Psychiatric Pearls: Recognizing, Treating, (and Preventing) Complicated Grief

1. Psychiatric Pearls:Recognizing, Treating, (and Preventing) Complicated Grief Richard L. O'Sullivan, MD Principal Psychiatrist Western Connecticut Mental Health Network Waterbury, CT

2. What is Complicated Grief? Proposed definitions: A unique entity: phenomenology, risk factors, clinical correlates, course, and outcomes for CG are distinct from those PTSD, MDD, and AD. Characterized by a unique pattern of symptoms following bereavement that are typically slow to resolve and can persist for years if left untreated. Symptoms are associated with persistent mental and physical health morbidity and require specifically designed clinical interventions. Lichtenthal W, Cruess D, Prigerson H. (2004).

3. Distinguishing Complicated from Uncomplicated Grief

4. Objective Measures of Complicated Grief: Imaging Studies A) Nucleus accumbens activity (10, 20, −6) in response to grief-related vs. neutral words that was significantly greater in the Complicated Grief group compared to the Noncomplicated Grief group (pictured at pb.05). B) Bar graph showing nucleus accumbens activity (10, 20, −6) in response to grief-related vs. neutral words for those with Complicated and Noncomplicated Grief. (O’Connor et al.,2008)

5. Characteristics Persists > 6 months after loss Sense of disbelief regarding the death Persistent, intense longing for deceased Preoccupation with the deceased Recurrent intrusive images of the dying person Abnormal avoidance of painful reminders of the death Individuals may report anger, bitterness related to the death Estrangement from friends and relatives Cannot find satisfaction in ongoing life

6. Common Comorbid Conditions Current PTSD and MDD comorbidity in treatment-seeking individuals with CG disorder (n = 206). (Simon et al., 2007)

7. Many Variables Affect the Grief Experience • Sociocultural norms • Relationship/attachment to the deceased • Timing of the death • If the deceased is a child • Circumstances of the death: murder, suicide, accident, etc. • Quality/extent of preparation for death • Perceptions of the death as comfortable, peaceful, accepted: (“…a good death”) • Resiliency/coping abilities of those grieving • Appropriate supports for those grieving

8. Case Study: C.K. • 36 y/o male with mild MR and psychotic disorder NOS, living in family home • Mother died 12 months ago of ovarian cancer • Older sister planned to sell family house, and put him in group home • Presented to clinic for routine medication management and group home placement • Discussion revealed that he had feelings of sadness about leaving his home, where he still felt his mother’s presence/security • No prior efforts were made to inquire about his loss, help him process the loss

9. The Importance of Recognizing Complicated Grief: • Have a high index of suspicion in persons with limited cognitive abilities/communication skills • Need to do more than perfunctory assessment of reason for placement: • May need to ask difficult questions • May need to ask more than one way • Uncover risk factors • Difficult with patients having long, complex histories • Difficult during times of transition (new personnel, settings, etc.)

10. C.K.’s Treatment Plan • Sister planned to sell the home; therefore, he still required placement in the group home • Received weekly supportive counseling with social worker • Medication revision to include an antidepressant • Adult Day Treatment Program instituted to increase his socialization and activity • Involved C.K. in the process—the move, choosing favorite objects from the home (allowed him to make decisions)

11. Case Study: J.B. • 78 y/o female s/p cardiac failure secondary to recent PWMI; required CPR twice due to cardiac arrest • In CCU for 3 weeks, intubated, on IABP; developed limb ischemia, required amputation, left leg • Became septic, delirious, developed renal failure • J.B.’s grown daughter spent nights in the hospital • Multiple medication regimes not successful in reversing the RF, sepsis, or improving cardiac function • Patient’s delirium extremely disturbing to daughter (combative, agitated, hostile to daughter, paranoia about “people trying to kill her.”) • J.B. was made a DNR by daughter; died in CCU, day 27

13. Difficult Death Experiences Increase the Risk for Developing Complicated Grief

14. 8 months after J.B.’s death… • Her daughter went to her PCP with complaints of difficulty sleeping. PCP also noted 20 pound weight loss since prior visit. • PCP suspected depression: performed depression screening questions • Questions prompted J.B.’s daughter to cry and express sadness over her mother’s death • Agreed to talk to a counselor and undergo an antidepressant trial • J.B.’s daughter disclosed intrusive thoughts of her mother’s traumatic death in the CCU w/counselor

15. Terminal Delirium • Reversible: Organic causes need to be identified and treated (i.e., sepsis, electrolyte imbalance, urinary retention, constipation/impaction, sleep deprivation, medications….) • Haldol and thorazine may be used • Irreversible: Does not seem to respond to conventional treatment, but studies are lacking • Therefore, treat the symptoms in order to decrease the perceived suffering of the patient • Benzodiazapines, barbiturates, Propofol may be used: goal is sedation

16. Case Study: M. T. 35 y/o male serving 25 year sentence in a maximum security hospital after being found NGRI for the murder of his father 5 years ago. M.T. was on LSD; was hallucinating that his father was plotting to kill him. Shot his father in the chest with shotgun (in his home). He was serving his sentence without major disciplinary problems, having parole hearings to be placed in a less secure environment. At final pre-parole psychiatric evaluation, M.T. breaks down, describes extreme guilt, says he is not worthy of parole, misses his father and his estranged family.

17. Complicated Grief Reactions may Predispose Individuals to Maladaptive Behavior • M.T. had never processed his father’s death; never discussed his feelings of guilt in while in prison • Important to identify and support even those individuals who are responsible for the death • Unmanaged grief may result in maladaptive or dysfunctional behaviors, such as violent episodes, inability to perform work, difficulty in social situations

18. Summary and Conclusions • Grief with previous psychiatric morbidity exacerbates the worsening of each condition • The grief experience in individuals with intellectual disabilities present unique challenges, and is an area in need of additional research • Traumatic events during the time of death: clinicians need to help those grieving even before death occurs (examples: ICU and delirium) • Individuals need to effectively work through guilt associated with the death to minimize maladaptive responses and behaviors

19. CG Effect on Clinicians • Make self-checks on emotional limits: be supportive, or get someone who can. Not everyone is suited for working with grieving persons • Have awareness to reactions to own losses • Explore areas of discomfort with patients: your reaction may be indicating potential areas requiring clinical intervention • Autognosis (Messner, 1986)

20. Questions and Comments