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Bereavement full


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Bereavement full

  1. 1. Welcome to Topic presentation Dr. Panchanan Acharjee MD (Psychiatry) Phase-A Resident B.S.M.M.U.
  2. 2. Bereavement & Grief
  3. 3. Overview: Definitions Normal course Theorists Types Physiological and neurological processes Grief and developmental stages Stages of grief Styles of grief response Losses Complicated grief Risk factors for complicated grief Management
  4. 4. Definitions Bereavement = the state of being deprived of someone by death and refers to being in the state of mourning. Kaplan and Sadock's Synopsis of Psychiatry 10th edition; Page-62) Broad term that encompasses the entire experience of family members and friends in the anticipation, death and subsequent adjustment to living following the death of a loved one. Report on Grief and Bereavement Research, Center for the Advancement of Health, 2004)
  5. 5. Definitions Grief = the subjective feeling precipitated by the death of a loved one. Kaplan and Sadock's Synopsis of Psychiatry 10th edition; Page-62) Subjective experience of loss. (Sabar : Complex set of cognitive, emotional, and social difficulties that follow the death of a loved one. Report on Grief and Bereavement Research, Center for the Advancement of Health, 2004)
  6. 6. Definitions Mourning = the process by which grief is resolved; it is the societal expression of postbereavement behavior and practices. Kaplan and Sadock's Synopsis of Psychiatry 10th edition; Page-62) A public process involving recognition by others support and social, cultural and religious customs and rituals Root meaning: “remembering with care and sorrow” Sabar :
  7. 7. Normal course of Bereavement 1) 2) 3) 4) Protest: Initial numbness, sense of unreality. Searching behavior: Waves of distress occur as bereaved suffer intense pining, yearning. Despair & detachment: Disorganization emerges as loneliness sets in. Re-organization & recovery: Kaplan and Sadock's Synopsis of Psychiatry 10th edition; Page-63)
  8. 8. Common Myths about Grief All bereaved grieve in the same way It takes a year to “get over” a significant loss It’s better to not think or talk about the pain The intensity and length of your grief reflects how much you loved the deceased
  9. 9. Grief Theorists : • John Bowlby : - The stronger or more ambivalent the attachment, the stronger the grief reaction. • William Worden- Four Tasks of Mourning . • Monica McGoldrick - Family Grief Response • Therese Rando • Judy Tatelbaum
  10. 10. Different types of grief: Anticipatory grief Normal/ common grief Complicated grief: - Inhibited/ absent grief - Delayed grief - Chronic grief - Distorted grief Bonanno GA, Kaltman S: The varieties of grief experience. Clin Psychol Rev 21 (5): 705-34, 2001. [PubMed]
  11. 11. Normal Grief Self-limiting Common symptoms gradually diminish There is an increasing acceptance of the reality of death Steady integration of loss Grief is seen as normal Easing of symptoms can be observed 6 months to a year following the death. When it needs clinical attention, termed as uncomplicated grief.
  12. 12. Normal Grief Reaction Stage -1 : Hours to days Stage -2 : Weeks to 6 months Stage-3: Weeks to months Denial Disbelief Numbness Sadness, weeping, waves of grief. Somatic symptoms of anxiety Poor sleep, Guilt, Blame of others, Illusions, hallucinations Preoccupation with memories of the deceased Social withdrawal Symptoms resolve Social activities resumed Memories of good times (Shorter Oxford Textbook of Psychiatry, 6th Edition, Page-172)
  13. 13. Points to remember: The stages don’t always occur in order. Neither the patient nor the loved one, escapes grief. People grieve at different rates of time. Cultural differences, age, gender, race, and personality change the way people grieve. Bereaved persons have higher rates of depression, and are at greater risk for illness than non-bereaved.
  14. 14. Normal Grief Somatic distress. Emotional distress. Physical responses. Behavioral changes. Physiologic changes.
  15. 15. Physiological and neurological processes Studies of fMRI scans of women showed that grief produced a local inflammation response as measured by salivary concentrations of pro-inflammatory cytokines These responses were correlated with activation in the anterior cingulate cortex and orbitofrontal cortex.
  16. 16. Grief causing stress is linked with the emotional processing parts of the frontal lobe. Activation of the anterior cingulate cortex and vagus nerve is similarly implicated in the experience of heartbreak. O'Connor, Mary-Frances; Irwin, Michael R.; Wellisch, David K. (2009). "When grief heats up: Pro-inflammatory cytokines predict regional brain activation". NeuroImage 47 (3): 891–6
  17. 17. Those who report many intrusive thoughts about the deceased show ventral amygdala and rostral anterior cingulate cortex hyperactivity Freed, Peter J.; Yanagihara, Ted K.; Hirsch, Joy; Mann, J. John (2009). "Neural Mechanisms of Grief Regulation". Biological Psychiatry 66 (1): 33–40.
