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Recent advances in grief research

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Normal and abnormal grief reaction

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    Recent advances in grief research Recent advances in grief research Presentation Transcript

    • Recent Advances in Grief Research Presented by :Dr. Ramkumar G.S Chairperson : Dr. Geetha Desai
    • Overview
      • Terminology and theories
      • Phenomenology and outcome
      • Classification and proposals for DSM V
      • Grief , Depression, PTSD
      • Research on abnormal grief and interventions
      • Conclusion
    • Terminology
        • With loss and death come bereavement, grief, and mourning.
        • Bereavemen t - the process of adjusting to the death of a loved one.
        • Grief - the complex emotional responses that one has during the bereavement process, such as experiencing sorrow, hurt, anger, guilt, confusion, and so on Hooyman & Kiyak, 2002; Santrock, 2006
        • Mourning - the culturally structured patterns and expectations of how individuals express their grief Hooyman & Kiyak, 2002 .
        • Grieving is a natural process which can be very important toward coping constructively with loss and death Attig, 1996
    • Why do we grieve?
        • To spare oneself from grief at all cost can be achieved only at the price of total detachment, which excludes the ability to experience happiness- Erich Fromm
        • Grief is the “cost of commitment” Colin Murray Parkes
        • Nevertheless the situation of loss of a loved one is of vast adaptive significance, a special state shaped to cope with that situation—by signalling others, by changing goals, by preventing further losses, by reassessing priorities and plans and other relationships.
    • Grief Theories, Models...
        • Sigmund Freud (1917)- the painfull relinquishing of ties to the deceased the work of grief.
        • Lindemann(1944) – normal, abnormal reactions to loss.
        • Bowlby(1969)- Attachment Theory emphasize that the work of grief involves a series of attachment behaviours rather than simply separation.
        • He preferred the term reorganization rather than detachment while referring to adult bereavement.
    • Grief theories...
      • Parkes(1972)- Grief as a series of shifting pictures
      • Worden(1983)- 4 tasks of mourning
      • Two studies in 1990
      • 1. Hogan and Desantis, 1992
      • 2. Silvermann colleagues, 1992
      • Continuing grief: a new understanding of grief(1996) ‏
    • Grief theories...
      • Dual process model -1999 Stroebe and Schut
      • Loss orientation
      • Restoration orientation
      • Grief to personal growth theory -2002 Hogan
    • Six components of acute grief Lindemann-1946
        • Intense somatic distress
        • Thoughts of the deceased preoccupy the survivor
        • Quilt feeling, survivors accuse themselves
        • Irritation and anger are directed at themselves, the deceased and others
        • Restlessness, agitation, aimlessness, amotivation
        • Identification phenomena
    • Phenomenology of Grief
        • Proposed grieving process models- includes at least three partially overlapping phases or states
        • 1) Initial shock, disbelief and denial
        • 2) Intermediate period of acute discomfort, social withdrawal
        • 3) A culminating period of restitution and reorganization
    • Elisabeth Kübler-Ross stages
    • Evidence for stage theory
      • An Empirical Examinationof the Stage Theory of Grief
      • Yale Bereavement study(YBS) ‏ Paul K. Maciejewski et al 2007
      • Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss.
      • Disbelief decreased from an initial high at 1 month post loss. Yearning peaked at 4 months post loss.
      • Anger peaked at 5 months post loss, and depression peaked at 6 months post loss.
      • Acceptance increased throughout the study observation period.
    • Emperical evidence for grief stage
      • The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief.
      • Identification of the normal stages of grief following a death from natural causes enhances understanding of how the average person cognitively and emotionally processes the loss of a family member.
      • Given that the negative grief indicators all peak within approximately 6 months postloss, those who score high on these indicators beyond 6 months postloss might benefit from further evaluation
    • Stage theory refuted The Myth of the Stages of Dying, Death and Grief Russell Friedman and John W James 2008 Refutes the stage theory and challenges the YBS. Kubler Ross in Grief and Grieving - the stage theory has much evolved and much misunderstood over the past three decades. “ They were never ment to tuck messy emotions into neat packages. Our grief is as individual as our lives. Not every one goes through all of them or goes in a prescribed order”.
    • Reorganisation, Bowlby1969
        • Reorganization- the optimal psychological resolution of the grief process involving two major tasks
        • Accepting the death of the attachment figure, returning to daily activities, and forming new bonds
        • Maintaining a symbolic attachment to the deceased integrating the lost relationship within a new reality.
