2015: Bereavment and Treating Bereavement-Related Conditions-Zisook

Diagnosing and Treating Bereavement-Related Conditions Sidney Zisook

Disclosures and Thanks

Parts of this presentation were supported by grants from the National Institute of Mental Health, the American Foundation for Suicide Prevention and the John A Majda MD Foundation.Otherwise, I have no disclosuresBut I would like to thank my long time collaborators on this work: Richard Devaul, Steven Shuchter, Kathy Shear, Ron Pies, Naomi Simon, Chip Reynolds, Barry Lebowitz and the entire HEAL team

Diagnosing and Treating Bereavement-Related Conditions

What is ordinary/normal grief?Treatment?

What is Complicated Grief?Treatment?

What is bereavement-related depression?Treatment?

1. WHAT IS ORDINARY/NORMAL GRIEF?

TREATMENT?

Bereavement

Loss of a loved one is an experience shared by all humanity

Yet grief can leave us feeling more alone and confused than almost any other experience

Bereavement Grief

Grief: The expected response to bereavement

Grief is the form love takes when someone we love dies

Kathy Shear, personal communication

Acute Grief (Time Limited)

• Disbelief• Yearning; sorrow; intense

emotions• Insistent thoughts• Sense of insecurity• Disengaged from ongoing

life

Characteristics of Acute Grief

It is not just an emotion

No circumscribed stages

Bursts/waves

Positive feelings intermixed

Intensity peaks in days, weeks to months

• But doesn’t totally go awayZisook and Shuchter, JCP, 1993

Mourning Transforms Acute Grief (Transient) to Integrated Grief (Permanent)

• Yearning and sorrow, muted• Thoughts of the

deceased accessible and bittersweet• Renewed engagement in

ongoing life

Adaptation to Loss

WHAT IT MEANS THAT OUR LOVED

ONE IS REALLY GONE

WHAT OUR RELATIONSHIP

WITH OUR LOVED ONE WILL BE LIKE

WHO WE ARE WITHOUT OUR LOVED ONE

Bowlby Loss 1980 Thank you, again, Katherine Shear

SUMMARY: “ORDINARY GRIEF”

Bereavement Acute Grief Integrated Grief

Grief is often painful; it is normal, instinctive and requires

no treatment

2. WHAT IS COMPLICATED GRIEF?

TREATMENT?

What Does CG Look Like? Case Example: Kate

Kate is a pleasant 70 year old widow who lost her husband Jim 3 years ago who died from an unusual form of cancer.

She can’t stop asking herself why he got cancer and why it couldn’t be treated.

She often thinks about why she didn’t figure out what was wrong before it was too late.

Case Example: KateKate hasn’t changed anything in the house since

Jim died; she can’t look at pictures of him or go anywhere they went together.

She skips meals because it is too hard to prepare them as she did for 45 years.

She feels strangely incomplete with other people. She has a job but often calls in sick. She sees her children regularly but doesn’t feel

close to them anymore.

Case Example: Kate

Kate sometimes skips her hypertension medication knowing this could be dangerous.

She lost faith in God after Jim died.

She often finds herself daydreaming for hours about being with Jim.

Case Example: Kate

Friends and family, initially very supportive, tell her she needs to move on.

Although Kate Jim would want her to be happy again, she doesn't see how its possible after losing someone who was so much a part of her.

How Would You Diagnose Kate’s Problems?

1. Adjustment Disorder2. Major Depressive Disorder3. Post Traumatic Stress Disorder4. No Disorder5. Persistent Complex

Bereavement Disorder (Complicated Grief)

Kate has Complicated Grief

Grief Complications maladaptive thoughts dysfunctional behaviors poorly regulated emotionality

Characteristic Features – Prolonged and Intense Acute Grief Difficulty accepting the reality of the death Intense yearning, longing and sorrow Frequent insistent thoughts and memories of the

deceased Avoidance of reminders Difficulty imagining a future with purpose and

meaning.

Complicated Grief: Common ThemesPersistent yearning, longing or

searching for the deceased, with ideas such as

“Grief is all I have left”“It would be a betrayal to feel whole”“I am stuck; time is moving on, but I am not”

Hypothesized Pre-loss Risk Factors

Prior Psychiatric conditions (especially mood, anxiety or substance use disorders)Trauma historyPrior important lossesFemale genderInsecure early attachmentEspecially close relationship with the deceased Shear et al., 2011; Newson et al., 2011; Kersting et al., 2011;

Fujisawa et al., 2010; Bui et al., in press; Mutabaruka et al., 2012; Hargrave et al., 2012

Hypothesized Loss-Related Risk Factors

Prominent caretaking role

ChildrenChronically ill

Especially close relationship

SpouseParentSoul Mate

Untimely deathSudden deathLoss due to suicide, homicide or accidentDeath of a child or young adult

