Curr Psychiatry Rep (2013) 15:406

DOI 10.1007/s11920-013-0406-z

GERIATRIC DISORDERS (H LAVRETSKY, SECTION EDITOR)

Bereavement and Complicated Grief

M. Katherine Shear & Angela Ghesquiere &
Kim Glickman

Published online: 26 September 2013

# Springer Science+Business Media New York 2013

Abstract Bereavement is a common experience in adults Introduction

aged 60 and older. Loss of a loved one usually leads to acute
grief characterized by yearning and longing, decreased inter- “Grief turns out to be a place none of us know until we
est in ongoing activities, and frequent thoughts of the de- reach it…Nor can we know ahead of the fact…the
ceased. For most, acute grief naturally evolves into a state of unending absence that follows, the void, the very oppo-
integrated grief, where the bereaved is able to reengage with site of meaning, the relentless succession of moments
everyday activities and find interest or pleasure. About 7 % of during which we will confront the experience of mean-
bereaved older adults, however, will develop the mental health inglessness itself.” (p. 188–9) Joan Didion The Year of
condition of Complicated Grief (CG). In CG, the movement Magical Thinking [1]
from acute to integrated grief is derailed, and grief symptoms
remain severe and impairing. This article reviews recent pub-
lications on the diagnosis of CG, risk factors for the condition Didion’s book is a vivid and powerful description of her
and evidenced-based treatments for CG. Greater attention to grief following the sudden death of her 71-year-old husband,
CG detection and treatment in older adults is needed. her close companion for more than 40 years. She finds the
experience to be (perhaps thankfully) unlike anything she could
have imagined. In this, Didion’s response is not unique. Though
Keywords Complicated grief . Bereavement . Older adults . bereavement is an event experienced by all humanity, there are
Grief . Loss . Attachment theory . Symptoms . Treatment . few events as unfamiliar or as unsettling. Clinicians can assist
Psychiatry the bereaved to cope with bereavement and its disruptive con-
sequences. However, treatment of the bereaved can be contro-
versial because the pain and disruption are universal and intrin-
sic to the situation. It can be challenging to distinguish between
typical bereavement responses and more intense reactions that
This article is part of the Topical Collection on Geriatric Disorders
could constitute a mental health disorder.
M. K. Shear (*) Bereavement and its care are particularly relevant to older
Columbia University School of Social Work, Room 829,
adults because they experience bereavement at a much higher
1255 Amsterdam Avenue, New York, NY 10027, USA
e-mail: [email protected] rate than younger adults; one study found that over 70 % of
older adults experienced bereavement in a 2.5-year period [2].
A. Ghesquiere Spousal loss is very common [3], but deaths of friends or non-
Weill Cornell Medical College Psychiatry, 21 Bloomingdale Road, 7
spousal relatives (especially siblings) may account for the
South, White Plains, NY 10605, USA
e-mail: [email protected] greatest proportion of losses among older adults [2, 4]. In
order to be optimally supportive to bereaved older adults, it
K. Glickman is important for clinicians to be knowledgeable. The purpose
Department of Social Sciences, School of Health and Behavioral
of this article is to provide details on recent research on
Sciences, York College of the City University of New York,
94-20 Guy R. Brewer Blvd., Jamaica, NY 11451, USA bereavement and bereavement care in older adults that may
e-mail: [email protected] be useful to clinicians.
406, Page 2 of 7 Curr Psychiatry Rep (2013) 15:406

We begin by clarifying terminology. We use the term Dyregrov and Dyregrov [7] point out, however, that certain
bereavement to refer to the experience of having lost a loved difficult circumstances of a death can leave virtually everyone
one, not the response to such a loss. Grief refers to the desirous of professional support. For example, after a suicide,
psychobiological response to bereavement. Acute grief is the up to 80 % of bereaved people say that they want professional
initial response, often intense and disruptive. Integrated grief help [8]. When the bereaved do seek support, clinicians can
is the permanent response after adaptation to the loss in which add their voices to the chorus of support, bringing both their
satisfaction in ongoing life is renewed. Complicated grief is a professional expertise and their humanity to the encounter.
form of prolonged acute grief, where the term complicated is They can educate people about the rocky uncharted pathway
used in the medical sense of a superimposed process that ahead. However, they must be humble in their expertise.
impedes healing. Complicated grief is a distinct mental health Informed clinicians can provide Sherpa-like guidance to be-
disorder. Mourning denotes the array of psychological pro- reaved people, walking by their side as they navigate the
cesses set in motion by the loss to facilitate adaptation [5]. arduous path to rediscovery of meaning and purpose, and
new possibilities for joy and satisfaction.

