Emotional anaesthesia: a cognitive-behavioural treatment of prolonged grief in a client with complex comorbidities-the importance of reintegrating attachment, memory, and self-identity
Keywords:
Psychosis, inpatient, case-report, prolonged/complicated grief, cognitive behaviour therapy, bereavementAbstract
AbstractObjective: This case-report presents the formulation and treatment of a patient with a primary diagnosis of schizophrenia, and significant complex comorbidities. It was hypothesised that much of the presentation was secondary to unresolved grief. This raises issues regarding treatment and diagnosis of unresolved grief in psychiatric inpatient units, as the DSM-5 does not currently recognise Prolonged Grief Disorder (PGD). We argue that failing to recognise PGD as a distinct syndrome has implications for research into effective psychotherapeutic interventions for patients with unresolved, prolonged, or complicated grief. Method: A case-report of a patient diagnosed with schizophrenia and multiple co-morbidities who received 31 sessions of psychotherapy (i.e. integrative cognitive behaviour therapy for prolonged grief disorder) as part of a rehabilitation programme. The following measures were administered pre- and post-treatment: (i) The Depression Anxiety Stress Scale, to measure levels of depression, anxiety, and stress; (ii) The Beck Depression Inventory-II to assess more specifically levels of depression; and (iii) the Prolonged Grief Disorder (PG 13) to assess symptoms of prolonged grief disorder. Results: Upon completion of therapy, reductions were observed in PG-13 scores, stress on The Depression Anxiety Stress Scale, and depression on The Beck Depression Inventory-II. Conclusions: This case report demonstrates the utility of going beyond the DSM-5 when formulating complex patients. It also highlights the importance of identifying precursory and perpetuating factors driving complex presentations, and implementing a flexible and evidence-based treatment that sensitively addresses the presentation.
References
American Psychological Association (2013). Diagnostic and statistical manual of mental disorders, 5th Edition: DSM 5. Washington, DC: APA.
Beck AT, Steer RA, Brown GK (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Boelen PA (2016). Improving the understanding and treatment of complex grief: an important issue for psychotraumatology. European Journal of Psychotraumatology 7. doi:10.3402/ejpt.v7.32609.
Boelen PA, de Keijser J, van den Hout MA et al (2007). Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 75(2): 277–284. doi:10.1037/0022-006x.75.2.277.
Boelen PA, Prigerson HG (2007). The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study. Eur Arch Psychiatry Clin Neurosci 257(8) 444–452. doi:10.1007/s00406-007-0744-0.
Boelen PA, van de Schoot R, van den Hout MA et al (2010). Prolonged grief disorder, depression, and posttraumatic stress disorder are distinguishable syndromes. J Affect Disord 125(1–3) 374–378. doi:10.1016/j.jad.2010.01.076.
Bonanno GA (2004). Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 59(1) 20–28. doi:10.1037/0003-066x.59.1.20.
Bonanno GA, Kaltman S (2001). The varieties of grief experience. Clinical Psychology Review 21(5) 705–734. doi:10.1016/S0272-7358(00)00062-3.
Cozza SJ, Fisher JE, Mauro C et al (2016). Performance of DSM-5 persistent complex bereavement disorder criteria in a community sample of bereaved military family members. American Journal of Psychiatry 173(9) 919–929. doi:10.1176/appi.ajp.2016.15111442.
Eisma MC, Boelen PA, Schut HA et al (2016). Does worry affect adjustment to bereavement? A longitudinal investigation. Anxiety, Stress & Copin 30(3) 1–10. doi: 10.1080/10615806.2016.1229464.
Evans JJ, Gast DL, Perdices M et al (2014). Single case experimental designs: introduction to a special issue of Neuropsychological Rehabilitation. Neuropsychol Rehabil 24(3–4) 305–314. doi:10.1080/09602011.2014.903198.
Higson-Smith C (2014). Complicated grief in help-seeking torture survivors in sub-Saharan African contexts. Am J Orthopsychiatry 84(5) 487–495. doi:10.1037/ort0000009.
Horowitz MJ, Siegel B, Holen A et al (1997). Diagnostic Criteria for Complicated Grief Disorder. Am J Psychiatry; 154: doi:10.1176/ajp.154.7.904.
