13.5 (17.7) Bereavement

Question 1

Define the following terms:
1. Bereavement
2. Grief
3. Mourning
4. Anticipatory grief
5. Pathological grief (list 2 variants)(!!!)
6. Disenfranchised grief

Answer 1

1. Bereavement - STATE of loss (usually referring to loss of life)
2. Grief - RESPONSE associated with loss (emotional, physical, cognitive, behavioral)
3. Mourning - process of adaptation including cultural and social RITUALS prescribed as accompaniments
4. Anticipatory grief: precedes the death and results from expectation of that event
5. Pathological grief: abnormal outcome involving psychological, social, or physical morbidity
   (variants: COMPLICATED grief, PROLONGED grief)
6. Disenfranchised grief: HIDDEN sorrow of the MARGINALIZED where there is less social permission to express many dimensions of loss

Question 2

List four types of theory to explain the phenomenon of bereavement*

Answer 2

See table 13.5.1 (17.7.1):
1. attachment theory*
(secure/insecure attachment influences impact of loss)
2. psychodynamic theory*
(early relationships lay down template for future relationships)
3. interpersonal model
4. psychosocial transition
5. sociological model*
(cultural influences shape form/content of grief)
6. family systems theory
6.Cognitive stress coping theory
7. traumatic model
8. ethology
9. meaning-centered model
Cognitive behavioural theories*

*4 categories of predominant explanatory models

Question 3

What are the two orientations described by the dual process model of grief - What is focused on in each state?

Where does active grief work take place?

Answer 3

LOSS orientation - a focus on the loss itself

RESTORATION orientation - focus shifts to attending to ongoing life, counter negative emotions with some positive reappraisal/construction of meaning of event

Active experience of grief sits in a dynamic equilibrium with some avoidance of grief. Bereaved adjust balance via emotion-based coping

active grief work occurs when the bereaved are loss oriented (*not mentioned in 6th edition)

Question 4

List 4 dimensions of grief

Answer 4

1. Emotional
2. Physical
3. Cognitive
4. Behavioural

Question 5

List four emotional displays of normal grief

Answer 5

unavoidable crying
loss of concentration and purpose
preoccupation with thoughts of deceased
sadness
anger
despair
Anxiety
guilt

FS: emotions aspect of MSIGECAP (no suicidal ideation) and BESKIM

Question 6

List 1 common cognitive manifestation of grief

Answer 6

Cognitive processes dominated by MEMORIES (reflected in storytelling, reminiscences, conversations about the deceased)

Question 7

List four physical manifestations of grief

Answer 7

numbness
restlessness
tension
tremors
sleep disturbance
anorexia
weight loss
fatigue
aches and pains

FS: physical aspect of MSIGECAP and BE SKIM (anxiety)

Question 8

list three behavioural manifestations of normal grief

Answer 8

social withdrawal
seeking company and consolation
wandering
searching

Question 9

Beside loss of life - list four other domains where loss is expected

Answer 9

loss of :
work
leisure activities
financial security
independence
sense of certainty about life
further physical impairments
body image change
altered perception of well being
loss of health

FS: health, wealth, independence, work, leisure

Question 10

List four emotional indicators for risk of complicated grief in a person/family experiencing anticipatory grief

Answer 10

intense distress
Anger
denial of the seriousness of the threat
protective avoidance

withdrawal from involvement

FS: DADA
Distress, anger, denial, avoidance

Question 11

List 2 ways clinicians can help a family experiencing anticipatory grief

Answer 11

1. Encourage them to openly share their feelings
2. Recognize saying goodbye as a process over time - support opportunities for reminiscence, celebration of life/contribution of dying person, expressions of gratitude, completion of unfinished business

FS: encourage (1) share feelings (2) saying goodbye

Question 12

Family and friends are gathered around the death bed of a loved one who is dying.