Is Grief an Illness? The Consequences of Bereavement in Older Adults

Some say grief should not be pathologized, as though a It is important that any clinicians working with bereaved older
clinician would choose to create pathology when our whole adults be aware that bereavement in older adults can be
purpose is to relieve it. Inflammation is the painful, universal associated with a number of negative outcomes. Loss of a
response to exposure to certain bacteria, yet we do not debate loved one is associated with worsening health, including
whether a clinician is pathologizing a natural human experi- weight loss, increased rates of illness and functional impair-
ence by diagnosing and treating it. However, mental disorders ment [9, 10]. Mostofsky et al. [11•] analyzed data from the
carry the added burden of stigma, and there is the diagnostic Determinants of Myocardial Infarction Onset Study (mean
challenge that most mental disorders exist on a continuum age 61; MIOS) and documented a 21.1-fold (95 % CI 13.1–
with normal functioning. Perhaps for these reasons, a diagno- 34.1) increase in incidence of MI within 24 h of learning of the
sis can sometimes seem like a gratuitous negative judgment death of a loved one. Incidence declined each subsequent day
rather than a first step in accessing appropriate treatment. but remained significantly elevated for a month. Khanfer et al.
Again, Didion’s clearly articulated discourse is helpful. She [12•] studied older adults (average age 73) bereaved for
writes: “The power of grief to derange the mind has…been 2 months compared to age and sex-matched non-bereaved.
exhaustively noted…The mourner is in fact ill, but because this Bereavement was associated with lower neutrophil superox-
state of mind is common and seems so natural…we do not call ide production when challenged with bacteria or a protein
[it] an illness” (p.34, quoting Melanie Klein). Freud also felt kinase activator, and higher cortisol/DHEAS ratios that corre-
that grief should not be considered a mental disorder [6], and lated with elevated depressive and anxiety symptoms. Anoth-
many clinicians follow Freud and Klein and do not regard any er study assessed cardiovascular and immune functioning at
grief response as an illness. Yet, many bereaved people are 2 weeks and 6 months post-loss in bereaved relatives (average
suffering. What then is the role of clinicians in the management age 65) of patients who died in an ICU. The authors found
of grief? When and how should clinicians provide help? changes in blood pressure, heart rate, sleep, neuroendocrine
The answers to these questions are not clear-cut. Dyregrov and immune functioning [13]. Most of these changes normal-
and Dyregrov [7] stress the importance of relying on existing ized by 6 months post-loss, however.
social supports for bereaved people, and we concur with this Bereavement also appears to increase risk for mortality in
perspective. Providing comfort and support in the early be- the early period after the event. In a large primary care data-
reavement period is usually very natural for family, friends, base in the UK, bereavement was associated with increased
neighbors and others in the community. There are prescribed hazard of mortality, 1.25 (CI 1.21, 1.37), highest in the first
periods of contact such as visitation, funeral, sitting shiva and 90 days. This finding was stronger for those with no recorded
other ritualistic gatherings. Others can be helpful as caring chronic medical conditions prior to the loss and among those
listeners who share in reminiscence and join in seeking an- from high-income communities [14•]. Spouses bereaved by
swers to unanswerable questions; they must resist the urge to unexpected death also have a higher rate of mortality [15].
provide answers or gratuitous advice. As time goes on, These increased mortality rates appear to be attributed primar-
though, others can provide gentle encouragement to re- ily to suicide, accidents, heart disease and cancer [9].
engage in ongoing life, even when the bereaved person is In addition, bereavement is associated with changes in
not well motivated to do so. For most bereaved individuals, social and emotional factors in older adults, including a de-
natural social supports will be sufficient. crease in satisfaction and well-being and an increase in
Curr Psychiatry Rep (2013) 15:406 Page 3 of 7, 406