Howick J, Chalmers I, Glasziou P et al (2011). The 2011 Oxford CEBM Evidence Table (introductory document). Oxford: Centre for Evidence-Based Medicine.
Jordan AH, Litz BT (2014). Prolonged grief disorder: diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice 45(3) 180–187.
Kersting A, Brahler E, Glaesmer H et al (2011). Prevalence of complicated grief in a representative population-based sample. J Affect Disord 131(1–3) 339–343. doi:10.1016/j.jad.2010.11.032.
Loranger AW (2001). Professional Manual: OMNI Personality Inventories. Odessa, Florida: Psychological Assessment Resources.
Lovibond PF, Lovibond SH (1995). The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy 33(3) 335–343. doi:10.1016/0005-7967(94)00075-U.
Maccallum F, Bryant RA (2013). A Cognitive Attachment Model of prolonged grief: integrating attachments, memory, and identity. Clin Psychol Rev 33(6) 713–727. doi:10.1016/j.cpr.2013.05.001.
Mauro C, Shear MK, Reynolds CF et al (2016). Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients. Psychol Med 1–8 doi:10.1017/s0033291716002749.
Prigerson H, Ahmed I, Silverman GK et al (2002). Rates and risks of complicated grief among psychiatric clinic patients in Karachi. Pakistan. Death Stud 26 doi:10.1080/07481180290106571.
Prigerson HG, Horowitz MJ, Jacobs SC et al (2009). Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 6 doi:10.1371/journal.pmed.1000121.
Rosner R, Hagl M (2007). Effective treatments for grief following the loss of a loved one. A literature review of treatment studies with adults. Psychodynamische Psychotherapie 6 47–54.
Rosner R, Kruse J, Hagl M (2005). Quantitative and qualitative review of interventions for the bereaved. Paper presented at the 9th European Conference on Traumatic Stress (ECOTS). Stockholm.
Rosner R, Lumbeck G, Geissner E (2011). Effectiveness of an inpatient group therapy for comorbid complicated grief disorder. Psychother Res 21(2) 210–218. doi:10.1080/10503307.2010.545839.
Rosner R, Pfoh G, Kotoučová M (2011). Treatment of complicated grief. European Journal of Psychotraumatology 2 doi:10.3402/ejpt.v2i0.7995.
Rosner R, Pfoh G, Kotoucova M et al (2014). Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial. J Affect Disord 167 56–63. doi:10.1016/j.jad.2014.05.035.
Schaal S, Elbert T, Neuner F (2009). Narrative Exposure Therapy versus group Interpersonal Psychotherapy - a controlled clinical. Psychother Psychosom; 78: doi:10.1159/000229768.
Shear K, Frank E, Houck PR et al (2005). Treatment of complicated grief: a randomized controlled trial. JAMA; 293(21): 2601–2608. doi:10.1001/jama.293.21.2601.
Singer N, Jacoby N, Lin T et al (2016). Common modulation of limbic network activation underlies musical emotions as they unfold. Neuroimage; 141: 517–529. doi:10.1016/j.neuroimage.2016.07.002.
Stroebe M, Schut H (1999). The dual process model of coping with bereavement: rationale and description. Death Stud; 23(3): 197–224. doi:10.1080/074811899201046.
Sumner JA (2012). The mechanisms underlying overgeneral autobiographical memory: an evaluative review of evidence for the CaR-FA-X model. Clinical Psychology Review; 32(1): 34–48. doi:10.1016/j.cpr.2011.10.003.
Tal I, Mauro C, Reynolds CF 3rd, et al (2016). Complicated grief after suicide bereavement and other causes of death. Death Stud, 1–9, doi: 10.1080/07481187.2016.1265028.
Wagner B, Knaevelsrud C, Maercker A (2006). Narrative Exposure Therapy versus group Interpersonal Psychotherapy - a controlled clinical. Death Stud 30(5) 429–453. doi:10.1080/07481180600614385.
Wakefield JC (2013). DSM-5 grief scorecard: assessment and outcomes of proposals to pathologize grief. World Psychiatry 12(2) 171–173. doi:10.1002/wps.20053.
