CHAPTER 2.................................................................................................................................................... 10
2.7 Abnormal or pathological grief reactions
Several bereavement scholars acknowledge that there is no simple definition of
―normal-grief‖ (Robinaugh, Marques, Bui & Simon, 2012; Zisook & Shear, 2009). The experience of bereavement in the absence of complicating factors, such as the death of a loved one through suicide, trauma, murder, or disaster (Higson-Smith, 2014;
McClatchey et al., 2014), often resolves itself without professional interventions (Shear et al., 2011). However, acute grief can gain foothold and could become a chronic debilitating condition called complicated grief (Shear et al., 2011).
Complicated grief (CG) or more recently Prolonged Grief Disorder (PGD) refers to the ―circumstances surrounding the death of a loved one and the debilitating grief symptoms that are potentially delaying or disrupting a process of healthy adjustment and recovery‖ (Higson-Smith, 2014). Such a grief derails or impede healing after loss and lead to a period of prolonged and intensified acute grief. Therefore, ―grief that is never expressed, grief that is expressed, but intense and goes on for too long, and grief that involves self-injury, may be considered abnormal‖ (Gire, 2014, p. 9). Same as acute grief, CG reactions cannot be confined to one taxonomy across all cultures, because of the very same factors that shape the expression of acute grief (Gire, 2014).
Within the bereavement literature CG (Horowitz et al., 1997; Wittouck, Van Autreve, De Jaegere, Portzky, & van Heeringen, 2011; Shear et al., 2011) is often used interchangeably with PGD (Prigerson et al., as cited in Burke et al., 2014) to describe this atypical grief. According to Higson-Smith (2014), and Hall (2014) one of the two should have been incorporated within the DSM-5 as representing this atypical grief.
However, despite several research studies proving that there is an identifiable syndrome that support the diagnosis of CG or PGD (Wakefield, 2013; Rando et al., 2012), the DSM-5 still failed to adopt either CG or PGD as a formal diagnosis, but instead put forth the diagnosis of Persistent Complex Bereavement Disorder (PCBD). In light of the competing arguments the DSM-5 task team recommend further research to support a formal diagnosis of grief disorder such as the proposed PGD (Hall, 2014).
PCBD symptoms include memories or intrusive fantasies related to the lost relationship, upsetting strong longings and desires that the deceased is still living, and strong feelings of loneliness or personal emptiness that interfere with social or recreational activities (Horowitz et al., 1997). Shear et al. (2011) maintain that complicated grief involves the presentation of certain grief-related symptoms beyond time considered adaptive. According to McClatchey et al., (2014) the concept spells out difficulties in the bereaved person‘s relationship to the deceased. The symptoms warranting the diagnosis of PCBD are as follows; the person yearns for the deceased on a daily basis or to a disabling degree of 6-months or more after the loss of a significant other. In addition, at least five of the following should be reported as experienced on a daily basis or to a disabling degree: confusion about role in life or diminished sense of self; difficulty accepting the loss; avoidance of reminders of the reality of the loss; inability to trust others since the loss; bitterness or anger relating to the loss; difficulty moving on with life; absence of emotion since the loss; feeling that life is empty or meaningless since the loss; and feeling stunned or shocked by the loss. Finally, the disturbance should cause clinically significant impairments in functioning, and should not be better accounted for by other disorders such as major depression, generalized anxiety, or PTSD (DSM-5, 2013; Higson-Smith, 2014).
Various factors have been associated with CG. Amongst others, these include previous loss, exposure to trauma, a previous psychiatric history, attachment style, and the relationship to the deceased (Lobb et al., 2010). Factors associated with the actual death include violent death, the quality of the caregiving or dying experience, close kinship relationship to the deceased, marital closeness and dependency, and lack of preparation for the death (Lobb et al., 2010; Kristjanson, Lobb, Aoun, &
Monterosso, 2006). On the other hand, perceived social support plays a key role after death, along with cognitive appraisals and higher distress levels (Lobb et al., 2010). Rando et al. (2012) state that complicated grief is complicated and cannot be confined to one syndrome or disorder. The implication of this statement is that multiple factors can predispose one to CG. To avoid confusion in diagnosis, Pregerson et al. (2008) did propose for the use of Prolonged Grief Disorder (PGD) to condense all forms of complicated grief. For instance, another form of complicated grief is the disenfranchised grief, which is grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned or socially supported (Doka, 1989; Hall, 2014). Disenfranchised grief may be triggered by experiencing a stigmatising death, such as death through suicide, autoerotic asphyxiation, or socially unrecognized relationships (Hall, 2014; Doka, 2002). These individuals are denied the benefits typically afforded to enfranchised grievers such as validation, social support, expressions of sympathy, and accommodations at work (Davidson, 2010, p, 7). This form of grief is common among the lesbian and gay community, especially due to overt forms of heterosexist prejudice toward sexual minorities in the society (McNutt & Yakushko, 2013).
Bereavement research has also turned attention to how bereavement can affect people‘s basic assumptive worldviews and potentially affecting their grief trajectory (Burke, Neimeyer, Young, Bonin & Davis, 2014). Burke and Neimeyer (2014) have pointed out that recent research suggests that traumatic loss can violate mourners‘
basic assumptive worldviews, and can precipitate a spiritual crisis following loss, also known as complicated spiritual grief (CSG). The authors define CSG as a sense of discord, conflict, and distance from God, and at times from members of the survivor‘s spiritual community.
When confronted with death, faith and belief are challenged. There is confusion and a sense of betrayal, and such a state paves way to the experiencing of either spiritual struggle, spiritual crisis, complicated grief, or complicated spiritual grief of the bereaved (Burke et al., 2014). In line with this view, Rando et al. (2012) recommend that clinicians and researchers should assess the ways that cultural and spiritual/philosophical factors complicate and facilitate the grieving process. For instance, themes such as resentment and doubt towards God, dissatisfaction with the spiritual support received, and substantial changes in the bereaved person‘s spiritual beliefs and behaviours can lead to complicated spiritual grief and call for different treatment protocols (Burke et al., 2014). The specific cause of death, such as natural anticipated death, natural sudden death, homicide, suicide and/or fatal accident deferentially also predicts levels of CG and CSG (Burke & Neimeyer, 2014).
Individuals who have suffered atrocities, such as homicide, might be more prone to feeling or expressing extreme anger towards God (Neimeyer & Burke, 2014). The CSG is a relatively new area in bereavement studies and it is gaining more attention.