loneliness and social isolation [9, 16]. However, there appear testing diagnostic criteria, and Prigerson et al. published an
to be substantial variations in these outcomes based on socio- influential series of papers with an evolving set of proposed
economic factors. Arbuckle and De Vries [17] examined criteria (e.g., [24, 25]). However, the Prigerson criteria were
functioning, life satisfaction and hopefulness for the future based upon results of community studies with a small number
2–15 years after older adults lost a child or a partner. They of individuals with CG. Our group [26•, 27•] proposed a
found bereaved elders experienced less satisfaction and less slightly different set of diagnostic criteria based upon clinical
hopefulness but greater self-efficacy than controls who were experience and a much larger data set of individuals with CG
not bereaved. Negative social and health effects were signif- who sought help. The recently released fifth edition of the
icantly greater among women, and less education and income American Psychiatric Association’s Diagnostic and Statistical
were also associated with worse bereavement outcomes. An- Manual (DSM-5) includes criteria for CG in the section on
other study found that, in households where married couples “Disorders Requiring Further Study.” Here, the condition is
had high-loss intra-household financial dependency, after called “Persistent Complex Bereavement Disorder” [28]. Table 1
widowhood, in households with high financial dependency, outlines the DSM-5 criteria for diagnosis in adults.
bereaved men (the breadwinners) compared to married con- While these various criteria sets differ in some respects and
trols, experienced a significant loss in global well-being, consensus still needs to be reached, all proposals include symp-
whereas both widows and widowers experienced greater toms of prolonged acute grief, such as frequent intense yearning,
bereavement-related psychosocial distress. Bereaved women intense sorrow and emotional pain, preoccupation with the de-
experienced greater financial distress, regardless of pre-loss ceased and/or circumstances of the death, excessive avoidance of
dependency status [18]. reminders of the loss, difficulty accepting the death, feeling alone
and empty, and feeling that life has no purpose or meaning
without the deceased person. Identified CG symptoms also meet
Complicated Grief in Older Adults many of the criteria outlined by Stein and colleagues [29] needed
to confirm validity of a new diagnostic entity. We and others are
For most bereaved older adults, the health and emotional currently conducting a field trial of the proposed DSM-5 CG
consequences of bereavement resolve in a few months, and criteria, as well as alternative proposed criteria. We believe that
pre-loss functioning is restored [19]. However, for a clinically consensus will be reached in the near future.
significant minority, complications derail the natural mourn- As with all mood and anxiety disorders, the co-occurrence
ing process and prolong acute grief, resulting in a mental of CG and major depressive disorder (MDD) [30, 31] is
health condition. There is ongoing debate over what this common, with studies finding that 25 % of those with
condition should be called. Our group has used the term bereavement-related depression have CG, and 36-55 % of
“complicated grief” (CG) because (1) much of the literature those with CG have comorbid depression [32–34]. However,
has been published using that designation and (2) it is a non- CG has been found to constitute a distinct cluster of symptoms
pejorative yet descriptive term. that can be distinguished from depression [23, 35]. Table 2
George Engel [20] conceived of grief as analogous to outlines clinical differences between CG and MDD. It is
infection or injury, and we agree with this conceptualization important to identify CG even when it is comorbid with
[21•]. Thus, we also use the term “complicated” in the medical depression because CG has unique clinical features and ap-
sense of a superimposed condition that impedes the course of pears to require unique treatment. Treatment of CG in patients
another health problem (in this case, typical acute grief). For with depression is associated with reductions in depressive
some bereaved individuals, the natural healing process is symptoms [36] but the reverse is not true [37]. More detail on
interfered with by various complications, just as a wound does CG treatment is provided below.
not heal properly when it becomes infected. The injury anal- A recent population-based survey found 6.7 % of bereaved
ogy is apt for bereavement because healing requires painful individuals develop CG, and individuals 61 and older had
emotional activation similar to the physical pain of a wound. more than double the rate (9 %) of younger adults. Older
Grief becomes complicated when there are problems related to women in particular had a rate of CG (9.6 %), much higher
the circumstances, consequences or context of the loss or by than that of younger adults (2.7 %) [38••]. CG can be chronic
an internal problem with the adaptation process. Didion does and persistent, markedly interfering with functioning. For
not like the term “healing,” and the analogy is not perfect, but example, Stammel et al. [39] surveyed 775 Cambodians
considering a loss to be similar to a serious injury recognizes who had lost at least one family member during the Khmer
the severity of the pain and disruption, the possibility for Rouge regime and found 14 % endorsed CG 30 years later.
complications and the potential usefulness of clinical atten- CG can be reliably detected with standardized measures, such
tion, without implying an underlying problem. as the Inventory of Complicated Grief (ICG) [40]. Reliable
CG was first proposed as a diagnostic entity for DSM IV by measures of CG have also recently been developed and tested
Hartz [22]. Horowitz et al. [23] published a seminal paper for people with intellectual disabilities [41] and validated in other
406, Page 4 of 7 Curr Psychiatry Rep (2013) 15:406

