of sadness and grief. I do not feel as though I've moved past this event, so to speak. I don't feel that I have experienced any "stages" of coping with this loss. I've come to accept that this is simply how grief feels. Thoughts?

Mary-Frances O'Connor: Thanks for your question. I think it is really important to make a clarifying statement about complicated grief. Most people who experience the death of someone close to them will feel grief, which is extremely upsetting and distressing. And it will last for a long time, with peaks and valleys. This is completely normal, and is not the same as complicated grief. Over time, as people adapt to their new reality, they may experience an easing of the painfulness and a reduction in frequency of crying. They are able to enjoy their friend and their activities again. There are two criteria for complicated grief that are importantly different. One is that it must intrude on your daily life every day for at least 6 months. The second is that it must interfere with doing your job, or raising your family, or feeling connected to your loved ones, or feeling that there is a meaningfulness to life. It must prevent some form of normal functioning for 6 months to be diagnosed.
Middletown, MD: My wife died March 17 of this year. We were married 30 years, have 2 children and 5 grandchildren. For the last year of her life she died a slow, painful, debilitating death of metastatic breast cancer. I held her hand as she died in the ICU. I live in the house we built 27 years ago. I am struggling with profound grief over this loss. Laying aside the insult of being compared to a drug addict, what would the authors suggest would be an appropriate time for me to "adapt"?
Joe Alexander Middletown, MD

Rob Stein: I was concerned when I wrote the piece that the reference to drug addiction might be seen as somehow denigrating the feelings of people experiencing this. Several researchers I spoke with, including Dr. O'Connor, expressed similar concern. The intention was not that at all, but just as a way to trying to convey why people may be experiencing this prolonged grief. Many people do experience grief for months after a loss. The key difference seems to be that the intensity doesn't recede with time.
Fairfax, Va.: Hi! Thank you for this article, it is very interesting. I have been going through a similar situation. I lost someone two years ago-not even my best friend, but someone I would talk to about absolutely everything, and I still find myself missing her a lot! It's a though I miss having her attention. I have started treatment for depression which has helped my mood overall, but I still can't stop missing my friend! What is the best way to "get over" a loss and get on with a more productive life? Thanks!

Rob Stein: Dr. Shear at Columbia University has reported more success in treating patients with complicated grief using a form of therapy that focuses more on the death of the loved one. She thinks this helps the emotional part of the brain make the connection with the thinking part of the brain and accept the loss.
Burke, Va.: I suddenly lost my husband last August and the pain is just as acute now as when it first happened. I have been attributing it to the fact that I simply loved him so much and really miss him. I have lost other family members and have not reacted this way -- i.e., I have been able to accept it and move on. So would it necessarily be something in the brain that causes this grief, or would it be more related to the degree of closeness and affection for the person you have lost?

Mary-Frances O'Connor: Thanks for sharing your question. There are a few things that predict who is more likely to develop complicated grief that have been determined through scientific research. This type of research is very meticulous, and it enrolled couples in the study before either of them had died. Then it followed them for 10 years, and studied the difference in those who lost a spouse vs. those who were still married. Risk factors have included a history of childhood separation anxiety, parental abuse or death, and lack of preparation for the death. They also include marital supportiveness and dependency. In fact, the researchers discovered that ambivalent relationships to the deceased did not predict complicated grief. Dependency can mean depending on the person for tasks (cooking, finances, etc.) and also emotional dependency (fear of going out alone, etc). But it can also include supportiveness--couples who work together as well as live together and have a lot of time together. Or couples who are able to help emotionally regulate each other.
Chevy Chase, Md.: So what should I do if I think I have complicated grief?

Rob Stein:You might want to try to find a therapist who has had experience specifically with complicated grief. At this point, the condition is not considered an official syndrome so that may be difficult. But more and more therapists are becoming familar with it.
Mary-Frances O'Connor: I would just like to add to the question about addiction. First, it is important to note that in the history of psychotherapy we haven't been terribly successful in treating prolonged or pronounced grief. In response to that, I think that we really need to consider that the ways we have thought about grief in the past may not be the only ways to consider it. Thinking about other human conditions that last and last DESPITE people wanting to move past them, may prove a valuable step in developing new therapies.