    • Reorganisation, Bowlby1969
        • separation vs attachment dilemma.
        • “ editing” of the hierarchy of attachment figures , resembles the replacement of parents by peers as primary attachment figures during adolescence.
        • Bereaved adults can transform the functions of the deceased as a symbolic rather than a physically present source of security (“ attachment figures in reserve ” (Weiss, 1981)) .
    • 4 tasks of mourning-Worden 1983 1. to accept the reality of the loss 2. working through the pain of grief 3. adjusting to the environment in which the deceased is missing 4.to emotionally relocate the deceased and move on with life
    • Grief outcome
        • Existing evidence suggests that most of the bereaved are resilient, ultimately coping well with major loss Bonanno, 2004
        • However, between 10 and 20% of survivors experience unremitting and intense grieving that substantially impairs the quality of their lives ( Bonanno, Wortman, & Nesse, 2004) ‏
        • Predicts long-term risks to physical and mental health
        • (Ott, 2003; Parkes, 1996; Prigerson & Jacobs, 2001) ‏
    • ICD 10
      • Normal bereavement reactions
      • Chapter XXI Z63.4-Disappearance, death of family member
      • Z73.3- stress not elsewhere classified
      • Abnormal grief reactions
      • F43.22- mixed anxiety& depressive reaction
      • F43.23- with predominant dis. of other emotion
      • F43.24- with pred. Dis. Of conduct
      • F43.25- mixed dis. Of emotions &conduct
      • F43.21- Prolonged depressive reaction
    • DSM IV
      • V 62.82 Bereavement
      • Depressive symptoms that occur within first 2months after death of loved one.
      • Lists 6 symptoms to distinguish from MDD
      • MDD diagnosed only if marked functional impairment, morbid preoccupation with quilt, suicidal ideation, or P M retardation are present
      • The rationale for exclusion , the depressive state is a culturally sanctioned response to death of loved one
    • Proposals for DSM V
      • Kendler et al. (2008) report that the similarities between bereavement-related and other life stressor-related depression far outweigh their differences, arguing against the continued use of the bereavement exclusion criterion in DSM-V.
      • Wakefield et al. (2007), on the basis of similar findings, proposed to exclude both types of sadness from the DSM-V diagnosis of major depression (i.e., to introduce a “contextual” criterion excluding intense sadness that appears “proportionate” to a loss) ‏
    • Proposals for DSM V
      • Whether an adverse life event has been really decisive in triggering a depressive state may be difficult to establish in several cases.
      • Aubrey Lewis(1967), testing a set of criteria aimed to distinguish between “contextual” and “endogenous” depression, concluded that most depressive cases were “examples of the interaction of organism and environment,” so that “it was impossible to say which of the factors was decidedly preponderant”
    • Proposals for DSM V
      • Current official psychiatric nomenclature does not
      • recognise chronic grief reactions as an independent entity
      • Earliest described diagnostic algorithm for complicated grief was by Horowitz et al(1997).
      • Another was by Prigerson et al(1999) ‏
    • Assessing between Grief and Depression
      • Grief
      • Anhedonia
      • Hopelessness
      • Response to support
      • Overt expression of anger
      • Guilt is focused on aspect of loss
      • Not demoralizing or humiliating
      • Preoccupation with deceased
      • Suicidal gestures rare in uncomplicated grief
      • Elicits sympathy, concern and desire to embrace
      • Depression
      • Anhedonia
      • Pervasive hopelessness
      • Unresponsive to support
      • Anger not as pronounced
      • Guilt is preoccupied with a negative self-image
      • Demoralizing and humiliating
      • Preoccupation with self
      • Suicidal gestures not unusual in depression
      • Elicits irritation, frustration and a desire to avoid
      • Differentiating symptoms of complicated Grief and depression among psychiatric outpatients John S Ogrodniczuk et al 2003
      • A total of 398 psychiatric patients who suffered bereavement provided ratings on standard measures of grief and depression.