Table 1 DSM-5 criteria for persistent complex bereavement disorder Table 2 Comparison of major depressive disorder and complicated grief

A. The individual experienced the death of someone with whom he or she Major depressive disorder Complicated grief
had a close relationship
B. Since the death, at least one of the following symptoms is experienced Pervasive sad mood Sadness related to missing the deceased
on more days than not and to a clinically significant degree and has Loss of interest or pleasure Strong interest in the deceased maintained
persisted for at least 12 months after the death in the case of bereaved in most activities
adults and 6 months for bereaved children: Pervasive sense of guilt Guilt related to the death or deceased
1. Persistent yearning/longing for the deceased Low self-esteem Self-criticism only related to the loss
2. Intense sorrow and emotional pain in response to the death Suicidal thoughts related to Suicidal thoughts focused on not wanting
3. Preoccupation with the deceased a range of negative to live without the deceased or a wish to
emotions and cognitions rejoin the deceased
4. Preoccupation with the circumstances of the death
Not seen in depression Avoidance of situations and people related
C. Since the death at least six of the following symptoms are experienced
to reminders of the loss
on more days than not and to a clinically significant degree, and have
persisted for at least 12 months after the death in the case of bereaved Not seen in depression Intense yearning for the person who died
adults and 6 months for bereaved children:
Adapted from Shear & Mulhare [73]
Reactive distress to the death
1. Marked difficulty accepting the death
2. Experiencing disbelief or emotional numbness over the loss as the ability to think optimistically, attend to the needs of
3. Difficulty with positive reminiscing about the deceased others, maintain plans and goals, remain calm, reduce painful
4. Bitterness or anger related to the loss emotions and be able to laugh. Golden and Dalgleish [46]
5. Maladaptive appraisals about oneself in relation to the deceased or studied three groups of midlife adults and found significant
the death (e.g., self-blame) relationships between CG symptoms and both self-
6. Excessive avoidance of reminders of the loss (e.g., avoidance of devaluation and negative self-related cognitions about the
individuals, places or situations associated with the deceased) future. Those with CG also had greater negative cognitions
Social identity disruption about the future for close others. Bereaved individuals had
7. A desire to die in order to be with the deceased high rates of self-related counterfactual thoughts about the
8. Difficulty trusting other individuals since the death death. Consistent with clinical observations, those with CG
9. Feeling alone or detached from other individuals since the death had these thoughts significantly more frequently, and the
10. Feeling that life is meaningless or empty without the deceased, or thoughts were associated with greater distress. Also consistent
the belief that one cannot function without the deceased with clinical observations, Boelen [47••] asked bereaved in-
11. Confusion about one’s role in life or a diminished sense of one’s dividuals to write a list of seven goals and found those with
identity (e.g., feeling that a part of oneself died with the deceased)
CG produced less specific goals, and reported lower sense of
12. Difficulty or reluctance to pursue interests since the loss or to
plan for the future (e.g., friendships, activities)
control and lower likelihood of achieving goals.
D. The disturbance causes clinically significant distress or impairment in
CG is associated with negative health and mental health
social, occupational or other important areas of functioning consequences in older adults, beyond that of bereavement itself.
E. The bereavement reaction is out of proportion to or inconsistent with Prigerson et al. [48] found that the risk of hypertension is ten
cultural religious, or age-appropriate norms times greater among older adult widowed subjects who meet
Specify if: With traumatic bereavement: Bereavement due to homicide the criteria for CG compared to those who do not, and sleep
or suicide with persistent distressing preoccupations regarding the impairment is associated with CG in older adults [35].
traumatic nature of the death (often in response to loss reminders),
Suicidality is twice as high among widowed older adults with
including the deceased’s last moments, degree of suffering and
mutilating injury, or the malicious or intentional nature of the death CG than those without CG [49].
Recent reviews [50–56] summarize possible risk factors for
Reproduced with permission from the American Psychiatric Association CG and suggest these are seen across samples, nationalities and
[28]: Diagnostic and statistical manual of mental disorders, fifth edition.
age groups. CG is associated with female gender, low education
Arlington, VA: American Psychiatric Association, 2013.
level, older age, low socioeconomic status and low social support
both before and after the death. A history of anxiety disorders or
languages, such as Japanese [42]. Most people with CG are aware depression before the death and past history of multiple trauma or
that something is wrong but don’t know what it is and are relieved loss also appear to be risk fators. Several investigators found that
to receive a diagnosis [43]. spiritual belief systems may decrease the risk for developing CG
People with CG show a range of cognitive and affective [57–59]. Denckla et al. [60] compared ratings on healthy depen-
differences from bereaved people without CG. Gupta and dency, destructive overdependence and dysfunctional detach-
Bonanno [44] found the ability to flexibly enhance or suppress ment among a small group of bereaved middle-aged people with
emotional expression at will was reduced in CG. Burton et al. and without CG and found that those with CG were more likely
[45] found CG associated with less “forward coping,” defined to have dysfunctional detachment.
Curr Psychiatry Rep (2013) 15:406 Page 5 of 7, 406