  18. 18. Grief and Developmental Stages Age Understanding of Death Is not yet able to understand death. Infancy to 2 years Separation from mother causes changes. Expressions of Grief Quietness, crankiness, decreased activity, poor sleep, and weight loss.
  19. 19. Death is like sleeping. Asks many questions (How does she go to the bathroom? How does she eat?). Problems in eating, sleeping, and bladder and bowel control. Fear of abandonment. Tantrums. 2–6 years Dead person continues to live and Magical thinking (Did I think function in some something or do something that ways. caused the death? Like when I Death is temporary, said I hate you and I wish you not final. would die?). Dead person can come back to life.
  20. 20. Death is thought of as a person or spirit Asks specific questions. (skeleton, ghost, bogeyman). 6–9 years May have exaggerated fears about school. Death is final May have aggressive behaviors (especially boys). and frightening. Some concerns about imaginary illnesses. Death happens to others; it will not happen to ME. May feel abandoned.
  21. 21. Everyone will die. Death is final and 9 and older cannot be changed. Even I will die. Heightened emotions, guilt, anger, shame. Increased anxiety over own death. Mood swings. Fear of rejection; not wanting to be different from peers. Changes in eating habits. Sleeping problems. Regressive behaviors (loss of interest in outside activities). Impulsive behaviors. Feels guilty about being alive (especially related to death of a brother, sister, or peer). (Source: Wass H, Corr CA: Childhood and Death. Washington, DC: Hemisphere Publishing Corporation, 1984.)
  22. 22. Issues for grieving children There are three prominent themes in the grief expressions of bereaved children: - Did I cause the death to happen? - Is it going to happen to me? - Who is going to take care of me? (Doka KJ, ed.: Children Mourning, Mourning Children. Washington, DC: Hospice Foundation of America, 1995.)
  23. 23. Helping Children to Cope Be straightforward; distortions can do lasting harm i.e. “he’s gone to sleep” can lead to a fear of sleep or “God took her,” leads to a hate for God. Reassure that they are no way to be blamed and will be taken care of. Let child participate in the family sorrow and grief. Give as much attention to the child who cries as to the one who doesn’t cry. Silence between family and friends makes it worse. Don’t say, “you are the man of the house now” or “be brave.”
  24. 24. Basic Grieving Styles : • Both intuitively and instrumentally • Tend to express emotions intensely • Usually have a greater emphasis on one polarity to • Respond to loss cognitively • Modulate emotion Instrumental Blended • Respond loss • Through emotion Intuitive • Respond to loss: • Express grief in terms of thoughts and activity
  25. 25. Primary Loss:  Significant loss event, such as death
  26. 26. Secondary Losses Arise as a chain of events from primary loss - Death of spouse: loss of companionship, financial security, sexual intimacy, family role, social status - Job loss: self-esteem, identity, financial security, sense of future - Childhood sexual abuse: loss of innocence, trust, sense of control, etc. - Mental illness: loss of control over emotions, thoughts, family role, loss of occupation
  27. 27. Ambiguous Loss (AL) Two types 1. Physically absent /psychologically present: (e.g. kidnapping, people missing from natural disaster, divorce situations, baby put up for adoption) 2. Physically present / psychologically absent: person is emotionally and cognitively missing (Alzheimer’s, traumatic brain injury, addictions) The uncertain characteristics of AL can cause long term dysfunctional coping, often contributing to complications in the grieving process .
  28. 28. Let’s talk about complicated grief:
  29. 29. Prolonged or Complicated Grief as a Mental Disorder In an attempt to clearly distinguish between normal grief and complicated grief, following are the proposed diagnostic criteria for complicated grief:
  30. 30. Criterion A: Person has experienced the death of a significant other, and response involves three of the four following symptoms, experienced at least daily or to a marked degree: - Intrusive thoughts about the deceased - Yearning for the deceased - Searching for the deceased - Excessive loneliness since the death.
  31. 31. Criterion B: In response to the death, of the following symptoms are experienced at least daily or to a marked degree: - Purposelessness or feelings of futility about the future. - Subjective sense of numbness, detachment, or absence of emotional responsiveness. - Difficulty acknowledging the death (e.g., disbelief). - Feeling that life is empty or meaningless. - Feeling that part of oneself has died. - Shattered worldview (e.g., lost sense of security, trust, control). - Assumption of symptoms or harmful behaviors of, or related to, the deceased person. - Excessive irritability, bitterness, or anger related to the death.
  32. 32. Criterion C :  The disturbance (symptoms listed) must endure for at least 6 months. Criterion D : The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. Prigerson HG, Vanderwerker LC, Maciejewski PK: A case for inclusion of prolonged grief disorder in DSM–V. In: Stroebe MS, Hansson RO, Schut H, et al., eds.: Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association, 2008, pp 165-86.