      • Factor analysis of 56 items of these measures were used to explore the possibility that grief and depression could form seperate dimensions of distress
    • Result
      • The grief formed three different clusters representing different dimensions of CG.None of the depression items loaded heavily on these grief dimensions. The depression items formed two different clusters
      • Conclusion : while assessing psychiatric patient who have death losses, the clinician should consider different types of grief reactions. In the absence of depressive symptoms the clinician should not assume absence of CG
    • Bereavement and PTSD
      • In an epidemiological survey( Breslau, 1998 ) 60% of population experienced the sudden unexpected death of a loved one
      • This event accounted for 31% of PTSD more than any other traumatic event
      • When examining all cases of sudden death only 14% developed PTSD.
      • Schut et al,1991 examined self reported PTSD symptoms in bereaved spouses. Though most of spouses died of natural causes 20-30% had probable PTSD during at least one follow-up point between 4-25 months.
    • Comparison
      • Complicated Grief
      • Physical threat
      • Sadness
      • Yearning,
      • longing,
      • pleasurable feelings
      • PTSD
      • Loss
      • Fear
      • Nightmares
    • Complicated Grief- Worden ,1991
        • Four categories
        • (a) chronic grief reactions , in which the normal grief reactions continues for an excessive period of time without coming to a satisfactory conclusion,
        • (b) delayed reactions
        • (c) exaggerated grief reactions , overwhelmed by grief that they develop major psychiatric disorders
        • (d) masked grief reactions- experiences physical symptoms that may not at first appear to be related to the loss
    • A case for Complicated Grief criteria
      • Lichtenthal WG, Cruess DG, Prigerson HG(2004) proposes separate criteria .
      • Simon et al(2007) - The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief.
      • Of 206 subjects who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder.
      • When present, psychiatric comorbidity was associated with significantly greater severity of grief.
    • A case for Complicated grief criteria.
      • Are normal and complicated grief different constructs? a confirmatory factor analytic test.
      • Dillen L, Fontaine JR, Verhofstadt-Denève L.2008 Nov
      • These analyses revealed that CG and NG reactions can be distinguished by their very nature, except for one CG reaction (viz.'yearning'), that loaded on both factors
    • Criteria for Prolonged Grief Disorder Proposed for DSM-V Prigerson
        • Separation Distress : 1 of 3 daily or distressing or disruptive degree:
        • 1. Intrusive thoughts related to the lost relationship
        • 2. Intense feelings of emotional pain, sorrow, or pangs of grief related to loss
        • 3. Yearning for the lost person
        • Cognitive, Emotional, Behavioural Symptoms : 5+ daily or distressing or disruptive degree:
        • 1. Confusion about one’s identity (e.g., one’s role in life or diminished sense of self) (i.e., feeling that a part of oneself has died) ‏
    • Criteria for Prolonged Grief Disorder Proposed for DSM-V
        • Difficulty accepting the loss
        • Avoidance of reminders of the reality of the loss
        • Inability to trust others since the loss
        • Bitterness or anger related to the loss
        • Difficulty moving on with life (e.g., making new friends, pursuing interests)‏
        • Numbness (absence of emotion) since the loss
        • Feeling that life is unfulfilling, empty, and meaningless since the loss
        • Feeling stunned, dazed or shocked by the loss
    • Criteria for Prolonged Grief Disorder Proposed for DSM-V Prigerson
        • Duration : Duration at least six months from the onset of separation distress
        • Impairment : The above symptomatic disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (e.g., domestic responsibilities) ‏
    • Why not Complicated Grief? Why Prolonged Grief Disorder? Prigerson
        • Complicated = “ difficult to analyze,understand,explain”
        • Complicated Bereavement in DSM-IV refers to other mental disorders secondary to bereavement (MDD, PTSD) ‏
        • Prolonged refers to persistently severe set of maladaptive grief symptoms
        • Prolonged is NOT the only indicator of pathology, the PGD criteria set predict enduring morbidity
    • Health hazard of CG
      • Increased risk of cardiac events, BP, and cancer Prigerson et al, 1997
      • suicidality Prigerson et al, 1995,1997
      • Social dysfunction Silverman et al, 2000
      • Low energy Prigerson, Shear et al 1999
      • Global impairment Prigerson et al, 1997
    • Risk Factors for Adverse Health Outcomes Stroebe et al., 2007
        • Include
        • – Nature of relationship with the deceased,
        • complexities of attachment
        • – Circumstances of death
        • Eg violent, sudden, unexpected, suicide, untimely
        • – Personal factors particularly
        • Personal traits,
        • Personal history / experience
        • Genetic variables
        • – Perceptions of support eg unhelpful is adverse
    • Unnatural death
      • The circumstances surrounding the death have a marked impact on how people grieve.
