I wrote a blog post yesterday morning setting the scene for a two day workshop I was about to go to with Professor Kathy Shear on her treatment approach for complicated grief.  Well, how did the day go?  It was very interesting, inspiring, and also a little too much "simply sitting listening" for my tastes. It's hard to know what the best design for this kind of two day seminar should be. I strongly suspect though that just sitting taking in, even such excellent information with the opportunity for regular questions, isn't the most effective way of transferring knowledge.  Hard to do it, but more active audience participation would probably serve the workshop's goals even better.  Despite this, the material being shared was great ... really fascinating and important.

Some of the questions going round in my head were what is "complicated grief", how is it identified, how common is it, how "serious" is it as a condition, what is its prognosis untreated, how effective are current responses to it, what does Kathy's treatment add, and what other treatment options are currently available or in development?  Well, taking these questions in sequence, first "what is complicated grief?".   The excellent Center for Complicated Grief website states "Complicated grief is an intense and long-lasting form of grief that takes over a person’s life.  It is natural to experience acute grief after someone close dies, but complicated grief is different. Complicated grief is a form of grief that takes hold of a person’s mind and won’t let go.  People with complicated grief often say that they feel “stuck.”  For most people, grief never completely goes away but recedes into the background.  Over time, healing diminishes the pain of a loss.  Thoughts and memories of loved ones are deeply interwoven in a person’s mind, defining their history and coloring their view of the world.  Missing deceased loved ones may be an ongoing part of the lives of bereaved people, but it does not interrupt life unless a person is suffering from complicated grief.  For people with complicated grief, grief dominates their life rather than receding into the background."  Craig White, in his helpful book "Living with complicated grief" writes graphically (p.18) "With complicated grief you are, as it were, living in an eternal present of grief, stuck in the pain. There is no movement.  Complicated grief gets a grip - a stranglehold, even - on life and it is impossible to 'make peace' or reach a sense of resolution following the death.  You might feel that time is moving on and you are not. You or others may have noted that the mourning process seems to be stuck, derailed or unresolved." 

As with pretty much all psychiatric diagnoses, it's tricky to draw a precise dividing line between what qualifies as a formal disorder and what is considered a troublesome but normal process.  With complicated grief there is still debate on exact definitions and even whether one should use the term "complicated" or some other variant like "prolonged", "complex" or "traumatic".   What is clear is that there is a huge amount of suffering bound up in stuck or derailed grief processes.  Very sadly, health professionals are poor at identifying these complicated grief syndromes and are even worse at knowing how best to treat them.  Back in 2005, Piper & colleagues put forward a good argument that two simple questions could identify a high percentage of complicated grief sufferers - see "Screening for complicated grief: when less may provide more".  The questions are "Pictures about it popped into my mind" or "I tried not to think about it".  I have included these questions in a more general 15 item life events questionnaire, which is downloadable as a Word doc and as a PDF file.  More recently - in their excellent, freely downloadable article "Brief measure for screening complicated grief: reliability and discriminant validity" - Masayo Ito, Kathy Shear & colleagues tested a 5-item "Brief grief questionnaire" as a screening measure for complicated grief in a population who had experienced the death of a loved one "at least six months earlier".  This questionnaire is available as an appendix to the original Ito et al article, and here are copies as a Word doc and as a PDF file.  For those who score 4 or more on this assessment measure, it is recommended that they then fill out the full 19-item "Complicated grief inventory (CGI)", again available here as a Word doc and as a PDF file.  There is some debate about what score on the CGI qualifies as probable "Complicated grief".  In her recent research Kathy has studied populations with scores of 30 or more on the CGI.  Holly Prigerson, a developer of the questionnaire, has said that a score of over 25 suggests complicated grief.  In fact, Kathy commented that even scoring in the low 20's is often linked with excessive suffering & dysfunction that might well benefit from focused treatment.  

Kathy's proposed diagnostic criteria for complicated grief are (A) at least one symptom of the four following indications of persistent acute separation distress: 1. Persistent intense yearning or longing for the person who died.  2. Frequent intense feelings of loneliness or like life is empty or meaningless without the person who died.  3. Recurrent thoughts that it is unfair, meaningless or unbearable to have to live when a loved one has died, or a recurrent urge to die in order to find or to join the deceased.  4. Frequent preoccupying thoughts about the person who died, e.g. thoughts or images of the person intrude on usual activities or interfere with functioning. Plus (B) at least two of the following seven symptoms: 1. Frequent rumination about circumstances or consequences of the death.  2. Recurrent feeling of disbelief or inability to accept the death.  3. Persistent feeling of being shocked, stunned, dazed or emotionally numb since the death.  4. Recurrent feelings of anger or bitterness related to the death.  5. Persistent difficulty trusting or caring about other people or feeling intensely envious of others who haven’t experienced a similar loss.  6. Intense emotional or physical reactivity to reminders of the loss.  7. Change in behavior, e.g. excessive avoidance or the opposite, excessive proximity seeking.  Here are the criteria as a Word doc and here as a PDF file. 

So that's more information on what is "complicated grief" and how it's identified.  In further posts I'll look at how common it is, how "serious" it is as a condition, what its prognosis is untreated, how effective current responses are, what Kathy's treatment adds, and what other treatment options are currently available or in development - see, for example, the post "Complicated grief - how often does the grief process become stuck and why does this happen?"