Persistent grief disorder

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The prolonged grief disorder ( English grief prolonged disorder ) describes a mental disorder in which a Surviving a result of a serious loss (usually death developed a close relative), a pathological grief reaction. It is included in the ICD-11 as an independent diagnosis .

It is characterized by an abnormal and persistent longing for and preoccupation with the deceased, often accompanied by anger , feelings of guilt, and difficulty in accepting the loss, as well as an inability to reconnect with social and other activities after the bereavement. Persistent grief disorder can only be diagnosed if the response exceeds normal grief in terms of both timing and intensity . This has to be seen as a natural response to loss, taking into account different cultural, social and religious norms.

Orpheus mourns the death of Eurydice , 1814 painting by Ary Scheffer

Diagnosis

The ICD-11 was adopted by the World Health Organization in May 2019 and will come into force in 2022. The diagnostic criteria are currently listed in the online beta version of the ICD-11 as follows:

Diagnostic criteria ICD-11 (as of 2019)

Persistent grief disorder is a disease which, after the death of a (spouse) partner, parent, child or other close person, leads to a persistent and penetrating grief reaction, which is characterized by

  1. strong desire for the deceased or
  2. prolonged preoccupation (preoccupation) with the deceased accompanied by severe emotional pain
    1. (e.g. grief, guilt, anger, denial, reproaches,
    2. Difficulty accepting death
    3. Feeling of having lost part of yourself
    4. Inability to experience positive mood,
    5. emotional numbness
    6. Difficulty interacting socially with others or engaging in other activities).

The grief reaction lasts atypically long after the loss (more than 6 months) and exceeds clearly expected social, cultural or religious norms of one's own culture and context. Grief reactions that have persisted for a long time and are within a normal period of the given cultural and religious context are regarded as normal grief reactions without a diagnosis.

The disorder causes significant impairments in the personal, family, social, school or work context or other functional losses.

Frequency of persistent grief disorder

So far, there are only a few sufficiently valid studies on prevalence , comorbidity and particularly affected groups, as a meta study showed. It is only clear that older men are more often affected. Due to the different criteria, the different methods of data collection, for example with the help of questionnaires or interviews, and the elapsed time since the death, very different estimates are available. The few representative studies report a low prevalence. In a large German representative group of people between 14 and 95 years of age, there was an overall prevalence of 3.7 percent. Due to the low prevalence and comorbidity with other disorders, inclusion in the ICD-11 is occasionally criticized as a superfluous and harmful pathologization of grief.

Persistent grief disorder in children and adolescents

There are not yet any suitable diagnostic criteria for children and adolescents and so clinical judgment must be relied on for the time being. It is a great challenge to distinguish between pathological and normal grief reactions, especially because the level of development and the associated concept of death and understanding of death play an important role in children and adolescents. The main difficulty lies in being able to predict or define exactly how children will react to a loss, i.e. the death of a caregiver. Very young children think qualitatively differently than older children. Most do not yet understand the generality, constancy, and dysfunctional aspects of death. In addition to cognitive capacity, language development also plays a role in children. It is not possible for children of a certain age to express their emotions verbally or to express what they need. These aspects must be taken into account both in the diagnostic criteria that are still outstanding and in the therapeutic methods to be used. The first treatment measures in the direction of cognitive behavior therapy are used in children and adolescents. Empirical studies cannot yet sufficiently confirm the effectiveness, which is why randomized, controlled studies are recommended.

treatment

The persistent grief disorder is treated with the help of psychotherapy. Efficacy studies have shown that cognitive behavioral therapy is one of the most effective treatment methods here. But also newer, more innovative methods, such as B. Internet-based therapy programs, which are also based on the cognitive-behavioral therapeutic approach, deliver similar results and alleviate psychological stress.

