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Section 26
Comparison of Traumatic Grief and Complicated Grief Disorder

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Parallel with the development of consensus diagnostic criteria for Traumatic Grief by Prigerson and colleagues (Prigerson et al., 1999), Horowitz and his group have published criteria for Complicated Grief Disorder (Horowitz et al., 1997). Using latent class model analyses and signal detection procedures, they analyzed data from 70 voluntarily selected, bereaved persons who were evaluated 6 and 14 months after the death of a long term partner (Horowitz et al., 1997).

In our view, given the independent development of criteria by the Horowitz group and the consensus panel of experts, the amount of agreement on criteria is impressive and provides encouraging validation of the process of developing criteria. Both sets of criteria emphasize interference on impairment in functioning as a criterion. Both emphasize severe symptoms of separation distress, which Horowitz characterizes as intrusive symptoms, consistent with the nature of the pang of grief. Both include avoidance as a symptom, although this item does not perform well in either set of criteria, as we will discuss below. Both include loss of interest in usual pursuits, and both include reference to feelings of emptiness and loneliness, although the latter item in the consensus set was a product of receiver operating characteristic analyses by Prigerson and colleagues subsequent to the consensus process (Prigerson et al., 1999).

Avoidance is included in both criteria sets and deserves more discussion than the other shared items. Horowitz and colleagues specify signs of avoidance as one of their two main groups of symptoms and specify the behavior of "excessively staying away from people, places, or activities that remind the subject of the decreased." While we include "frequent efforts to avoid reminders of the deceased person" among the list of symptoms in our Criterion B, our preliminary testing of the consensus criteria set (Prigerson et al., 1999) and other recent studies (Spooren, Henderick, & Jannes, in press; Prigerson, Shear, et al., in press) demonstrate that this symptom is rarely endorsed and performs poorly as an indicator of Traumatic Grief. Even in the report by Horowitz and colleagues on their criteria for Complicated Grief Disorder (1997), the avoidance item as the recommended 14 months post-loss assessment had a low sensitivity of 0.29. We have left this item among the consensus criteria for the time being as it was a product of the consensus process and deserves definitive testing. Still, our preliminary analyses lead us to believe it is a weak, if not ineffective, diagnostic item.

Differences also exist in the two criteria sets. One difference exists in the criterion for duration of symptoms. For Complicated Grief Disorder, it is one-month duration and at least 14 months after the death. The consensus criteria for Traumatic Grief recommended two months' duration without defining a time relationship to the death. While the consensus recommendation reflects a value placed on early intervention within the natural history of bereavement, we are concerned that its early timing in the course of bereavement may incur a high false positive rate of diagnosis. In other words, it may identify some bereaved persons who will resolve their problems on their own over the next several months. Indeed, our preliminary analyses suggest that two months of bereavement may be premature for a diagnostic assessment, and six months may work better because this timing reduces false positives and improves the prediction of subsequent outcomes (Prigerson, Bierhals, Kasl, et al., 1997; Silverman et al., personal communication). Consequently, we will test competing criteria for timing of diagnosis in a field trial of criteria that is under way.

Each criteria set includes some unique symptoms, accounting for more differences. For example, the symptoms of Complicated Grief Disorder include interference with sleep, a symptom presumably reflecting hyperarousal. Sleep disturbance and other symptoms of hyperarousal were omitted from the consensus criteria. The consensus panel of experts reached this decision because a sleep study has shown no evidence of hyperaroused sleep in Traumatic Grief and no association between subjectively reported sleep disturbance in persons with Traumatic Grief and the Traumatic Grief symptoms (McDermott, Prigerson, & Reynolds, 1997). As a general proposition, the consensus panel concluded that symptoms of hyperarousal are not prominent in bereaved persons with Traumatic Grief except for that of irritability, which the panel construed as part of anger and protest over the loss.

Conversely, the set of consensus criteria for Traumatic Grief includes several symptoms under Criterion B that are not found in the criteria set for Complicated Grief Disorder. These symptoms reflect the devastation in the bereaved person's life caused by the death. They include:
1. numbness, detachment or absence of emotional responsiveness,
2. difficulty acknowledging the death (e.g., disbelief),
3. feeling that life is empty or meaningless,
4. difficulty imagining a fulfilling life,
5. feeling part of oneself has died,
6. harmful symptoms or behavior related to the deceased, and
7. a shattered worldview (lost sense of security, trust, or control).

These are among the best performing items in our preliminary analyses (Prigerson, Bridge, et al., in press). There are no closely related items in the criteria for Complicated Grief Disorder, with the exception of "emotional unavailability to others," which was initially included in the study and did not make it into the final set of criteria.

The symptom of "numbness, detachment or absence of emotional responsiveness" is of particular interest to us at it relates back to the question of avoidance discussed above. If avoidance were to mean "detachment from others" (that is, bereaved persons are removed and uninvolved with others perhaps as a function of their preoccupation with the deceased person, which is a hallmark of separation distress), it would appear to work well. Indeed, this is the case in our preliminary analyses. If avoidance were to mean "excessively staying away from people, places, and activities that remind the bereaved person of the deceased" as in the criterion for Complicated Grief Disorder, it does not appear to work well. "Excessively staying away" seems more closely related in meaning to the item from the consensus criteria on "frequent efforts to avoid reminders of the deceased," which also did not work well in our analyses, as noted above. In the development of the consensus criteria, the item "frequent efforts to avoid reminders" was closely related to, if not derived from, a model of traumatic disorders such as PTSD. The same derivation is likely true in the development of the criterion "excessively staying away" for Complicated Grief Disorder. Perhaps the contrast between these two items and the item on "numbness, detachment or absence of emotional responsiveness" illustrates an advantage inherent in defining diagnostic criteria in terms of the loss itself rather than in reference to another, generic disorder.

More needs to be done to address the differences described above and pursue the development of consensus criteria. Next steps in resolving the differences between the consensus diagnostic criteria for Traumatic Grief and the criteria for Complicated Grief Disorder might include both field trials in representative samples of a comprehensive range of diagnostic symptoms and follow-up, consensus conferences of experts to review the new data and reach agreement on diagnostic criteria.
- Jacobs, Selby, Mazure, Carolyn & Holly Prigerson, Diagnostic Criteria for Traumatic Grief, Death Studies, Apr/May 2000, Vol. 24, Issue 3.

Personal Reflection Exercise #12
The preceding section contained information about a comparison of traumatic grief and complicated grief disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 26
What symptoms were found in the criteria for traumatic grief but not found in complicated grief disorder?  Record the letter of the correct answer the Answer Booklet.