List 4 things you will discuss with them as a physician

Answer 12

1. comment on the process of dying explaining breathing patterns etc
2. normalize experience empathetically
   reassure family when a concern develops
3. discuss pain
4. discuss reasons for medications
5. skilled prediction of events
6. ask about and facilitate religious rituals
7. expression of sympathy

FS
1) signs of dying
2) symptoms (pain)
3) meds
4) rituals
5) empathy

Question 13

List 3 post-mortem practices that MD can provide to be supportive for family/friends of the deceased (immediately after death)

Answer 13

1. Respecting post-mortem cultural approaches
2. If relatives not present at time of death, invite to attend based on a deterioration and shares news on arrival
3. Unless there is a legal requirement for coroner’s postmortem, respect family’s views on autopsy
4. If concerns about emotional response of bereaved, consult cultural intermediary, support with short acting benzo Rx, follow up phone call next day

FS:
1) share news on arrival of family
2) respect rituals/autopsy views
3) bereavement call

Question 14

List 4 scenarios in which grief could be marginalized or disenfranchise the bereaved from usual supports

Answer 14

1. Ageism (death is normalized because it appears in step with life cycle & family members given less support)
2. Suicide
3. Homicide
4. Euthanasia

Question 15

The duration of grief is based on what two major factors

Answer 15

strength of attachment to the lost person

cultural expression

Question 16

What are the four general phases of acute grief

Answer 16

1. initial numbness and sense of unreality
2. waves of distress begin to occur as the bereaved yearn for lost loved one
3. phase of disorganization emerges as loneliness resulting from the loss sets in
   (periods of restlessness/inattention/sadness/despair/social withdrawal can last for several months)
4. phase of reorganization and recovery - altered world view constructed + personal growth

FS:
Numb
Distress
Disorganized
Reorganize

Question 17

List 3 factors that help to differentiate normal from pathological grief

Answer 17

1. time course
2. intensity of reaction
3. presence of range of grief related behaviours

FS: think of DSM

Question 18

List four common psychiatric conditions that accompany grief and are separate entities from complex grief

Answer 18

1. PTSD
2. EtOH or other substance abuse/dependence
3. MDD
4. anxiety disorders
5. psychotic disorders

Question 19

1. Name the diagnosis proposed by DMS-5 for complex grief
2. What are the general diagnostic criteria for this

Answer 19

1. Persistent Complex Bereavement Disorder
2. a) for at least 12 months (if bereaved adult) otherwise 6 months (if child) following the death, there is:
   b) persistent longing for the deceased
   c) intense sorrow and
   d) preoccupation with the deceased
   e) at least 6/12 symptoms of reactive distress
   d) significant social/occupational impairment
   e) bereavement reaction is out of proportion to cultural/religious/age-approp norms

FS: SLP SOS - ABCDEF (12 months in adults, 6 months in child)

Sorrow (intense)
Longing
Preoccupation

Social/occupational impairment
Out of proportion
Symptoms min 6/12 (ABCDEI): see below

Anger
Blame (self)
Cancelling positive memories of loved ones
Denial
Empty
“Few” Interest

Question 20

Prolonged grief can lead to a range of health problems - list 4

Answer 20

1. cardiac distress
2. hypertension
3. increased ETOH and cigarette consumption
4. suicidal ideation

Question 21

List 5 signs of pathological grief*

Answer 21

1. greater degrees of separation distress
2. emotional numbing and dissociation
3. mood symptoms
4. impaired social functioning
5. maladaptive coping styles

FS: think of DSM 5 criteria

Question 22

List 2 maladaptive coping strategies seen in pathological grief

Answer 22

avoidance or denial*
distortion through excessive anger*
despair
guilt
idealization or somatization
prolongation that culminates in chronicity

FS: think of DSM

Question 23

The husband of a patient who has died does not demonstrate distress after his partner dies. Does this suggest a superficial bond? Is this pathological?

Answer 23

does not suggest superficial bond

may indicate normal emotional response to grief (ie numbess) or pathological

(in those with other signs of complicated grief, may require intervention)

Question 24

What is 1 major risk factor for chronic grief

Answer 24

Chronic grief - particularly associated with overly dependent relationships (!!!) in which a sense of abandonment is avoided by perpetuation of relationship through memorialization of deceased

Question 25

What causes traumatic grief? List 2 unique symptoms of traumatic grief

Answer 25

Death is UNEXPECTED or SHOCKING (ie traumatic, violent or stigmatized or perceived as undiginified) Intensive recollections including flashbacks and nightmares*** recurrent intrusive memories**** causing hyperarousal, disbelief, insomnia, irritability, disturbed concentration shock of death can lead to mistrust, anger, detachment, unwillingness to accept reality FS: denial, anger, flashbacks, intrusive memories - kind of like PTSD?