      • Survivors of suicide have been found to experience a severe form of bereavement that differs both quantitatively and qualitatively from other forms of bereavement Silverman, Range, & Overholser, 1994-95
      • The sudden death of a child leads to unique grief responses by the parents Lang & Gottlieb, 1993
      • Therapeutic interventions that have proven helpful in these groups include the provision of information regarding the death, opportunity to view the body, or photographs of the body, support groups, and advice regarding the likelihood of further such deaths in the family Clark & Goldney, 1995
    • Efficacy of intervention..
        • Breavement Care interventions: a systematic review . Amanda L. Forte et al (2004)
        • 74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement.
        • Among studies utilizing a structured therapeutic relationship 8 featured pharmacotherapy (4 CG), 39 featured support groups or counselling (23 CG), and 25 studies featured CBT, psychodynamic, psychoanalytical, or interpersonal therapies (17 CG). Seven studies employed systems-oriented interventions (all had CG).
        • Other than efficacy for pharmacological treatment of bereavement-related depression, no consistent pattern of treatment benefit among the other forms of interventions
        • Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression.
        • BMC Palliative Care 2004, 3:3 systematic review
    • Efficacy of intervention..
        • The following five factors are postulated to impede scientific progress regarding bereavement care interventions:
        • 1) excessive theoretical heterogeneity,
        • 2) stultifying between-study variation,
        • 3) inadequate reporting of intervention procedures,
        • 4) few published replication studies, and
        • 5) methodological flaws of study design.
        • BMC Palliative Care 2004,3:3 systematic review
    • Efficacy of intervention
        • Routine intervention for bereavement has not received support from quantitative evaluations of its effectiveness and is therefore not empirically based.
        • Outreach strategies are not advised, and even provision of intervention for those who believe that they need it and who request it should be carefully evaluated.
        • Intervention soon after bereavement may interfere with “natural” grieving processes. Intervention is more effective for those with more complicated forms of grief
        • HENK SCHUT and MARGARET S. STROEBE, 2005
    • Can grief therapy cause harm.. Neimeyer(2000) - meta analysis of 23 scientifically adequate outcome studies of grief therapy pub. Btw 1975-98 The selected studies offered psychosocial intervention to randomly assigned participants in control and intervention groups Two measures used 1. degree of benefit with participation 2. estimate of treatment induced deterioration.
    • Result
      • For participants experiencing uncomplicated bereavement there was “ essentially no measurable positive effect on any(outcome) variable” and “nearly one in two clients suffered as a result of treatment”.
        • Dale G. Larson William T. Hoyt 2007 claims that the data on which these figures are based on data that have never been published and peer reviewed, and used a statistical technique also never peer-reviewed.
        • Meta-analysis by- Allumbaugh and Hoyt (1999) – found that the effects of grief counseling were positive, although somewhat smaller than those generally seen in other forms of counseling.
    • Methodological issues Margaret Stroebe, Wolfgang Stroebe, Henk Schut 2003
        • Data collection. Surveys , interviews
        • Control group
        • Measurement. Qualitative, Quantitative
        • Selection and Generalizability
        • Ethical issues
    • Neurobiology
        • Functional Neuro Anatomy of Grief and
        • Bereavement Gundel et al. 2003
        • Posterior Cingulate Cortex, Medial / Superior
        • Frontal Gyrus, Cerebellum
    • Grief&Craving
        • Enduring grief activates brain's reward center
        • O’Connor et al. Neuroimage. 2008
        • Study : Bereaved women (11 CG,12 NCG) event-related fMRI
        • scan, using pictures of deceased.
        • Result : Only those with CG showed reward-related activity in the nucleus accumbens (NA). This NA cluster was positively correlated with self-reported yearning, but not with time since death, participant age, or positive/negative affect.
        • Conclusion: This study supports the hypothesis that attachment
        • activates reward pathways. For those with CG, reminders of the
        • deceased still activate neural reward activity, which may interfere with adapting to the loss in the present
    • Grief&craving..
        • The idea is that when our loved ones are alive, we get a rewarding cue from seeing them or things that remind us of them.
        • After the loved one dies, those who adapt to the loss stop getting this neural reward. But those who don’t adapt continue to crave it, because each time they do see a cue, they still get that neural reward.