CG also tends to occur after loss of a very close relationship encouraging and suggest that CG can be effectively treated by
with the deceased, such as loss of a spouse. Loss of a child identifying CG, addressing grief complications and facilitat-
poses an especially high risk [61]. Traumatic circumstances of ing the natural healing process.
the death, a lack of preparation or difficult interactions with Pharmacotherapy might also be helpful to people with CG.
medical or other staff at the time of the death can increase the Simon et al. (2008) found that patients taking antidepressants
risk of CG. Chiu et al. [59] found CG was associated with were more likely to complete CGT, with no such effect on
perceived general disapproval from others, longer duration of completion rates for IPT. Zygmont et al. [69] also found com-
caregiving and medical disease history in the caregiver. Use of bination treatment with paroxetine or nortriptyline administered
hospice care decreased the risk. Kramer et al. [53] found higher with CGT was effective in reducing grief symptoms. Results
CG symptoms in caregivers from families with low conflict with medication alone are more mixed. Pasternak et al. [70] and
before the end of life but higher conflict at the end of life, in Reynolds et al. [37] found treatment with antidepressant med-
those who had family members with difficulty accepting the ication reduced depression but not CG, whereas in an open
illness and among caregivers with greater fear of death. pharmacotherapy trial Hensley et al. [71] found that citalopram
improved depressive, anxiety and grief symptoms.

