As I go through the second holiday season since the death of my wife, I have been thinking again about the process of healing, why it is so difficult sometimes, and what happens when it cannot happen.
I think that the issues around the holidays are familiar enough to those of us who go through this every year, and who have diaries about it. My bottom line is that the holiday season can sure suck, especially for those who went through their loved ones death during that season. I am always glad when it ends, and life returns to what passes for normal.
But what I want to write about here is when grief gets Complicated. With the capital 'C. Like every other aspect of life, it does that sometimes. No less an authority then the New England Journal of Medicine says so.
Welcome, fellow travelers on the grief journey
and a special welcome to anyone new to The Grieving Room.
We meet every Monday evening.
Whether your loss is recent, or many years ago;
whether you've lost a person, or a pet;
or even if the person you're "mourning" is still alive,
("pre-grief" can be a very lonely and confusing time),
you can come to this diary and say whatever you need to say.
We can't solve each other's problems,
but we can be a sounding board and a place of connection.
Unlike a private journal
here, you know: your words are read by people who
have been through their own hell.
There's no need to pretty it up or tone it down..
It just is.
The latest online edition of the New England Journal of Medicine, which is the premier medical journal in the world, as judged by its impact on medical research, had an article which was too on-topic to not comment about. It is about Complicated grief, written by Katherine Shear, who heads the Center for Complicated Grief at Columbia University. (the link is
here) As it is behind a paywall, I can summarize it and give readers the relevant points.
The article starts with a little case vignette, which is characteristic of that journal. See if this is familiar:
A 68-year-old woman seeks care from her primary physician because of trouble sleeping 4 years after the death of her husband. On questioning, she reveals that she is sleeping on a couch in her living room because she cannot bear to sleep in the bed she shared with him. She has stopped eating regular meals because preparing them makes her miss him too much; she still has meals that she cooked for him in her freezer. The patient often ruminates about how unfair it was for her husband to die, and she is alternately angry with the medical staff who cared for him and angry at herself for not recognizing his illness earlier. She finds it too painful to do things that she and her husband used to do together, and she thinks about him constantly and often wishes she could die to be with him. How should this patient be evaluated and treated?
With the obvious implication that this lady is suffering from grief that has persisted and is majorly affecting her life and health. The article notes that this entity of complex grief was accepted in to the DSM-V, which is essentially the authoritative guide as to what constitutes mental illness, as an entity deserving further study.
I have to note here, that this was not without controversy in the mental health world, and I remember reading a rather heated debate about whether this should or should not be a specific diagnostic entity. No one wants to pathologize grief; it is what we feel when we lose a loved one. It would be almost pathologic not to feel intense emotions of sadness, remorse, anger and so forth; even temporarily hallucinations or vivid dreams are not thought to be overtly abnormal. And yet the feeling has been growing that there is an abnormal response in the sense that if prolonged or unusually severe or affecting one's life, it is perhaps something that can be treated, whereas 'normal' grief (whatever that is) needs support and time.
Maybe I can be even more personal here: It had now been more than two years since I went through the death of my spouse after a long and very painful battle with cancer, and I don't think I am over it, and I I suppose I shall never be, but I am at the point where I can function. I have to.
But I am conflicted. Very much so. That is the subject of a future diary.
And I see Complicated Grief here. A lot.
Anyway, the article goes on to describe what is believed to be Complicated Grief. The clinical points are succinctly summarized by Dr Shear:
COMPLICATED GRIEF:
• Complicated grief is unusually severe and prolonged, and it impairs function in important domains.
• Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased person.
• Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means.
• Randomized, controlled trials provide support for the efficacy of a targeted psychotherapy for complicated grief that provides an explanation of this condition, along with strategies for accepting the loss and for restoring a sense of the possibility of future happiness.
• Other treatments include other forms of psychotherapy as well as antidepressant medication, although pharmacotherapy for this condition has not been studied in randomized trials
The author further goes on to detail what the precise definition would be for classification:
Provisional Proposed Guidelines for the Diagnosis of Prolonged Grief Disorder in the International Classification of Diseases, 11th Revision.
Essential features
History of bereavement after the death of a partner, parent, child, or other loved one
A persistent and pervasive grief response characterized by longing for or persistent preoccupation with the deceased, accompanied by intense emotional pain (e.g., sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to have a positive mood, emotional numbness, or difficulty in engaging with social or other activities)
A grief response that has persisted for an abnormally long period of time after the loss, clearly exceeding expected social, cultural, or religious norms; this category excludes grief responses within 6 mo after the death and for longer periods in some cultural contexts
A disturbance that causes clinically significant impairment in personal, family, social, educational, occupational, or other important areas of functioning; if functioning is maintained only through substantial additional effort or is very impaired as compared with the person’s prior functioning or what would be expected, then he or she would be considered to have impairment due to the disturbance.
Features overlapping with normal bereavement
Grief reactions that have persisted for <6 mo or for longer periods that are within a normative period of grieving given the person’s cultural and religious context are viewed as normal bereavement responses and are generally not assigned a diagnosis.
In assessing whether the duration of the grief reaction exceeds cultural expectations, it is often important to consider whether people in the patient’s environment (e.g., family, friends, and community members) regard the response to the loss or the duration of the reaction as exaggerated or within normal limits.
Additional features
Persistent preoccupation may be manifested as preoccupation with the circumstances of the death or as behaviors such as the preservation of all the deceased person’s belongings exactly as they were before the death; oscillation between excessive preoccupation and avoidance of reminders of the deceased may occur
Other emotional reactions may include difficulty accepting the loss, problems coping without the loved one, difficulties in recalling positive memories of the deceased, difficulty in engaging with social or other activities, social withdrawal, and feeling that life is meaningless
Increased tobacco, alcohol, and other substance use, as well as increased suicidal ideation and behavior may be present
Well, here is what we can draw from this language: Grief has to be taken in the context of a particular culture (we all know that, but reminding never hurts); that it is to be distinguished from major depression, but can look and feel like it, and even in the absence of major depression places the sufferer at increased risk for substance abuse disorders, withdrawal (and although it was not said, let me say it: The effect on those close to the grieving one who suffer in their own way, particularly children) and maybe suicide, although that last point isn't quite proven.
To use an analogy I have used previously, it is like a wound which doesn't heal, unlike grief which does heal but leaves scars. I have scars. they wind around my heart, and they still ache, on and off. Not quite the same.
And the reason for all this is that therapy and even at times pharmacology can be helpful. The article states that the person in this vignette does merit psychotherapy - and this is an important point - ideally with someone skilled in grief counseling who can help the sufferer think more about the person in contrast to avoidance, and reintroduce them to pleasurable activities that they used to do. Oh, and let me say this: I see grief in my job on a not infrequent basis. Whether what I have been through helps or hurts, I am not certain. So information on grief is always relevant to me.
Human beings are complicated, particularly as they grow up, become adults and accumulate years of experiences, learnings, and memories. Love is almost never simple; it is multifaceted, complex and becomes more so over time. So is sex, so is heartbreak, almost endlessly so. I would then ask, why not grief, and further maybe every grief is complicated in its own way.
The interventions or lack thereof may be different, but they all address what springs from the same deep source of the human heart.