        • O’Connor cautions that she is not suggesting that reveries about the deceased are emotionally satisfying but rather that they may serve as a type of craving that may make adapting to the reality of the loss more difficult.
    • Preparedness for the Death, grief
        • Retrospectively
        • Prepared caregivers 2.4 times less likely have PGD Barry2003 ; 2.9 times among bereaved Alzheimer’s patient caregivers Hebert, 2006
        • Prospectively
        • Does preparation for the death (eg, sharing prognostic info) promote bereavement adjustment?
        • ↓ grief, ↑ acceptance in those with longer time from death Maciejewski et al. JAMA 2007
    • Intervention
        • “ Most bereavement services are based on the assumption that loss through death challenges coping abilities and that supportive interventions may facilitate post-death adaptation, reduce complicated grief reactions and promote wellbeing” Field et al. 2004.
    • Interventions available
      • Bereavement support
      • Bereavement counselling
      • Grief therapy
      • Can use IPT, CBT, CGT
      • Family therapy, Group Therapy
    • CGT: A targeted treatment
        • Integrates interpersonal psychotherapy, prolonged exposure and cognitive behavioural treatment strategies.
        • Based on a model of coping with grief that posits contemporaneous oscillating attention to loss- focussed work and life- focussed work
    • Treatment Strategy
        • Each session has a dual focus
        • Emotional processing of the loss
        • Imaginal revisiting of the death
        • Imaginal conversation with the deceased
        • Revisiting painful activities and places
        • Memories work
        • Restoration of satisfying life
        • Personal goals
        • Work on interpersonal problems
        • Revisiting satisfying activities and places
    • Treatment of Complicated Grief A Randomized Controlled Trial
      • Katherine Shear 2005
      • To compare the efficacy of a novel approach,complicated grief treatment, with a standard psychotherapy (interpersonal psychotherapy).
      • Participants were randomly assigned to receive interpersonal psychotherapy (n=46) or complicated grief treatment (n=49); both were administered in 16 sessions during an average interval of 19 weeks per participant
      • Complicated grief treatment is an improved treatment over interpersonal psychotherapy, showing higher response rates and faster time to response.
    • Evidence-based Recommendations for Breavement Intervetions Prigerson
        • Why Not to Intervene?
      • Stroebe, Walter and others concerned that professional intervention:
        • Thwarts natural assistance from family and friends
        • Inhibits bereaved person’s self-esteem and sense of efficacy
        • Implies certain forms of grief are not socially acceptable;
        • intervention gets unruly grief in line with cultural expectations
        • Wastes resources
        • Is stigmatizing.
    • Why Intervene? Prigerson
        • Vast majority fine and gradually move from very upset, disturbed to diminished distress, eventual adjustment
        • Questionable whether all would benefit from intervention
        • Significant minority not fine and at risk for enduring distress and dysfunction
        • Interventions improve their quality of life; potentially
        • reduce adverse outcomes: Social withdrawal, suicidality, alcohol abuse, high blood pressure, functional disability, loss of productivity
    • Who Benefits from Bereavement Interventions?
        • “ The general pattern emerging from this review is that the more complicated the grief process ... the better the chances of bereavement interventions leading to positive results.” Schut, Stroebe, Van den Bout, Terheggen 2001
        • “ most uncomplicated grief is probably naturally self limiting.... one of the most important trends in these reviews is the recognition that there are subgroups of mourners who are at elevated risk for dysfunction and who respond well to formal interventions.”
        • Jordan and Neimeyer 2003
    • Who should be targeted for interventions? Prigerson
        • Patients with socio-demographic & circumstantial risks:
        • Mothers, spouses
        • Lack of social, financial resources
        • Extreme dependency on deceased
        • Abuse, neglect or parental loss in childhood
        • Traumatic deaths
        • Multiple losses
        • Lack of preparation for the death
        • Patients with mental health risks/indicators of poor adjustment:
        • Suicidal ideation
        • Psychiatric disorder (MDD, GAD, PTSD), suicidality) – current or lifetime
        • Prolonged Grief Disorder
    • What to do for whom Prigerson
        • For low risk bereaved, recommend:
        • Stable sleep, exercise routines, daily schedules
        • Possibly support group
        • For MDD or GAD : usual treatments (eg SSRIs; CBT) ‏
        • For PGD promising interventions:
        • Pharmacotherapy , CGT
        • Attachment-based psychotherapy
        • Pre-loss preparation
        • Early intervention
    • Positive emotions
        • Bereaved gay men's appraisals about the death of their partner in the first month after the loss.