Shear et al., 2011; Newson et al., 2011; Kersting et al., 2011; Fujisawa et al., 2010; Bui et al., in press; Mutabaruka et al., 2012; Hargrave et al., 2012

Hypothesized Peri-Loss Risk Factors

Ambiguous loss or lack of information Unable to follow usual cultural healing rituals Alcohol or substance use Absent or hostile social companionship

Shear et al., 2011; Newson et al., 2011; Kersting et al., 2011; Fujisawa et al., 2010; Bui et al., in press; Mutabaruka et al., 2012; Hargrave et al., 2012

Differential DiagnosisOrdinary

(Normal/Uncomplicated) Grief

Major Depression

PTSD

Similarities to Depression

Sadness, dysphoria, irritabilityInsomnia/appetite changesConcentration difficultiesSuicidalityFunctional impairment

Affect is Different

Complicated Grief Major DepressionLoss, yearning, feeling of absence

Sadness; anhedonia

Occurs in waves; triggered by reminders

Persistent; not tied to triggers

Positive emotions are accessible

Pervasive unhappiness and misery

DSM-5: Diagnostic Criteria for Major Depressive Disorders (Footnote, Pg. 161)

Cognitions are DifferentComplicated Grief Major DepressionInsistent thoughts about the deceased; counterfactual rumination about the death

Self-critical or pessimistic rumination

Self esteem preserved; guilt tied to actions around the deceased or the death

Feelings worthless or self-loathing

Suicidal thinking focused on joining the deceased or not wanting to live without them

Suicidal thinking focused on feeling worthless or unable to cope

Not Either/Or -- Bereavement can Trigger both CG and MDD

Similarities to PTSDConfrontation with deathConfusion, disorientation,

shock DisbeliefIntrusive thoughts,

preoccupationAvoidance behaviors

Differences Between CG And PTSD (1)COMPLICATED GRIEF

Triggered by lossPrimary emotion: yearningIntrusive thoughts – person-relatedNightmares rare

PTSDTriggered by dangerPrimary emotion: fearIntrusive thoughts: event-relatedNightmares frequent

Differences Between CG And PTSD (2)

COMPLICATED GRIEF

Avoidance: loss-basedReminders linked to the person Proximity seeking is prominent

PTSD

Avoidance: fear-basedReminders linked to event Proximity seeking not seen

Comorbidity is Common

Shear et al., submitted

Participants in HEAL Study with Complicated Grief (n=395)

N %

Current MDD 262 66%

Current PTSD 154 39%

TREATMENT FOR COMPLICATED GRIEF

Many Potential Treatments for Complicated Grief

Psychotherapy Complicated Grief Therapy (Shear et al 2005, 2014) Guided Imaginal Conversation (Jordan 2012) Attachment Informed Psychotherapy (Schore 2011) Restorative Retelling (Rynearson 2001) Others

Potential Role of Pharmacotherapy For CG? For co-occurring conditions?

Complicated Grief Treatment (CGT) A 16-session psychotherapy model targeting CG symptoms Can be considered a form of CBTUses strategies and techniques from CBT (primarily PE) IPT and MI

Complicated Grief Treatment

Strategies

Address complicating thoughts, feelings and behaviors

Establish a rhythm of oscillation between confrontation and comfort

Attend to dual processes of reflection upon the death (loss-focus) and re-envisioning the future (restoration-focus)

Procedures Psychoeducation Involving significant other Grief monitoring Imaginal and situational

revisiting exercises Memories and pictures Imaginal conversation with

the person who died Attention to self care, core

values and meaningful future plans

Katherine Shear, Personal Communication

STUDY 1 (Pittsburgh) STUDY 2 (NYC)0%

20%

40%

60%

80%

51%

71%

28% 32%

CGT produced better response than IPT in both studies

CGT

CGT

IPT IPT

Two NIMH-funded RCT’s Compared CGT to a Rigorous Well-balanced Psychotherapy Control

Treatment response maintained at 6 month follow-up

Shear et al 2005, 2014

Clinical Management

Medication is not an effective treatment for CGCGT (or other evidence-based psychotherapy for CG) is the treatment of choice In the absence of CGT, informed clinical management helps

PsychoeducationEmpathic listeningSymptom monitoringSupport for a return to enjoyable activities without the deceased

Shear et al, in press

Persistent Complex Bereavement Disorder: A New Condition

Persistent Complex Bereavement Disorder was added to Trauma- and Stressor-Related Disorders as ‘Other Specified’ Disorder and In

Section III as a ‘Condition Requiring Further Study’

Based on compelling data that complicated (aka, traumatic, unresolved, persistent, pathological, etc) grief occurs and is:

Painful Distressing Disruptive Chronic Morbid Associated with SI Treatable

www.complicatedgrief.org

3. WHAT IS BEREAVEMENT-RELATED DEPRESSION?

TREATMENT?

