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2015: Bereavment and Treating Bereavement-Related Conditions-Zisook

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Bereavment and Treating Bereavement-Related Conditions

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2015: Bereavment and Treating Bereavement-Related Conditions-Zisook

  1. 1. Sidney Zisook
  2. 2. 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 disclosures But 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
  3. 3. What is ordinary/normal grief? Treatment? What is Complicated Grief? Treatment? What is bereavement-related depression? Treatment?
  4. 4. TREATMENT?
  5. 5. Loss of a loved one is an experience shared by all humanity
  6. 6. Yet grief can leave us feeling more alone and confused than almost any other experience Bereavement Grief Grief: The expected response to bereavement
  7. 7. Grief is the form love takes when someone we love dies athy Shear, personal communication
  8. 8. Acute Grief (Time Limited) • Disbelief • Yearning; sorrow; intense emotions • Insistent thoughts • Sense of insecurity • Disengaged from ongoing life
  9. 9. 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 away Zisook and Shuchter, JCP, 1993
  10. 10. 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
  11. 11. 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
  12. 12. SUMMARY: “ORDINARYGRIEF” Bereavement Acute Grief Integrated Grief
  13. 13. TREATMENT?
  14. 14. 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.
  15. 15. Kate 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. 1. Adjustment Disorder 2. Major Depressive Disorder 3. PostTraumatic Stress Disorder 4. No Disorder 5. Persistent Complex Bereavement Disorder (ComplicatedGrief)
  19. 19. 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.
  20. 20. 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”
  21. 21. Prior Psychiatric conditions (especially mood, anxiety or substance use disorders) Trauma history Prior important losses Female gender Insecure early attachment Especially 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
  22. 22. Prominent caretaking role Children Chronically ill Especially close relationship Spouse Parent Soul Mate Untimely death Sudden death Loss due to suicide, homicide or accident Death 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
  23. 23.  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
  24. 24. Ordinary (Normal/Uncomplic ated) Grief Major Depression  PTSD
  25. 25. Sadness, dysphoria, irritability Insomnia/appetite changes Concentration difficulties Suicidality Functional impairment
  26. 26. Complicated Grief Major Depression Loss, 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)
  27. 27. Complicated Grief Major Depression Insistent 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
  28. 28.  Confrontation with death  Confusion, disorientation, shock  Disbelief  Intrusive thoughts, preoccupation  Avoidance behaviors
  29. 29. Triggered by loss Primary emotion: yearning Intrusive thoughts – person-related Nightmares rare Triggered by danger Primary emotion: fear Intrusive thoughts: event-related Nightmares frequent
  30. 30. Avoidance: loss-based Reminders linked to the person Proximity seeking is prominent Avoidance: fear- based Reminders linked to event Proximity seeking not seen
  31. 31. Shear et al., submitted Participants in HEAL Study with Complicated Grief (n=395) N % Current MDD 262 66% Current PTSD 154 39%
  32. 32. 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?
  33. 33. A 16-session psychotherapy model targeting CG symptoms Can be considered a form of CBT Uses strategies and techniques from CBT (primarily PE) IPT and MI
  34. 34. 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
  35. 35. 51% 71% 28% 32% 0% 20% 40% 60% 80% STUDY 1 (Pittsburgh) STUDY 2 (NYC) CGT produced better response than IPT in both studies CGT CGT IPT IPT Treatment response maintained at 6 month follow-up Shear et al 2005, 2014
  36. 36. Medication is not an effective treatment for CG CGT (or other evidence-based psychotherapy for CG) is the treatment of choice In the absence of CGT, informed clinical management helps Psychoeducation Empathic listening Symptom monitoring Support for a return to enjoyable activities without the deceased Shear et al, in press
  37. 37. Persistent ComplexBereavement 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
  38. 38. www.complicatedgrief.org
  39. 39. TREATMENT?
  40. 40. In 1980,theDSM-IIIAddedaBereavement ExclusionfortheDiagnosisof 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.
  41. 41. 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
  42. 42. 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 MDE Genetically influenced Similar personality characteristics as NBMD Similar symptom profile and impairment as NBMD Similar patterns of co-morbidity as NBMD Biological features, including sleep architecture, heart rate variability, immune impairment and cortisol dysregulation similar to NBMD Similar duration and risk of recurrence as NBMD Responds to antidepressant medications Treatment of BRD does not interfere with grief Treatment 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
  43. 43. 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-5Task Force: http://www.empr.com/dsm-5-approved-by-the-apa- board/article/270757/
  44. 44. Response to Objections Objection 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
  45. 45. Depression (small “d”) As in sad and blue – a “normal” emotion No Depression (big “D”) As in MDD – a miserable, disabling and chronic/recurrent condition Maybe – just like any other MDD If first occurrence and relatively mild, may wait and/or support and/or provide clinical management If more recurrent or severe, medication and/or psychotherapy To treat, or not to treat?
  46. 46. SUMMARY:BEREAVEMENTANDTHE DSM-5 Added Persistent Complex Bereavement Disorder Eliminated the Bereavement Exclusion
  47. 47. Question 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 treatment Clinical management and/or psychotherapy and/or medication

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