        • In contrast to traditional assumptions, positive appraisals (e.g., a positive attitude toward death, or a belief in self-growth from difficult events) were more common than negative appraisals.
        • Positive appraisals were associated with improved morale, more positive states of mind, and less depression at 12 month
        • Stein, Folkman,Trabasso, and Christopher-Richards ,1997
    • Positive emotions
        • In a similar study, appraisals from middle-aged widows and widowers at the 6-month point in bereavement.
        • Positive appraisals were again more common than negative appraisals.
        • Further, although positive appraisals were unrelated to outcome, negative appraisals were associated with increased grief 25 months after the loss, as measured by clinical interviews, and this association remained significant when initial interviewer ratings of grief, perceived social support, and the quality of the conjugal relationship were controlled.
        • Capps and Bonanno (1998) ‏
    • Continued relationship
        • The possibility of a continued relationship with the deceased is well-accepted outside the bounds of Western European cultures.
        • Is common in most Asian, African, and Hispanic cultures. Bonanno, 1998, 1999b; Kastenbaum, 1995;Opoku, 1989
        • In Chinese ancestral worship, for instance, elaborate and precisely enacted ceremonies are devoted to honoring the continued relationship with deceased relatives Ahern, 1973.
    • CULTURE AND CONTINUING BONDS
        • A prospective comparison of bereavement in the united states and the people’s republic of china
        • Kathleen M. Lalande and George A. Bonanno, 2006
        • The authors used data from a cross- cultural study of 61 participants from the United States and China who completed measures of continuing bonds and adjustment at 4 and 18 months of bereavement.
        • Higher levels of continuing bonds in the China at 4 months were related to better adjustment at 18 months.
    • Culture and continuing bonds
        • In contrast, results in the US showed that higher levels of continuing bonds were related to poorer adjustment at 18 months.
        • The data suggest that culture should be addressed in the development of effective grief therapies, especially when considering continuing bonds with the deceased.
    • Conclusion
      • Grief and loss: past, present and future Allan Kellehear 2002
      • Recent research has attempted to restore greater professional and conceptual balance to the earlier insights andconcerns.
      • There has been growing international acceptanceof a theory of “continuing bonds” — a recognition that people do not necessarily “let go”, but transform their former relationships by renewing their meanings about them and continuing the relationship in new ways.
    • Conclusion
      • There has been some recognition of the limits to professional help, reflected by the growing interest, worldwide, in support and self-help groups.
      • There has been greater attention to the different ways people grieve according to their own social norms, cultural prescriptions and personal styles.
    • Conclusion
      • Greater interest in normal and positive aspects of grieving. There is a growing realisation that the dead may be important role models for the grieving; that they may continue to be “significant others” to the bereaved.
      • We need to return our attention to the diverse expressions of normal and healthy grieving, while continuing to recognise that grief can cause marked health changes in some individuals. The new insights also highlight the limits to professional care and the need to create supportive environments in our communities for people living with loss as well as specialist medical and psychological services.
    • References
      • Amanda L Forte, Malinda Hill, Rachel Pazder and Chris Feudtner. Bereavement care interventions: a systematic review. BMC Palliative Care 2004, 3:3
      • Atchley R. C. & Barusch, A. S. Social forces and aging. Belmont, CA: Wadsworth 2004.
      • Attig, T. How we grieve: Relearning the world. New York: Oxford University press. 1996
      • Cavanaugh, J.C. & Blanchard-Fields, F. Adult development and aging (5th, ed). Belmont, CA: Wadsworth 2006.
      • Clark, S. E., Goldney, R. D. Grief reactions and recovery in a support group for people bereaved by suicide. Crisis 1995, 16, 27-33
      • Colin Murray Parkes. Bereavement: studies of grief in adult life, Edition: 2. Published by Taylor & Francis, 1986.
      • Currier J M, Holland J M, Neimeyer R A.The effectiveness of bereavement interventions with children: a meta-analytic review of controlled outcome research. Journal of Clinical Child and Adolescent Psychology. 2007 Apr-Jun;36(2):253-9.
