Life after death of a loved one…Bereavement

Bereavement, grief & mourning are terms that apply to the psychological reactions of those who survive a significant loss.

1.Bereavement:

is the complete set of reactions that occurs with the death of a loved one .

2.Grief:

is the subjective feelings precipitated by the death of a loved one.

3.Mourning:

is the process by which grief is resolved.
It is the societal expression of post bereavement behaviour & practices.

Funeral & Cremation acknowledge the real & final nature of death, countering denial.
These rituals protect the survivors from isolation & set a time limit of grief.

Intense grief do not usually continue beyond 4-6 months. Continuing beyond this time suggests the possibility of pathological response.

Persistent complex bereavement disorder:

DSM-V Criteria

A. Death of someone in close relationship.
B. At least 1 of the following symptoms should be present to a clinically significant degree & has persisted for :

>12months in adults.
>6months in children.

1. Persistent yearning/longing for the deceased.
2. Intense sorrow & emotional pain in response to death.
3.Preoccupation with the deceased.
4.Preoccupation with the circumstances of the death.

C. At least 6 of the following are present:

👉Reactive distress to the death:
1. Marked difficulty accepting the death.
2. Experiencing emotional numbness over the loss.
3. Difficulty with positive reminiscing about the deceased.
4. Bitterness/Anger related to the loss.
5. Maladaptive appraisals about oneself in relation to deceased or death (e.g-self-blame)
6. Excessive avoidance of reminders of the loss.
👉Social /identity disruption:
7. A desire to die in order to be with the deceased.
8. Difficulty trusting other individuals since the death.
9. Feeling alone or detached from other individuals since death.
10. Feeling that life is meaningless without the deceased.
11. Confusion about one’s role in life or a diminished sense of self identity.
12. Difficulty or reluctance to pursue interests or to plan for the future.

D. Disturbance causes clinically significant distress in social, occupational or other important areas.
E. Reaction is out of proportion to cultural/religious/age appropriate norms.

Risk  Factors:

1. Pre-existing vulnerability:

(a) Avoidant & Dependent personalities
(b) Polymorphism of 5HTTLPR gene
(c) Prior loss (Multiple losses in a short period)
(d) Separation anxiety in childhood.
(e) Substance abuse
(f) Pre-existing psychiatric disorder.

2.Nature of lost relationship:

Death of child is associated with greater vulnerability.

3. Circumstances of death:

(a) Sudden unexpected death brings an extra level of emotional shock.
(b) Death due to homicide or the mass violence of terrorism may lead to fear and anxiety along with distress.

(c) When people are missing, believed dead, the uncertainty may lead to alternating hope & dread.

4. Social support:

Poor family support & social network make them more vulnerable.

5. Multiple other adversities:

Financial difficulties, loss of resources, changed status, physical illness or injuries may increase vulnerability.

Effects on mental health

•Anxiety disorder.
•Depression.
•Substance abuse.
•Bipolar disorder.
•Traumatic stress disorder (when there is violent death).
•Suicide.

Management

•Telling the bereaved person how to grieve, that they should ‘forget about the past’, that ‘time heals all’ is usually perceived as unhelpful.

•Counseling requires hopeful, compassionate, psychotherapeutic intervention which recognizes the human suffering involved, validate the person’s strength & respect their spiritual needs.

•Treating grief as a disease (for ex. giving Antidepressants for normal grief), interferes with their capacity to grieve for their loved one.

•If assessment indicates that psychiatric disorders have arisen (Depression, Anxiety, Post-Traumatic Stress Disorder or Substance use disorder), these conditions should be treated with medicines alongside counseling for the bereavement.

•They should be assessed for suicidal risk & managed accordingly.

Reference:

  • New Oxford Textbook of Psychiatry(2nd edition).
  • Kaplan and Sadock’s Synopsis of Psychiatry: 11th Edition

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