Cognitive-behavioral therapeutic approaches

In the last few years, various cognitive-behavioral approaches for treating persistent grief disorder have been developed. The most popular are the cognitive behavioral therapy according to Boelen, van den Hout and van den Bout (2006), which comprises 12 sessions, the Complicated Grief Treatment (CGT) according to Shear, Frank, Houck and Reynolds (2005), which comprises 16 sessions and the Integrative cognitive behavioral therapy (CBT-PG) according to Rosner, Pfoh and Kotoučová (2011), which comprises 20 to 25 sessions and can be carried out in outpatient individual as well as inpatient group settings. The three approaches share the assumption that unhelpful thinking and inflexible behavioral patterns block the normal grieving process and cause emotional difficulties (Lorenz & Forstmeier, 2013). Central components of therapy are exposure and cognitive restructuring . During an exposure, the patients are confronted with stressful memories of the deceased. As part of the cognitive restructuring, the worst thoughts and possible feelings of guilt about death are checked for their reality. In first, methodologically strong studies, these approaches achieved good results, but there is much more research to be done in this relatively young field.

In Integrative Cognitive Behavioral Therapy (CBT-PG), relaxation procedures are used and the handling of dysfunctional cognitions, dysfunctional grief thoughts, emotions and perceptions are discussed. The aim here is to discuss dysfunctional processes and to convert them into functional processes. This is done, for example, by questioning the content and checking unhelpful grief thoughts or thinking errors and a subsequent cognitive restructuring. In the further course of therapy, exposure to bereavement takes place, which takes place in sensu. Here, the mourner should deal with the worst moments in detail and finally change them mentally. This step is particularly difficult for many mourners; so it often happens that mourners avoid dealing with the worst moments. However, since this is considered to be central to overcoming persistent grief disorder, this step should take place in graduated form even if it is avoided. A summary of the exposition will then take place in the following session. Therapy will focus on the role of the acceptance of death and its circumstances in further sessions. The aim of the last part of therapy for persistent grief disorder is the integration and transformation of the bereavement and the conclusion of the therapy. The main topics of these sessions will be the legacy and the continuing bond, but also the memory of the deceased and one's own future. The last two sessions will mainly focus on the new life without the deceased and the farewell between patient and therapist.

Related disorders

It is often discussed whether the persistent grief disorder is not already covered by the existing disorders of anxiety disorders , post-traumatic stress disorder (PTSD) or depression . The justification of an independent disorder is therefore often questioned. However, it could be shown that the symptomatology of anxiety, depression and persistent grief differ and that the persistent grief disorder should therefore be viewed as an independent disorder.

With regard to the similarity to PTSD, it can also be stated that although some commonalities between the two disorders can be determined, the respective focus in the symptoms is different. In addition, the diagnostic criteria show that many similarities between the two disorders can also be found in other mental disorders. It can currently be assumed that the differences in the disorder patterns predominate and that the persistent grief disorder can be viewed as an independent disorder.