The interesting finding in the brain is that this area active in complicated grief is well-established in reward processing. What does that mean? When you see something that you want, that you really want, this part of the brain is helping you come to that conclusion. So, seeing a picture of someone you loved dearly, and really, really wanting them, is not so terribly surprising. What is interesting is that the group who had adapted, even though they were showing brain areas related to pain, were instead using brain areas for memory or imagery, rather than for "wanting" or reward.

The wording I used in the NeuroImage article was: “The addiction-relevant aspect of this neural response (Knutson et al., 2001) may help to explain why it is hard to resist engaging in pleasurable reveries about the deceased even though engaging in these reveries may prevent those with CG from adjusting the to the realities of the present. Many who suffer from addiction-like disorders experience them as afflictions; similarly we are not suggesting that reveries about the deceased are emotionally satisfying, but rather may serve as craving responses that may make adapting to the reality of the loss more difficult.”
Philadelphia, Pa.: Is it still normal to mourn the death of a pet from 28 years ago? The sadness does not affect my ability to act in life, but every now and then I recall and it makes me sad. In a way, I'd hate to think I would ever forget. Is this normal?

Mary-Frances O'Connor: I am sorry to hear about your pet--and it is a relationship that many experience grief after losing. I would say that you have hit the nail on the head--it doesn't affect your ability to act in life (which it would if it were complicated grief). But I would hate to think anyone would forget a person or being that they loved! It is very common to remember those who we have lost with sadness, even tears, especially around holidays and times of remembrance.
Rob Stein: Yes, having lost a dear pet myself recently I can attest to how sad that can be. I'm sure I'll be thinking about our dog for a very long time.
Just Grief: I lost my closest friend 15 years ago to a random act of violence. He was missing for two weeks before his body was found. I finally sought therapy after six months had passed. I really thought I was going crazy. Not having the Internet in the early 90s, I spent so much time at the library trying to read anything I could on grief. Another reason I went to therapy is that people around me thought I should be acting normal just three months after his death. To me, between 3-6 months is really the hardest part because you can no longer "fool" yourself that your loved one is just away for a while. It really hits home that you will NEVER see them again. To add insult to injury, it also seems that the 3-6 month timeline is when friends and family think you should be getting back to normal. Is grief made more complicated because of expectations of
other loved ones that you should be getting on with your life?

Rob Stein: I know that the woman I interviewed for my story expressed similar sentiment. She felt like people were expecting her to get over the loss and "move on" well before she could. She hoped that the more people understood about "complicated grief" the more understanding they would be.
Middletown, Md.: Apology accepted, but my question remains unanswered.
Joe Alexander
Middletown, Md.

Mary-Frances O'Connor: In answer to the time frame for adaptation during grief:
It is very clear that adaptation is a highly variable process. Scientific research shows that close to 50% of bereaved folks do not experience depressive symptoms and are highly resilient. In a recent study, the feelings of yearning were higher than the feelings of acceptance for the first six months, when everyone was averaged together. For 24 months, however, even though feelings of acceptance were higher than feelings of yearning, yearning was still present at low levels. The study only lasted for 24 months. However, research also shows that there are different individual paths in adapting. Some are depressed before the death ever happens, and of those, some get better following the death event, and some remained depressed. Some become depressed following the death, and then at 18 months they look like they did before, and others remain depressed. (Note: in this particular study, they were not studying complicated grief, but depression specifically).

I would say that in determining one's own path in adapting after a loss, what matters is your ability to function in your life. If it has been years and you still feel that you can't be playful, or creative, or joyful, or empathic, you may want to seek professional help. No one should have to live that way forever.
Kindred, N.D.: How does one get a person with complicated grief to go to a qualified therapist? Are there any therapists of that could deal with that kind of grief in the Fargo, N.D., area?

