A 62-year-old woman comes to the office accompanied by her daughter, who is concerned that her mother is depressed. The daughter says that since her father's unexpected death from a heart attack 2 years ago, her mother seems withdrawn and socially isolated. The patient reports that she still misses her husband terribly and thinks about him constantly. She says, "I can't believe he is gone." She feels guilty that she did not recognize his heart condition and blames herself for not insisting that he get medical care earlier. The patient does not have sleep or appetite disturbance, but sleeps on the couch because she can't bear to lie in the bed that she and her husband shared. She has stopped playing golf and attending concerts––activities that they had enjoyed together. The patient has no suicidal ideation. She continues to work at her part-time job and help her daughter with the grandchildren. Which of the following is the most likely explanation for this patient's symptoms?
This patient's prolonged grief (>12 months after the loss), difficulty accepting the death, persistent yearning for the deceased, and avoidance of reminders of the deceased are suggestive of persistent complex bereavement disorder (also known as complicated grief, prolonged grief, or complex grief). The estimated incidence of complicated grief in bereaved individuals is 7%, with increased risk associated with unexpected or violent death of a loved one and death of a spouse or child. Difficulty envisioning a meaningful life without the deceased, suicidal ideation or wish to join the deceased, and guilty ruminations about the circumstances of the death are also common.
If left untreated, persistent complex bereavement disorder can continue for years or decades after the loss and result in poor quality of life, increased substance use, and increased mortality due to medical conditions or suicide. Treatment consists of psychotherapy specifically geared to helping the patient come to terms with the loss and re-engage in a meaningful life without the deceased.
(Choice A) Dependent personality is characterized by a lifelong pattern of excessive need to be taken care of and pervasive fear of separation, and is usually manifest by early adulthood. It is less likely in this patient with good premorbid functioning and onset of symptoms in the setting of bereavement.
(Choice B) Symptoms of persistent complex bereavement disorder overlap with those of major depressive disorder (MDD) (eg, sadness, social withdrawal, guilt, suicidal ideation) but center around the loss of a loved one. Suicidal ideation, if present, is focused on not wanting to live without the deceased rather than the more generalized suicidality seen in MDD. In MDD, sadness and guilt are pervasive and not just related to missing the deceased or self-blame regarding the deceased. MDD typically includes changes in energy, sleep, appetite, and concentration, which this patient does not have.
(Choice C) This patient's intense and persistent grief for 2 years is more characteristic of persistent complex bereavement disorder. Normal grief typically improves over the course of a year, with gradual adaptation to the loss and renewed interest in life.
(Choice E) Post-traumatic stress disorder (PTSD) involves fear and hypervigilance in response to intrusive flashbacks and distressing memories of a traumatic event, whereas complicated grief is characterized by sadness and yearning. Comorbid PTSD is common in complicated grief when the death is accidental, violent, or unexpected.
Educational objective:
Persistent complex bereavement disorder is characterized by prolonged grief, difficulty accepting the death, persistent yearning for the deceased, and maladaptive ruminative thoughts and behaviors. Psychotherapy is the treatment of choice.