Question 26

At what point after a death is MDD most likely to develop?

Answer 26

Within initial 2 months (per 5th edition)

Question 27

The Family Environment Scale identifies five classes of families to determine if they are at risk for complicated bereavement. What are the five classes of family? At risk families experience what three problems?*

Answer 27

See Table 13.5.2: supportive conflict resolving conflictual uninvolved low communicating loss of cohesiveness communication breakdown increased conflict

Question 28

List 4 risk factors for pathologic grief (!!!)

Answer 28

see table 13.5.3 (17.7.3) Strengths and vulnerabilities of the bereaved* -past history of psychiatric disorder (eg depression) -personality and coping style (intense worrier, low self-esteem) -cumulative experiences of losses Nature of the death * -untimely within the life cycle -sudden and unexpected -traumatic -stigmatized (ie. HIV, suicide) Nature of the relationship with the deceased* -overly dependent -ambivalent (angry, insecure, gambling, infidelity) Family and support network* -dysfunctional family (poor cohesiveness) -isolated (new immigrant) -alienated (perception of poor support)

Question 29

List 3 health related consequences of bereavement

Answer 29

-increased rate of death occurring over the first year in 45-75yr range -increased cardiovascular events in first six months* -accidents -suicide* -alcohol and substance abuse* -Cirrhosis -increased use of health services - consultations/hospitalizations -increased psych distress, somatic sx -more days of disability -greater reliance on meds -depressive/anxiety disorders, PTSD

Question 30

What are two types of bereavement follow up that can be offered by the treatment team to a bereaved family

Answer 30

expression of condolences via telephone, card, or visit by nurse/GP, invitation to periodic commemorative service by palliative care team for those at risk of complex grief - preventative intervention with bereavement counselling FS: 1) bereavement call 2) bereavement counseling

Question 31

Who should be offered grief therapies?

Answer 31

those at risk of maladaptive outcome should be treated preventatively those who develop complicated bereavement when they are identified FS: 1. If risk factors for PCBD are identified (4) 2. If individual presents with PCBD (DSM 5)

Question 32

List 3 therapy models for grief support

Answer 32

CBT* complicated grief treatment* family focussed grief therapy* supportive-expressive therapy interpersonal psychotherapy

Question 33

What are the four major tasks of mourning?

Answer 33

accepting the reality of loss working through pain of grief adjusting to a new environment without the loved person establishing a collection of positive and useful memories of the deceased for future reference FS: AWAKe Accept Work Adjust Kollect memories

Question 34

List four risk factors for suicide in bereavement

Answer 34

1. Self those who abuse EtOH current or past hx of MDD 2. Relationship with deceased elderly widowers 3. Relationship with others socially isolated

Question 35

At what age do children start to understand the concept of death and what age do they grasp finality of death

Answer 35

5-6 years understand 9-10 years old - finality

Question 36

Personal growth and positive outcomes can be experienced after successful grief and bereavement. List 2 such outcomes

Answer 36

renewed sense of meaning self-awareness increased empathy* appreciation of family and relationships* independence reprioritized goals and values deepened spirituality increased altruism

Question 37

List four bereavement symptoms in children

Answer 37

fear insecurity Guilt Sadness Behavioural problems FS: FIGS

Question 38

Other than the family environmental scale. What tool can be used to screen families for risk of complicated reactions to stressful events?*

Answer 38

Inventory of complicated grief

Question 39

List four types of meds used for bereavement

Answer 39

Benzos - anxiety and sleep antidepressants if bereavement complicated by depression or anxiety/pain attacks TCAs - insomnia occasionally antispsychotics for hypomania or other types of psychosis

Question 40

Clinician exploration of spirituality with the patient and family may help address bereavement.* 1. How might patients/families express their spiritual dimensions or philosophy of life. List 3 ways 2. How can clinician understanding of this be helpful to the bereaved? List 2 ways

Answer 40

1. religious beliefs, cultural customs, traditions 2. i) Using the above values to understand the life of the deceased helps appraise their accomplishments, worth, the meaning their life had -- achieving consensus with the bereaved about this can assist in their acceptance of the death ii) Rituals can assist bereaved in mourning. Clinicians can help the bereaved by endorsing its value