Pathological Complicated Grief, or CG, is a complex condition that uses a variety of diagnosis and treatment approaches to manage. In this research paper from Ultius, we'll take a deeper look at the history, causes, and signs of the condition. 

Defining "Pathological Complicated Grief"

According to Shear (2012), CG may be defined as a chronic mental health and emotional pathology impairing one’s ability to navigate and proceed through the normal grieving process. From a medical standpoint, the term “complicated” refers to a

“superimposed process that alters grief and modifies its course for the worse” (p. 119).

In this sense, grief or bereavement may be conceptualized as a wound; metaphorical to a physical wound, and the complication, in this sense would metaphorically parallel a medical complication impairing the healing of a physical wound, such as an infection. In the same way, complicated grief becomes complicated by a pathological alteration to the normal, natural adaptive grief-healing process. CG is medically diagnosed in approximately 7 percent of people, nation-wide.

In cases of CG, the grieving individual is caught in a perpetual cycle of rumination pertaining to worry the loss one is grieving. In CG, the five normal stages of grieving (denial, anger, bargaining, depression and acceptance (Pottinger, 1999)) are prolonged. Being unable to cope with and accept the finality of loss, one suffering from CG copes in a maladaptive way through excessive avoidance, plagued by emotional intensity. Grief progressed to such a condition requires clinical attention, management and treatment in order to heal from (Shear, 2012).

The primary discrepancy between the condition of normal grieving and complicated grieving involves the prolonging of grief experience associated symptoms. In cases in which individuals are experiencing CG, grieving symptoms and experiences are prolonged and to either a mild or severe extent, debilitating. In cases of CG, a numbness and detachment may be present. This often prevents the affected from participating normally in activities of daily living.

In some cases, the grieving person may be plagued by suicidal thoughts and an inability to accept loss. Guilt is also common, as the bereaved individual may question whether or not the loss was their fault. Additionally, in cases of CG, the bereaved individual’s self-esteem and sense of self-worth is often affected and deteriorates as a result.

The psycho-emotional consequences of CG impairing one’s ability to perform normal daily activities and functions can subsequently result in adverse physical health outcomes, increasing the griever’s risk of chronic conditions such as immune dysfunction, cardiac disease, cancer, hypertension, suicide and overall diminished quality of life (Worden, 2009). Further health complications of CG that can result include chronic depression, suicidal behaviors and intentions, PTSD, anxiety, sleep disruptions and substance abuse habits as maladaptive coping mechanisms (Mayo Clinic, 2018).

As Davies (2016) notes, CG is a chronic condition that can be life threatening and requires clinical management. In light of this condition, the remainder of this discussion will review possible causes of CG, sings, stages, indicators of suicidal ideation and management recommendations.

Causes of Pathological Complicated Grief

In order to understand causes of CG aside from the primary grief-instigating incident of loss or bereavement, it is necessary to understand what instances, events and risk factors may occur and be present that cause one’s grieving process to divert from the what is considered normal to a prolonged and intensified condition of chronic grieving.

Certain risk factors that place a griever at an increased likelihood of developing CG include experiencing the death of someone intimately close, which is in many cases harder to cope with than the death of a mere friend or acquaintance. This could include the death of a spouse or child. Additionally, lacking family and social support through the grieving process places on at an increased risk of developing CG.

How a bereaved person is notified of death and loss can also impact how that person progresses through the grieving process in maladaptive or adaptive ways, by impacting the level of perceived guilt and/or anger she or he experiences. If a loss was especially violent or traumatic, the grieving process can be even more difficult to navigate. Similarly, partners involved in a long-term and highly codependent marriage can experience extreme psycho-emotional difficulty upon losing a spouse, often making them more susceptible to experience CG (Mayo Clinic, 2018).

The Mayo Clinic (2018) also notes that studies report females who have experienced multiple losses to be more susceptible to developing CG than other gender and age demographics. Similarly, females experiencing loss in which the death was unexpected and sudden see an increased risk of CG.