Complicated Grief Treatment

Conclusions
Given that CG can be reliably identified and differentiated
from other mental disorders, and given its prevalence, we Bereavement is a common life experience among older adults.
believe there is a need for an effective treatment. To meet this For most, an initial period of acute grief evolves naturally into
need, we developed complicated grief treatment (CGT), a 16- integrated grief. The bereaved older adult still has feelings of
week individual treatment that is guided by an attachment yearning and sorrow, but these are not frequent or intense
theory model of grief. According to this model, the death of enough to be disruptive. Daily activities are interesting, and
a loved one provokes an acute crisis of attachment with life holds the possibility for finding joy and meaning. This
activation of the attachment working model and associated population of bereaved older adults can benefit from
proximity seeking. This activation results in symptoms of psychoeducation and general support from clinicians. Ap-
yearning, longing and preoccupation with thoughts and mem- proximately 7 % of older adults will develop complications
ories of the deceased that alternate with a desire to escape from that derail the normal mourning process, however, resulting in
the painful reality. The loss also triggers a natural mourning the syndrome of complicated grief (CG), also called
process that leads the bereaved person to find a way to make prolonged grief and persistent complex bereavement disorder.
peace with the finality and consequences of the loss, revise the Treatments for CG have also been tested, with the 16-session
internal working model, and redefine life goals and plans. complicated grief treatment (CGT) showing the best evidence
Sometimes this process is derailed by complications that of efficacy, including a study in older adults.
impede the natural healing process. CGT seeks to address There has been important progress in understanding and
these complications and to reinvigorate the natural healing treating CG in older adults, but there is still much that needs to
process. A set of loss-related and restoration-related strategies be done. Consensus regarding the best name for the disorder and
and procedures is used to do this. agreement on a criteria set are important next steps to support
We published the first randomized controlled treatment both clinical and research efforts. More must be done to increase
trial for CG [36]. Funded by the National Institute of Mental the public and professional awareness of CG in order to help
Health, this study showed CGT was superior to interpersonal ensure that those suffering from the condition receive needed
psychotherapy (IPT). A replication of this study in older adults help. To this end, we have established a Center for Complicated
is nearly complete, and a third multi-site study is underway. In Grief at the Columbia University School of Social Work, with
a smaller study conducted at multiple sites, Boelen et al. [62] resources accessible at www.complicatedgrief.org. Other areas
reported similar findings, comparing cognitive behavioral that require exploration include better understanding of
treatment (CBT) with supportive counseling for CG, and similarities and differences in treatment modalities for CG in
found a significant reduction in CG symptoms and general older adults. Better understanding of how CGT works and for
psychopathology in the CBT group compared to supportive whom (mediators and moderators of treatment) is also needed.
counseling. A number of small studies using a similar inter- Elucidating what services those with CG are currently using in
vention have now been published, including Acierno et al. the community and whether these are effective is essential as
[63•], Asukai et al. [64], Rosner et al. [65], Papa et al. [66] and well. In addition, research on the dissemination of CGT and its
Supiano and Luptak [67•]. Wagner et al. [68] tested the acceptability to both clinicians and older adults with CG is
effectiveness of an Internet-based cognitive behavioral necessary. Prevention and early intervention efforts for CG
therapy for CG. Taken together, results of these studies are may also be helpful and should be tested. In short, research
406, Page 6 of 7 Curr Psychiatry Rep (2013) 15:406

efforts are needed to help reduce the sizable negative health and 13. Buckley T, Morel-Kopp MC, Ward C, et al. Inflammatory and
thrombotic changes in early bereavement: a prospective evaluation.
mental health burden of CG for older adults.
Eur J Prev Cardiol. 2012;19:1145–52.
14. • Shah SM, Carey IM, Harris T, et al. Do good health and material
Compliance with Ethics Guidelines circumstances protect older people from the increased risk of death
after bereavement? Am J Epidemiol. 2012;176:689–98. Provides
greater understanding of the pathways between bereavement and
Conflict of Interest M. Katherine Shear has received grants from the
mortality.
National Institute of Mental Health (NIMH) and American Foundation
15. Shah SM, Carey IM, Harris T, et al. The effect of unexpected
for Suicide Prevention, travel support from NIMH and compensation for
bereavement on mortality in older couples. Am J Public Health.
expert testimony from a private individual.
2013;103:1140–5.
Angela Ghesquiere is the recipient of an NIMH research fellowship in
16. Anderson KL, Dimond M. The experience of bereavement in older
geriatric mental health services (T32 MH073553, PI: Bartels).
adults. J Adv Nurs. 1995;22:308–15.
Kim Glickman declares that she has no conflict of interest.
17. Arbuckle NW, de Vries B. The long-term effects of later life spousal
and parental bereavement on personal functioning. Gerontologist.
Human and Animal Rights and Informed Consent This article does 1995;35:637–47.
not contain any studies with human or animal subjects performed by any 18. • Hallerod B. Gender inequality from beyond the grave: Intra-
of the authors. household distribution and wellbeing after spousal loss. Ageing
Soc. 2013;33:783–803. Useful details exploring the associations
between bereavement and functioning.
19. Chentsova Dutton Y, Zisook S. Adaptation to bereavement. Death
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