  33. 33. DSM-5TM, Section-III, Conditions for Further Study, Page : 789 - 792 Persistent Complex Bereavement Disorder. Criterion A- Criterion E Duration: At least 12 months in adult 6 months in children
  34. 34. Clinical Presentations of Complicated Grief Category Features Inhibited/ Delayed grief Avoidance postpones expression Chronic grief Perpetuation of mourning long-term Traumatic grief Unexpected and shocking form of death Depressive disorder Both major and minor depressions Anxiety disorder Insecurity / relational problems Alcohol and Substance abuse/ dependence Excessive use of adaptive coping PTSD Persistent, intrusive images with cues Psychotic disorder Manic, severe schizophrenia substances depressive impairs states, and Oxford textbook of Palliative Medicine, Third Edition, 2005.
  35. 35. Grief vs. Depression Depression Grief Consistent depressed mood Mood fluctuates Pain is chronichard to identify origin Pain directly related to loss Little decrease in somatic symptoms Decrease in somatic symptoms with time
  36. 36. Grief vs. Depression Depression Self esteem gradually decreases over time Isolation from self and others the norm May have suicide plan active Grief Sudden decline in self esteemrelated to loss Support from others reassuring May have vague thoughts of suicide
  37. 37. Grief and Anxiety: Anxiety symptoms are more prominent than depression and can be independent or comorbid. Depression related to lack of positive events, anxiety to presence of negative events. When anxiety and depression are comorbid, each tend to be more severe. (Watson, Clark & Carey (1988))
  38. 38. Risk Factors for Complicated Grief Category Range of Circumstances Nature of the death Untimely within life-cycle; sudden, unexpected, traumatic, stigmatized. Strengths and vulnerabilities of the carer/bereaved Past h/o of psychiatric d/o, personality/coping style, cumulative experience of losses. Nature of the relationship w/ the deceased Overly dependent, ambivalent. Family and support network Dysfunctional family, isolated, alienated. Oxford textbook of Palliative Medicine, Third Edition, 2005.
  39. 39. Management:  Counseling  Medication  Support Groups  Psychotherapy (Shorter Oxford Textbook of Psychiatry, 6th Edition, Page-173)
  40. 40. Counseling:  Help maybe needed to - accept that the loss is real. - work through the stages of grief - adjust to life without the deceased.  Parents who are grieving for stillborn child need special help. (Shorter Oxford Textbook of Psychiatry, 6th Edition, Page-173)
  41. 41. WHAT NOT TO SAY Call me. Casually ask, “How are you? I know exactly how you feel. It was probably for the best. He/she is happy now. It is God’s will. It was time to go. I’m sorry I brought up the subject. Let’s change the subject. You should be getting over this by now
  42. 42. WHAT NOT TO SAY …cont I have had other patients with the same illness and they suffered for a long time. You should be glad your loved-one passed away so quickly. You’re strong enough to cope with the loss. Be thankful you have your other children. You can always have more children. I lost my loved one… I understand, my loved-one was very sick too. Be happy he/she was only 6 months old and not six years. (Holly, Jacobs, & Selby, 2001;)
  43. 43. WHAT TO SAY I’m sorry for your loss. I can’t imagine the pain you are going through. What do you remember about [the deceased’s name] today? Say [deceased’s] name. Talk about deceased. Do you have any questions about the illness and treatment provided? How are you feeling? How has loss affected you? (Holly, Jacobs, & Selby, 2001)
  44. 44. Medication:  Cannot remove the distress of normal grief.  May be needed in special circumstances. - Anxiolytic or hypnotic for restoration of sleep - Anti- depressent if depressive criteria met. (Shorter Oxford Textbook of Psychiatry, 6th Edition, Page-173)
  45. 45. Psychotherapy:  For adults experiencing normal grief, interventions are likely to be unnecessary and largely unproductive, may even be harmful.  For adults at risk, may provide some benefit (esp in short term),  Complicated grief likely to provide benefit. (Report on Grief and Bereavement Research, 2004.)
  46. 46. Formal Bereavement Interventions Guided mourning (“grief work”). Interpersonal therapy. Psychodynamic therapy. Cognitive-Behavioral therapy. Brief Group Psychotherapy. Basic aids, art and music therapy.
  47. 47. Grief Therapies Basic thing is a supportive-expressive intervention causing shift in cognitive appraisal of the reality that is forever altered. Variation influenced by age, perception of support, nature of the death, personal health/co-morbidities of the bereaved.
  48. 48. Three Roles  Witness  Facilitator  Collaborator
  49. 49. Key Technique in Working With Loss, Grief, and Bereaved Clients  Master the Art of Silence  Respectful silence is bearing witness  Silence punctuates moments, prompts reflection, provides support, deepens process, and is healing  Create a space for coping, holding, adapting  Do not solve grief  Do not rescue grief
  50. 50. Thank You!