Literature confirms that it remains unknown exactly what causes CG in response to the aforementioned circumstances and risk factors (Mayo Clinic, 2018; Pottinger, 1999; Worden, 2009), yet some scholar and psychotherapist researchers speculate that causes may be predicted by a combination of environmental factors, genetic traits, physiological makeup and personality type.

The risk of developing CG in response to loss seems to increase with age, suggesting that as the griever ages, adaptability to stress diminishes. One speculated cause of CG is social isolation, meaning that if a bereaved person has no social support system from which to derive emotional assurance and comfort from, the bereaved may place excessive mental and emotional energy upon the lost person, for lack of the ability to concentrate on developing new relationships and activity habits otherwise incentivized by new social interactions and support. Additionally, those suffering from a history of psychological disorders such as PTSD, depression and separation anxiety may develop CG in response to grief, suggesting that such preexisting disorders in bereaved persons may cause CG in cases of loss (Mayo Clinic, 2018).

Likewise, experiences of neglect during childhood that were never healed or resolved may have a similar causal impact should the victim of neglect undergo a traumatic loss later in life. Clearly, causes are in many cases predicted by risk factors present and are also likely interwoven and complicated, just as complicated grief itself.

Signs and symptoms of Pathological Complicated Grief

The signs of a complicated griever compared to a normal griever may closely resemble one another during the first few months following bereavement. The two types of grieving between to differentiate as a complicated griever’s symptoms persist beyond a few months following grief, when a normal griever’s symptoms would generally begin to fade.

Rather than diminishing with time, a complicated griever’s symptoms persist if not worsen. The complicated griever experiences and chronic and intensified state of mourning that impedes the healing process.

Signs of emerging complicated grief are not limited to, but most commonly include:

• Extreme sorrow
• Emotional pain and rumination over the loss of a loved one
• An extreme psycho-emotional focus on reminders of the lost loved one, such as refraining from moving or removing a lost one’s clothing or personal items from the home
• An inability to focus on anything but the death of a loved one
• And an intense and persistent longing for the lost loved one.

Additionally, signs of CG include:

• Difficulty accepting loss despite continued lapsed time
• Ongoing detachment and numbness
• Emotional bitterness towards loss persisting over six months following a loss
• Loss of sense of meaning in life, an inability to trust others
• Lost ability to find joy, pleasure and positivity in life and life’s experiences
• Difficulty completing normal daily routines

Finally, social isolation and withdrawal that persists longer than six months, as well as persistent feelings of guilt, blame and sadness can also indicate the development of CG.

These types of feelings are a self-blaming perception of death. These feelings of self-blame can compromise one’s sense of self-worth, in many cases causing the bereaved person to believe that he or she did something wrong to cause the death and/or could have prevented the death. This can result in feeling a lack of meaning in life without the lost loved one and a self-perception that the bereaved person should have died along with the lost loved one. Such self-perceptions can lead to suicidal ideation, in severe cases, which will be discussed in a following section.

Stages of Pathological Complicated Grief

To clearly differentiate CG from normal grieving it is important to understand the stages of the grieving process, there general order (though this varies according to the individual and circumstances) and general time frame.

According to Pottinger (1999), the mental and emotional process of moving through grief and the healing process that follows is characterized by five primary stages, which include:

1. Denial
2. Anger
3. Bargaining
4. Sadness
5. Acceptance.

During the denial phase, a bereaved individual is likely to exhibit various defense mechanisms including a mental unwillingness to believe the loss has happened. A bereaved individual may attempt to ignore the fact of loss using isolation or distraction. During the anger phase, someone experiencing loss and grief may project emotional anger onto external circumstances and individuals, by exhibiting an intensified susceptibility to irritation and frustration. This may include experiences in which a bereaved person blames another for the loss and thus projects anger of the loss onto another. Even inanimate objects and strangers may be recipients of one’s anger.