Rob Stein: In response to your query and several others, I Dr. Shear at Columbia and where someone could get a referral for treatment for complicated grief. Here's her response:

People can call Rachel Fox at our treatment program at 212-851-2107 Monday, Tuesday or Friday or 212-543-5177 (Wednesdays and Thursdays). We can provide referrals in the NYC area, Pittsburgh and Boston. Unfortunately, there are not so many people trained to treat people. This is something we are working on. Our group is very interested in helping in whatever way we can.
Herndon, Va.: My husband of almost 50 years died in 2002 from kidney cancer. He had never been sick or in a hospital. When he was diagnosed I mourned deeply. When he died, and he died peacefully an naturally, at home, I felt great relief that he was saved a difficult ending. Of course, I miss him but my mother taught me that death is part of life, after my own father died before I was five years old. Losing a child, however, is a totally different thing, I'm sure.

Mary-Frances O'Connor: I am sorry to hear about your husband's death, but also cheered to hear that you have found a way through. I must say that relief is an extremely common emotion after the death of a loved one, and one that our society really comes down hard on. People are told, in no uncertain terms, that they are not grieving enough, as though that is related to how much they loved the person! This is absolutely false. It is also quite ironic, given that those who grieve for a long time are told that they should be over it.
I should also mention that one of the things that predicts resilience following the death of a loved one is having a worldview that incorporates death. This could be a philosophy or a religion, or just the way that you were raised.
Atlanta, Ga.: Thanks for this great article. I am working with a population where grief, specifically complicated grief, is an issue. Is it possible that multiple childhood losses/early trauma have an impact on the development of this syndrome? And, if so, in what way(s)? 

Mary-Frances O'Connor: Thank you for all the great work that you do--working with bereaved folks can be so rewarding. It is the case that childhood loss/early trauma predicts a greater likelihood of developing complicated grief in adulthood. There is also an indication that insecure attachment patterns (which may be related to the former) also are predictive. I would also like to mention in response that children also have different patterns of adaptation to the loss of a loved one, and that they may also show prolonged grief. It is really helpful to get them hooked up with an organization that works with kids and grief, to be around other kids who know what they are experiencing (unlike most of their peers will).
Maryland: I don't mean this to come across as insensitive, but the medium being what it is . . . how much of this has to do with the "Me" culture that is so prevalant today? For example, EVERYONE loses a parent at some point. It is a normal part of the life cycle. I simply cannot understand the thought process whereby someone believes their loss to be so much greater than another's that it warrants this kind of attention.

Rob Stein: The kind of emotional pain people seem to experience from 'complicated grief' seems to go far beyond what most people experience when they lose someone close to them.
Nashville, Tenn.: Last August both of my parents were killed in a car accident. I was the child who had stayed behind to tend to them following my last divorce so I had 16 years of time in terms of living in our jointly owned duplex together. Over time they became my past my present and my future as we dreamed up great ways to get old together. While I miss my parents tremendously; I made the decision to seek some counseling to help me come to terms with their deaths. But both my sisters who rarely saw them are struggling terribly. I'm wondering if the fact that they are both alcoholics has some bearing on their struggle with their grieving processes. You indicated in the article that there was a certain part of the brain involved in the process. I hope this is not a silly question.

Mary-Frances O'Connor: I'm so sorry to hear of a double loss, and also glad that you have found a way to incorporate it into your present life. As for your question (and there are no silly questions, if it is genuine, then it can be answered), I would tell you that psychologists study different ways of coping. We often split these ways of coping into two parts--approach coping and avoidance coping. Approach coping is what you describe, tackling a situation with a plan, and working away at it consciously. Avoidance coping is dealing with a problem by ignoring it, whether that means putting it out of your head, or drinking to help put it out of your head, or avoiding reminders and conversations. But it is clear that we can only handle so much grief at a time. So people oscillate back and forth between denial and grief, especially early on in bereavement. The shock and numbness that people experience some clinicians believe is to protect a person from a reality that they cannot yet deal with psychologically. The denial is a normal part--in fact, it allows people to work and feed their kids, and make funeral arrangements, or whatever task is at hand. On the other hand, continual denial without swinging back to the grief side, prevents long-term adaptation.
Tina in Falls Church, Va.: When I read the article it reminded me of the neurological changes in response to trauma events that result in PTSD...could there be a neurological response similarity?

