Complex Bereavement, sometimes called Persistent Complex Bereavement, could be mistaken for Major Depression. Rounding out the Major Depressive Disorder specifier series, I’d be remiss in not touching upon it. Still under research for inclusion in future editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), therapists working with depression are likely to encounter the presentation.

The presentation:

More of a complicated Adjustment Disorder of sorts, this condition would be currently diagnosed as Unspecified Depressive Disorder, Complex Bereavement. For a refresher on the topic of Unspecified, see the July 5th post of The New Therapist.It is important to differentiate it from MDD in general given the focus of treatment will be on coping with the loss to resolve it. At first glance, it could seem like pathologizing a normal existential process. Looking further, however, it’s not simply a tough time grieving. It is a chronic, unrelenting experience whereby sufferers are not adapting to the loss. The old saying “time heals all wounds” does not even remotely apply here, as the condition actually worsens with time. Such prolonged grief is noted to be present in upwards of 10% of bereaved individuals (Malgaroli et al., 2018). Take the experience of Marcie:

Marcie and her best friend, Lana, were always together since elementary school; they wre considered sisters in the community. Lana joined the Army Guard as a good way to serve her country and obtain some benefits for further education. Neither ever expected for Lana to go overseas for a conflict. Anxiety settling in, they spent extra time together prior to Lana’s deployment and kept in touch once she left. They were relieved Lana was to stay on a military base, and looked forward to her slated arrival home in six months. Then, on the news, Marcie’s worst fears were realized: Lana’s base was attacked. A week passed with no communication. Lana’s family called Marcie with the news: Lana was a casualty. Heartbroken, Marcie leaned on her family and other friends for support, and tried to keep Lana alive in her mind. A year later, Marcie still longed for Lana to come walking back in. She often awoke to dreams teasing her Lana was on the phone, and toss and turn all night after. She’d email her as if it could bring Lana back to life somehow. Everywhere Marcie went reminded her of the things they did together. Though they had good times together, Marcie’s focus was on the fact Lana was dead and all the good times they will never have. “I should’ve talked her out of the Army Guard,” she berated herself. It was impossible for Marcie to not feel alone; she needed Lana to support her, but Lana wasn’t there. As the year wore on Marcie frequently excused herself from work or begin sobbing at the picture of them on her desk. Her boss referred her to the Employee Assistance Program.

Obviously, Marcie’s grief reaction is not on a normal trajectory. Grief ebbs and flows for most, and life goes on. For Marcie, time stood still in the time of Lana, and it was eating her alive over a year later. She was not only sad, but her life lost meaning, she was unable to smile about their good times, and only focused on the fact it was no more. While the fact she has negative thoughts, emotions and sleeping issues like MDD, the core features are noticeably different.

The proposed diagnostic criteria are lengthy (interested readers can refer to pages 789-792 of the DSM-5). The basic framework includes:

  • Death of someone very close
  • Preoccupation with the deceased/their death
  • At least six additional criteria involving:
  • Duration of at least 12 months (6 months in children).

Treatment implications:

Assessing for suicidality in patients with Complex Bereavement is essential, especially if they allude to life becoming meaningless without the deceased. Being vigilant for substance use is also wise, as it is not uncommon for self-medicating to take hold.

Complex Bereavement requires more than a support group. Individual/family psychotherapy often pays off well with a skilled therapist who can provide significant emotional support while navigating the consequences of the empty space the patient is experiencing. I have found that patients who come to realize the relationship isn’t necessarily now void in the deceased’s absence, but rather it’s the nature of the relationship that has changed, fare well. This is likely to be easiest with religious/spiritual individuals.

Other areas that tend to be grist for the grief therapy mill include:

  • Patients long for social contact but may feel they are being untrue to the deceased, either with friendship loyalty or as a spouse. Confronting such excessive guilt is another step in the right direction.
  • Reframing the lens through which they view the loss. In a case like Marcie, moving them away from “crying because it’s over” to “smiling because it happened,” is essential in getting them to move on.
  • Lastly, it is possible that part of the hanging on is that there is unfinished business; perhaps a conflict was never resolved or a shared goal was never completed. Therapists must become creative and help patients resolve or achieve these items sans the deceased’s physical presence.
  • Exploring life meaning and examining the patient’s own existential fears that the loss may have brought up.

Psychotropic medication can help “get them over the hill,” and therapists would not be remiss in referrals to a psychiatrist if the patient is agreeable.

Most of us are squeamish about the topic of death, but, as the existentialists are fond of pointing out, its examination can enhance our living. Working with bereaved individuals is often a two-way street of growth; in being a fellow traveler with the patient, we are forced to reckon with the topic ourselves. Existential psychiatrist Irvin Yalom observes that examining the issue of mortality is like staring at the sun- it can only be done for so long. Even so, taking a cue from nature, we know that it takes little sunlight for healthy growth.

References:

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Malgaroli, M., Maccallum, F., & Bonanno, G. (2018). Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: A network analysis.Psychological Medicine,48(14), 2439-2448. doi:10.1017/S0033291718001769

Yalom, Irvin (2008). Staring at the sun (1st ed.). Jossey-Bass.