In 1980, the DSM-III Added a Bereavement Exclusion for the Diagnosis of MDD

MDD should not be diagnosed after the loss of a loved one UNLESS:

Persist for longer than 2 months Marked functional impairment Characterized by

psychomotor retardation morbid preoccupation with worthlessness psychotic symptoms suicidal ideation

The Bereavement Exclusion

Introduced in DSM-III to minimize the possibility of misattributing normal grief associated with the death of a loved one as a mental disorder.

Did the Bereavement Exclusion (BE) Make Sense?

Ultimately rests on the question: Is Bereavement-Related Depression (BRD) different than Nonbereavment-Related Depression (NMRD)?

To the extent that research supports differences, especially if the differences are in the direction of BRD being less severe, chronic and treatment responsive, the BE justifiable .If there are no major differences

All other MDEs should have a similar exclusions, or, The BE should be eliminated

Summary of 3 Reviews

BRD has most of the characteristics of MDE as NBRD

Most likely to occur in individuals with past personal and family histories of MDEGenetically influencedSimilar personality characteristics as NBMDSimilar symptom profile and impairment as NBMDSimilar patterns of co-morbidity as NBMDBiological features, including sleep architecture, heart rate variability, immune impairment and cortisol dysregulation similar to NBMDSimilar duration and risk of recurrence as NBMD Responds to antidepressant medications

Treatment of BRD does not interfere with griefTreatment of BRD may facilitate grief and prevent ‘Complicated Grief’ Zisook et al AJP 2009, Zisook et al World

Psychiatry 2010, Zisook et al Anx and Dep 2012

Reviews of published articles on “grief or bereavement” and "depression” that included individuals diagnosed with MDE or meeting threshold levels for clinically significant depression

IN 2013, THE DSM-5 ELIMINATED THE BEREAVEMENT EXCLUSION

Studies since DSM-III did not

support the notion that depressive

syndromes seen in the context of bereavement

were fundamentally different than

other depressive syndromes in

other contexts

The Bereavement Exclusion was poorly

understood, misapplied and gave the false impression to many that grief

should end at 2 months

Eliminating the BE removed a roadblock

to diagnosis and potentially life-

altering treatment for what is generally considered a serious,

severe and chronic mental disorder,

MDD

“It is very important that clinicians have an opportunity to make sure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a period of time.” ----David Kupfer, Chair, DSM-5 Task Force: http://www.empr.com/dsm-5-approved-by-the-apa-board/article/270757/

Response to ObjectionsObjection Response

Medicalizes sadness and grief

Limits ‘normal’ grief to 2 weeks, or perhaps 2 months

Provides the pharmaceutical industry a bonanza

Studies have found that myocardial infarcts, stroke, breast cancer and death from cardiac complications occur with increased frequency in bereaved individuals. Does that ‘medicalize’ grief?

Studies showing that antidepressants work for bereaved individuals with major depressive syndromes have been available for years without a rush for a new indication; plus, the DSM is not a treatment manual and should not be geared to help or hinder a particular industry.

With or without the Bereavement Exclusion, grief can last for weeks, months, years or even lifetimes.

A source of confusion: “Eliminating the BE does not mean that they do not grieve. They do. It does not mean that they do not feel terrible pain and loneliness. They do. Depression is a slippery word and we are so used to using it to mean “sad” or ‘blue”, or in this specific case, “grieving”. Major Depression – the diagnostic term – is something quite different”. Kendler, KS, www.dsm5.org.about/Documents/grief%20exclusion_kendler.pdf

Bereavement-Related Depression

Depression (small “d”)As in sad and blue – a “normal” emotion No

Depression (big “D”) As in MDD – a miserable, disabling and chronic/recurrent conditionMaybe – just like any other MDD

If first occurrence and relatively mild, may wait and/or support and/or provide clinical managementIf more recurrent or severe, medication and/or psychotherapy

To treat, or not to treat?

SUMMARY: BEREAVEMENT AND THE DSM-5

Added Persistent Complex Bereavement Disorder

Eliminated the Bereavement Exclusion

Summary: Back to the 3 QuestionsQuestion Answer Treatment

What is ordinary/normal grief?

A normal, instinctive response to loss

No formal treatment needed

What is Complicated Grief? Intense, prolonged and impairing acute grief

Psychotherapy – preferably CGT

What is bereavement-related depression?

“d” – sad and blue; grief“D” – MDD; may be triggered by loss and intensifies and prolongs grief

No formal treatmentClinical management and/or psychotherapy and/or medication