Rob Stein: Here's something Dr. Prigerson said about that in an email:

I want to say that this is a very welcome finding because it serves to distinguish what we now refer to as Prolonged Grief Disorder (PGD) from PTSD and focuses on attachment issues in bereavement that lie at the heart of this grief disorder. The findings are novel in that they indicate that ruminating, yearning and pining and longing for someone may be pleasurable and positively reinforces grieving/ruminating about the loss. This would explain why bereaved individuals with PGD get "stuck" and find it exceptionally difficult to move on with their lives without the deceased. It is more pleasurable and less painful to dwell on thoughts of the deceased than it is to accept the reality of the loss and find a new way without this cherished loved one.
Pittsburgh, Pa.: Thanks for taking my question about my nephew. I see that the number listed does referrals for Pittsburgh, where I live, so I may call, although I already have a therapist. I forgot to mention in my original post that about a month before the year anniversary for my nephew's death, I became completely overwhelmed and unable to work any more. Part of it was my anxiety and panic disorder rearing its ugly head, but I also felt like a lot of it was related to the upcoming anniversary. I couldn't stop thinking about my nephew for days on end. I was on short-term disability for four months, and have only recently gone to a new, low-paying job as a way to just get out of the house. Again, thanks for this discussion and the article. Rob Stein: Thank you for sharing your story.
Pittsburgh, Pa.: For Maryland: who said: "I simply cannot understand the thought process whereby someone believes their loss to be so much greater than another's that it warrants this kind of attention." It's not a conscious choice. I'm not comparing my grief over my nephew's death to anyone else's, although I do tend to think that losing a child is more of a shock than that of losing a parent or grandparent. (Not to denigrate those losses, I know those are huge.) So I'm not being all ME ME ME, I just can't seem to process this grief.

Rob Stein: Yes, that's seems like the experience for a lot of people who are having difficulty after the loss of a loved one.
Washington, D.C.: Thanks much for this insight. Having had a loss recently, I was grateful for the article. I was wondering if your research presented any differences between men and women and/or the type of loss (parent, spouse, child, friend, etc). Again, thanks.

Mary-Frances O'Connor: Thanks for your question. The research that I did was focused on women, because I was studying women who lost a mother or a sister to breast cancer, and identify with that female family member because of their own increased risk. It is important that future research extend this to both sexes and other cultures. However, other investigators research can speak to your question. It turns out that there are different patterns of response, when averaged across subgroups. But there are many caveats. For example, men are at higher risk of dying following the loss their wives than women are following the death of their husbands. And women are more likely to experience long-term difficulties with the loss of a child as compared to men. That doesn't mean that the opposite isn't true: this is averaged across people.
Washington, D.C.: You mention that it affects your ability to function normally for more than six months. Well, I go to work regularly, I travel to see friends, I go out to dinner and socialize. However, I have a very hard time feeling/being/acknowledging positive emotions such as: excitment, happy, fun, etc. I feel that it does a disservce to my loved one. Is this seperate from "complicated grief"?

Mary-Frances O'Connor: I am sorry to hear that you aren't able to experience this normal, happy part of life. I think you describe very well the difference between depression and complicated grief. Being able to "do" the things you do means that you are very likely not depressed. However, the positive things being too hard, that is likely related to your grief. In fact, many in the study reported it exactly the way you describe. As for being disloyal, that is a common comment, and one I think that would be worth discussing with others (and maybe even professionals, whether that is a priest, a therapist or a support group). I often ask people whether their deceased loved one would want for them to live that way--and therefore, which is more of a disservice?
Mary-Frances O'Connor: Thanks, Rob, and to all of you who shared your experiences and questions. Take care.
Rob Stein: Thanks everyone for your great questions, and for your willingness to share your personal stories. It's clear from this discussion that there's a lot of people who are struggling with their grief and could use some help. Hopefully research like this will help get us there. I'd like to thank Dr. O'Connor for taking some time today to join us.

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