The third stage, the bargaining stage, pertains to points in the grieving process in which the person experiencing loss begins to experience mental “what if” thoughts. In other words, the bereaved begins to wonder how the loss could have or may have been prevented, replaying the scenario in the mind and attempting to subconsciously, change the outcome. Guilt commonly accompanies this stage.

The fourth stage of the grieving process involves a high level of sadness and regret. During the sadness stage, a bereaved person may exhibit signs and symptoms of depression. Guilt is also commonly associated with this stage. The fourth stage is also often the stage in which the risk of suicidal ideation increases, as it is not uncommon for a bereaved person to experience thoughts regarding their own death during this time, and/or feel guilt for the impact their own grieving process and energy has had on the lives of their close companions and family. Shame, doubt and lowered self-esteem are commonly associated with this fourth stage.
   
Finally, the fifth stage, known as acceptance, is characterized by a sense of resolution to the grief. Though these stages rarely occur in complete and perfect sequential delineation, often the progression through grief is characterized by this overarching general order, with hints of prior and future stages interwoven. Thus, when a griever reaches the acceptance stage, he or she has likely experienced all of the prior stages and associated emotions. During the acceptance stage, one finally experiences capability to live and cope with their loss without anger, grief, sadness and depression related to the loss interfering with their everyday living.

This final stage may be thought of as a resignation and decision to move forward in life without that which was lost (Pottinger, 1999).

Indicators or Suicidal Ideation   

As noted, in severe cases of CG and/or if CG carries on unaddressed, unmanaged and unsuccessfully treated, suicidal ideation can sometimes occur, especially during the third and fourth stages of the prolonged grieving process. Suicidal ideation refers to the griever’s thoughts about and intentions of committing suicide as a result of an emotional inability to cope with the loss, or due to irreconcilable feelings of guilt and responsibility for the loss.

Indicators of suicidal ideation include

• Feelings of hopelessness
• Severe depression
• Prolonged exhibition of lacking sense of meaning in life
• Diminished self-care, excessing
• Extreme self-deprecating comments
• Intentions and plans surrounding a suicide plan

Ehrenpries, Houck, Prigerson et al. (1997) conducted a study examining how CG symptoms compared to pre-assigned baselines predicted suicidal ideation bereaved individuals undergoing depression. The study found that among elderly individuals who had lost their spouse within the past two years, suicidal ideation was more common among participants’ who had a history of depression and lacked social support systems following grief.

Clinical therapists and healthcare providers should consult the DSM5 for indicators of CG and suicidal ideation that may warrant screening should a grieving patient exhibit the following signs and symptoms over six months following bereavement:

• Self-reported loss of interest in life and activities once enjoyed
• Excessive self-deprecating actions
• Thoughts and verbalizations, thoughts and suggestions of harming themselves or another individual
• Sense of lost meaning in life
• Excessive contemplation of one’s own death and the potential reactions of friends or family to such an incident
• Thoughts and intentions of creating a suicide plan and/or behaviors indicative of plans to exit life, such as extreme social isolation, writing letters explaining suicide intent, getting rid of items and preparing for death
• Excessive discussion of suicide and death.

Conclusively, the study found that the combination of pre-existing depressive symptoms and CG made individuals more statistically prone to suicidal ideation.

Counseling approach recommendations for Pathological Complicated Grief

Treatment, counseling and management approaches for those suffering from pathological complicated grief and suicidal ideation are, as the subject implies, multi-faceted and complex. Often the course of therapeutic or counseling treatment is determined, in part, by the severity of and circumstances surrounding the bereaved individual, including possible social support system, pre-existing health status, mental health history, available resources location, psycho-emotional receptivity to therapy and more.

First, a brief discussion and mention of CG and suicidal ideation prevention in cases of grief may be noted, before discussing reactive counseling approaches to CG and suicidal ideation. The Mayo Clinic (2018) suggests seeking psychological support and help as soon as possible, following a loss, in addition to talking through emotions and about one’s loss may aid in diminishing the risk of developing CG and worse yet, suicidal ideation. Accessing positive support aimed at boosting self-esteem and re-enforcing self-worth and positive relationships during the third and fourth stages of grief, is especially critical in preventing suicidal ideation. This support may come from friends, family, social communities such as church groups, clinical therapists or mental health support groups.
   
