The video below is the section for Bereavement from Part 6 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 6, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Bereavement
NARRATIVE DEFINITION:
After a loved one has died, most individual’s experience marked sadness and may display other depressive symptoms such as insomnia, weight loss, and diminished appetite.
The ubiquitousness of such a response across our species signals the likely evolutionary adaptiveness of a period of “shutting down” and consolidating resources in the wake of serious loss.
The duration of the grief process varies on the basis of culture and context. Within the United States, the natural grieving process typically begins to resolve within a few months after a loved one’s death, but may last longer depending on the situation. Because certain depressive symptoms are so common after a person has experienced loss, Major Depressive Disorder is generally not diagnosed in grieving individuals without careful consideration based on the individual’s history and cultural norms for the expression of distress in the context of loss. In addition to prolonged, but relatively mild, depressive symptoms, the presence of more severe symptoms may suggest that an individual’s distress goes beyond normal Bereavement. Psychomotor retardation, feelings of worthlessness, psychotic symptoms other than transiently experienced auditory or visual perceptions of the deceased, suicidal ideation, feelings of guilt, and significant impairment in functioning may be more indicative of Major Depressive Disorder than of a grief reaction. Emptiness and loss are the predominant emotions in grief, whereas pervasive anhedonia (loss of pleasure) dominate Major Depressive Disorder. Waves of dysphoria associated with the deceased are indicative of grief, while unremitting feelings of worthlessness and self-lothing characterize Major Depressive Disorder.
In some cases, pathological grief reactions may involve symptoms reminiscent of Post-Traumatic Stress Disorder such as intrusive thoughts about or memories of the deceased and avoidance of places, people, and situations that evoke memories of the deceased. Individuals who were overly dependent on the deceased, who had negative feelings toward the deceased, or who have had difficulty with other major losses are at high risk of developing pathological grief reactions.
Risk factors for developing a pathological grief reaction include a history of depression, concurrent life stresses, difficulty expressing emotions, and lack of social support. Individuals experiencing a pathological grief reaction may become preoccupied with or intensely fearful of death; in some cases, they may manifest symptoms similar to those that were experienced by the deceased. Other individuals attempt to preserve things in the way they were when the deceased was alive, for example, by maintaining the deceased’s bedroom and personal effects as if he or she would return.
Children, particularly between the ages of 3 and 5 and during early adolescence, may be vulnerable to developing psychological disorders in response to grief. It is, however, important to recognize that children’s outward displays of Bereavement may not be the same as those of adults. Importantly, normal childhood reactions should not be pathologized. Children often incorporate their feelings into imaginative play; for example, they may engage in make-believe funerals with their dolls.
Children may also react to death in very practical or concrete ways. For instance, after losing a parent, children may worry about the financial well-being of the family. In many cases, children’s grief reactions involve anger (e.g., toward the deceased, surviving loved ones, doctors, God, and themselves); acting out in school or at home is common. Children sometimes interpret death as abandonment and may be fearful that they are responsible for the death. They are also likely to be concerned that other loved ones will soon die.
Research suggests that children who attend their loved one’s funeral or participate in other mourning rituals show less deviant behavior after a death. Research also indicates that behavioral and emotional problems are less likely to occur when children are allowed to cry openly and discuss the deceased with other people in their lives.
The DSM-5 includes a section called “Conditions for Futher Study,” which includes disorder that will be proposed as additions to the DSM once research has demonstrated adequately that they belong. Included in this section is the proposed diagnosis, Persistent Complex Bereavement Disorder. Persistent complex bereavement disorder occurs at any age and affects 2.4% to 4.8% of the population and is more common in females than in males. Risk for developing persistent complex bereavement disorder is heightened when there was increased dependency on the deceased person prior to the death or by the death of a child.
FLASHCARD:
Bereavement
1. Not a mental disorder but still come to clinical attention
2. Nearly all humans experience some behavioral expressions linked to depression after a major loss
Major depression
1. Not diagnosed unless grief symptoms are prolonged or involve such serious features as psychomotor retardation, feelings of worthlessness, psychotic symptoms, suicidal ideation, excessive guilt, and the like
2. Pathological grief reactions more likely in those with histories of depression, life stress, trouble with emotional expression, low social support
3. Major depressive disorder is more persistent and not tied to specific thoughts or preoccupations of the deceased
Children
1. May express grief in developmentally appropriate ways (e.g., play acting a funeral); open expression of emotion may prevent behavioral and emotional problems in children
QUESTION:
Which of the following symptoms is more indicative of a pathological grief reaction than normal bereavement?
ANSWERS:
A. A combination of marked sadness, weight loss, and decreased appetite.
B. Extreme feelings of hopelessness and isolation for more than one month.
C. Morbid preoccupation with worthlessness
D. Insomnia
RATIONALE:
C is correct. Of the responses listed, preoccupation with personal worthlessness is more indicative of a pathological reaction to grief. Sadness, weight loss, and decreased appetite are normal grief reactions in response to significant loss. Extreme feelings of hopelessness and isolation (B) could be indicative of Major Depression, but would not be considered pathological if the response is within two month of the loss. Insomnia could be normal or extreme depending on the length of time exhibited, but as one symptom, extreme preoccupation with personal worthlessness is more indicative of a pathological grief reaction than insomnia.