Individual evidence

  1. ↑ https://www.aerzteblatt.de/nachrichten/103394/Weltgesundheitsammlung-beschliesst-die-ICD-11
  2. ↑ https://icd.who.int/browse11/lm/en#/http://id.who.int/icd/entity/1183832314 .
  3. ↑ Marie Lundorff et al. a .: Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. In: Journal of Affective Disorders. , Vol. 212, April 2017, pp. 138-149.
  4. ↑ R. Rosner et al. a .: Persistent grief disorder: manuals for individual and group therapy. Hogrefe, Göttingen 2014.
  5. ↑ Representatives of existential psychotherapy and person-centered approaches such as B. Christian Metz: Person-centered grief therapy and palliative care. In: Wolfgang W. Keil, Gerhard Stumm: The many faces of person-centered psychotherapy. Springer, Vienna 2002, pp. 585–607.
  6. ↑ Unterhitzenberger, J. & Rosner, R. (2015). Grief in children. Childhood and Development, 24 (3), 146–155. doi: 10.1026 / 0942-5403 / a000170
  7. ^ Friedman RA (2012). Grief, Depression, and the DSM-5. New England Journal of Medicine (366), 1855-1857.
  8. ↑ Oltjenbruns KA (2002). Developmental Context of Childhood: Grief and Regrief Phenomena. In Stroebe, MS & Hansson, RO (Eds.). Handbook of Bereavement Research. Consequences, coping, and care. (3rd print). (pp. 169-197). Washington, DC.
  9. ↑ Moody, Richard A. Moody, Carol P. (1991). A familyperspective Helping children acknow-ledge and express grief following the death of parent. Death Studies. Journal; Peer Reviewed Journal, 15 (6), 587-602.
  10. ↑ Unterhitzenberger, J. & Rosner, R. (2015). Grief in children. Childhood and Development, 24 (3), 146–155. doi: 10.1026 / 0942-5403 / a000170
  11. ↑ Spuij, M., van Londen-Huiberts, A. & Boelen, PA (2013). Cognitive-Behavioral Therapy for Prolonged Grief in Children. Feasibility and Multiple Baseline Study. Cognitive and Behavioral Practice, 20 (3), 349-361. doi: 10.1016 / j.cbpra.2012.08.002
  12. ↑ Rosner, R., Pfoh, G., Rojas, R., Brandstätter, M., Rossi, R., Lumbeck, G., Kotoučová, M., Hagl, M. & Geissner, E. (2014). Persistent grief disorder: manuals for individual and group therapy. Göttingen: Hogrefe.
  13. ^ Wagner, B. & Maercker, A. (2011). Psychotherapy on the Internet - effectiveness and areas of application. Psychotherapists Journal 1, 33–42.
  14. ↑ Boelen, PA, van den Hout, MA & van den Bout, J. (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13 (2), 109-128.
  15. ↑ Rosner, R., Kotouĉová, M., & Pfoh, G. (2011). Treatment of complicated grief. European Journal of Psychotraumatology, 2, 7995. doi: 10.3402 / ejpt.v2i0.7995
  16. ↑ Rosner, R., Pfoh, G., Rojas, R., Brandstätter, M., Rossi, R., Lumbeck, G., Kotoučová, M., Hagl, M. & Geissner, E. (2014). Persistent grief disorder: manuals for individual and group therapy. Göttingen: Hogrefe.
  17. ↑ Prigerson, HG, Shear, MK, Newsom, JT, Frank, E., Reynolds, CF, Maciejewski, PK et al. (1996). Anxiety among widowed elders. Is it distinct from depression and grief? Anxiety, 2 (1), 1-12.
  18. ↑ Prigerson, HG & Jacobs, SC (2001). Traumatic grief as a distinct disorder: A rationale, consensus criteria, and a preminiary empirical test. In MS Stroebe, RO Hansson, W. Stroebe & H. Schut (Eds.), Handbook of bereavement research (pp. 613-645). Washington: American Psychological Association.
  19. ↑ Prigerson, HG, Shear, MK, Newsom, JT, Frank, E., Reynolds, CF, Maciejewski, PK et al. (1996). Anxiety among widowed elders. Is it distinct from depression and grief? Anxiety, 2 (1), 1-12.
  20. ↑ Boelen, PA, van den Bout, J. & Keijser, J. de. (2003). Traumatic grief as a disorder distinct from bereavement-related depression and anxiety. A replication study with bereaved mental health care patients. The American journal of psychiatry, 160 (7), 1339-1341.
  21. ↑ Boelen, PA & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes. A confirmatory factor analysis study. The American journal of psychiatry, 162 (11), 2175-2177.
  22. ↑ Boelen, PA & Prigerson, HG (2007). The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults. A prospective study. European archives of psychiatry and clinical neuroscience, 257 (8), 444-452.
  23. ↑ Boelen, PA (2013). Symptoms of prolonged grief, depression, and adult separation anxiety. Dis-tinctiveness and correlates. Psychiatry research, 207 (1-2), 68-72.
  24. ↑ Prigerson, HG & Jacobs, SC (2001). Traumatic grief as a distinct disorder. A rational, consensus criteria and a preliminary empirical test. In MS Stroebe, RO Hanson, W. Stroebe & H. Schut (Eds.), Handbook of Bereavement Research (pp. 613-633). Washington: American Psychological Association.
  25. ↑ Wittchen, H.-U. & Hoyer, J. (2011). Clinical Psychology & Psychotherapy (2nd ed.). Heidelberg: Springer Medicine Verlag.
  26. ↑ Bonanno, GA, Neria, Y., Mancini, A., Coifman, KG, Litz, B. & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of in-cremental validity. Journal of abnormal psychology, 116 (2), 342-351. doi: 10.1037 / 0021-843X.116.2.342 .