Successfully counseling a complicated griever who is exhibiting signs of suicidal ideation is not simple or easy feat. The skilled therapist must understand how to non-defensively respond to potential hostility, defensiveness, self-deprecation, vulnerability, unreceptiveness and anger, encouraging the griever to direct such feelings in a proactive manner, rather than a destructive manner. Encouraging the adaptation of continued or new bonds and friendships strengthens one’s support framework that acts as a defense mechanism against suicidal ideation (Davies, 2016).

Additionally, encouraging a griever to establish a healthy connection with a lost loved one, rather than resorting to obsessive thought patterns or complete emotional denial can also aid in alleviating the severity to CG symptoms exacerbating suicidal ideation. Healthy connections speculated to help the griever maintain emotional equilibrium may include visiting a deceased through dreams, adopting various spiritual and religious rituals honoring the deceased, or routinely visiting the lost one’s grave.

Studies suggest those with well-established spiritual belief systems are often better able to cope with and make sense of loss, seemingly indicating counseling approaches that encourage grievers to seek emotional support in spiritual frameworks of choice may more successfully navigate the stages of grieving, rather than developing pathology. Successful management of grief, in contrast to suicidal ideation, can lead to enhanced bonds with friends and family and an increased appreciation for life.
   
Cognitive Behavioral Therapy (CBT) has also been shown, in some studies, to be an effective treatment approach towards CG and cases of patients experiencing suicidal ideation. Specifically, Exposure Therapy and Cognitive Restructuring, as components of CBT, have been shown as effective when six weeks of exposure therapy is followed by six weeks of cognitive restructuring (Davies, 2016).

Furthermore, because grief experiences vary to a great degree depending upon the individual, grief counseling should provide each individual with an array of viable management options, depending upon individual circumstances choice, and progression through treatment. Careful pre-treatment assessment and ongoing monitoring (frequent check ins) are critical in cases of suicidal ideation in order to ensure the patient remains safe, protected and supported.
   
Finally, Shear (2012) discusses a treatment approach that emphasizes self-observation, reflection and companionship. Shear’s (2012) treatment model also uses imagery exercises to foster healing and learning. These tools are used to elicit positive (versus negative) emotions in the individual experiencing loss. Cumulatively, Shear (2012) found such treatment models in combination with SSRI (antidepressant) pharmacological therapies to be effective in treating suicidal ideation among complicated grievers.

Conclusion

In summary, pathological complicated grief is a complex condition in which a griever or bereaved person experiences prolonged symptoms of normal grief, which impair the griever from effectively carrying on daily living activities. In severe cases, such symptoms can give rise to suicidal ideation. Suicidal ideation may be effectively treated using combination approaches of CBT, self-observation, social support systems, monitoring and pharmacological treatment.

References

Davies, N. (2016). Pathological grief disorder: diagnostic criteria. Psychiatry Advisor. Retrieved from https://www.psychiatryadvisor.com/opinion/pathological-grief-disorder-diagnostic-criteria/article/504174/

Ehrenpries, L., Houck, P., Prigerson, H., Reynolds, C., Szanto, K. (1997). Suicidal ideation in elderly bereaved: the role of complicated grief. Suicide Life Threatening Behavior, 27(2), 194-207.

Mayo Clinic. (2018). Complicated Grief. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/complicated-grief/symptoms-causes/syc-20360374

Pottinger, A.M. (1999). After the storm there is the calm: An analysis of the bereavement process. Jamaica University of the West Indies: Canoe Press. Print.

Shear, M. K. (2012). Grief and mourning gone awry: pathway and course of complicated grief. Dialogues in Clinical Neuroscience, 14(2), 119–128.

Worden, W.J. (2009). Grief counseling and grief therapy, (4th ed). New York: Springer Publishing Company. Print.