      • Dale G. Larson, William T. Hoyt, Schmitz MF, Horwitz AV: Extending the bereavement exclusion for major depression ; Ann Acad Med, Singapore 2005;34:352-5
      • Dale G. Larson, Santa Clara University, William T. Hoyt, What Has Become of Grief Counseling? An Evaluation of the Empirical Foundations of the New Pessimism, Professional Psychology: Research and Practice, Vol. 38, No. 4.
      • Dillen L, Fontaine JR , Verhofstadt-Denève L . Are normal and complicated grief different constructs? a confirmatory factor analytic test. : Clinical Psychology Psychotherapy. 2008 Nov;15(6):386-95
      • Funk, Rainer. Erich Fromm: His Life and Ideas. Translators Ian Portman, Manuela Kunkel. New York: Continuum International Publishing Group, 2003.
      • Freud, S. (1957). Mourning and melancholia. In J. Strachey (Ed. And Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 152-170). London: Hogarth Press. (Original work published 1917)
      • Fulton, R. (1970). Death, grief, and social recuperation. Omega: Journal of Death and Dying, 1, p. 23-28.
      • Hogan NS, DeSantis L. Adolescent sibling bereavement, an ongoing attachment. Qual Health Res. 1992; 2(2) :159- 177
      • Hogan, Nancy S., Daryl B. Greenfield, and Lee A. Schmidt. "Development and Validation of the Hogan Grief Reaction Checklist." Death Studies 25 (2000):1–32
      • Hogan NS, Schmidt LA. Testing the grief to personal growth model using the structured equation modelling: death studies. 2002; 26:615- 634
      • Hooyman, N. R., & Kiyak, H. A. (2002). Social gerontology—A multidisciplinary perspective (6th ed). Boston: Allyn & Bacon.
      • Jacobs, Shelby, Carolyn Mazure, and Holly Prigerson. "Diagnostic Criteria for Traumatic Grief." Death Studies 24 (2000):185–199
      • Katherine Shear, Ellen Frank, Patricia R. Houck, Charles F. Reynolds III, Treatment of Complicated Grief ,A Randomized Controlled Trial. JAMA. 2005;293:2601-2608
      • Kendler KS, Myers J, Zisook S: Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry 2008; 165: 1449–1455 7.
      • Klass D, Silvermann P, Nickmann S eds. Continuing Bonds. A new understanding of grief. Washing D C. Taylor and Francis. 1996.
      • Lang, A. & Gottlieb, L. (1993). Parental grief reactions and marital intimacy following infant death. Death Studies, 17, 233-255
      • Lewis A: Melancholia: a clinical survey of depressive states, in Inquiries in Psychiatry: Clinical and Social Investigations. Edited by Lewis A. New York, Science House, 1967, pp 30–720
      • Lichtenthal WG, Cruess DG , Prigerson HG ; A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clinical Psychology Review. 2004 Oct;24(6):637-62.
      • Margaret Stroebe,Wolfgang Stroebe, Henk Schut 2003 Bereavement research: methodological issues and ethical concerns , Palliative Medicine 2003; 17: 235
      • O'Connor MF, Wellissch, Stanton A L, Eisenberger N I, Irwin M R, Lieberman M D. Craving love? Enduring grief activates brain's reward center. 2008 Aug 15;42(2):969-72.
      • Rando, Therese A. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press, 2000. Ann Acad Med Singapore 2005;34:352-5
      • Santrock, J. W. (2006). Life-span development. (10th ed). New York: McGraw-Hill.
      • Silverman, E., Range, L., & Overholser, J. (1994). Bereavement from suicide as compared to other forms of bereavement. Omega, 30, 41-51
      • Silverman PR, Nickmann SL, Worden JW. Detachment revisited The child's reconstruction of a dead parent. Am J Orthopsychiatry. 1992; 62(4) :494- 504
      • Simon N M, Shear K M, Thompson E H, Zalta A K, Perlman C, Reynolds C F, Frank E, Melhem N M, Silowash R; The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry 2007 Sep-Oct;48(5):395-9.
      • Wakefield JC, Schmitz MF, First MB, Horwitz AV: Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. Arch Gen Psych Rando, Therese A. Clinical Dimensions of Anticipatory Mourning. Champaign, IL: Research Press, 2000.
      • Wolfert, A. D. (1992). Understanding grief: Helping yourself heal. Florence, KY: Accelerated Development, Inc.
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