مورد برای ایجاد سوگ و داغداری پیچیده به عنوان یک اختلال روانی متمایز در DSM-V

Abstract In this paper, we contend that complicated grief (CG) constitutes a distinct psychopathological diagnostic entity and thus warrants a place in standardized psychiatric diagnostic taxonomies. CG is characterized by a unique pattern of symptoms following bereavement that are typically slow to resolve and can persist for years if left untreated. This paper will demonstrate that existing diagnoses are not sufficient, as the phenomenology, risk factors, clinical correlates, course, and outcomes for CG are distinct from those of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and adjustment disorder (AD). It is argued that the establishment of CG as a diagnostic entity is essential because its symptoms are associated with enduring mental and physical health morbidity and require specifically designed clinical interventions. We conduct a critical review of all published evidence on this topic to date, demonstrating that the advantages of standardizing the diagnostic criteria of CG outweigh the disadvantages. In addition, recommendations for future lines of research are made. This paper concludes that CG must be established in the current nosology to address the needs of individuals who are significantly suffering and impaired by this disorder.

. Introduction For years, researchers and clinicians alike have documented numerous mental and physical health complications associated with bereavement. The symptoms have included, but have not been limited to, depression, anxiety, interpersonal problems, substance abuse, hallucinations, physical illness, and even death (cf. Sable, 1992 and Stroebe et al., 2001). Rather than focusing on the vast range of complications that can arise following bereavement, this paper will argue for the establishment of a distinct set of symptoms as a specific mental disorder, complicated grief (CG), that should be included in future editions of mental disorder classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). Recent research efforts have advanced promising empirically derived diagnostic criteria to define CG, and in addition have explored its associated features and potential treatments. The current paper demonstrates that the symptoms of CG constitute a disorder that is distinct from posttraumatic stress disorder (PTSD), bereavement-related depression or major depressive disorder (MDD), and adjustment disorder (AD) by exploring its unique qualitative nature. Furthermore, the symptoms of CG are associated with mental and physical dysfunction that can persist for years and even decades if untreated. If the criteria of CG are not formally established, research to determine efficacious and effective interventions will be hindered. After presenting evidence of the distinctiveness of this disorder (see Table 1 for a summary of studies), a review and synthesis of this information will be conducted to demonstrate the merits of establishing CG as a unique diagnosis in the current nosology of mental disorders. Table 1. Studies demonstrating the distinctiveness of CG Study authors Major findings Methods used Findings replicated? Distinctive symptoms/phenomenology Prigerson, Frank, et al. (1995) CG unidimensional construct distinct from depression Principal components analysis Yes Prigerson, Maciejewski, et al. (1995) CG unidimensional construct; ICG empirical validation Exploratory factor analysis; purifying analysis Yes Prigerson, Bierhals, et al. (1996) CG unidimensional construct distinct from depression and anxiety Principal axis factoring Yes Prigerson, Shear, et al. (1996) CG unidimensional construct distinct from depression and anxiety Confirmatory factor analysis Yes Horowitz et al. (1997) Symptom indicators of CG; CG and MDD symptoms often did not overlap Latent class modeling; signal detection No Chen et al. (1999) CG unidimensional construct distinct from depression and anxiety Principal axis factoring Yes Prigerson, Shear, et al. (1999) Symptom indicators of CG Signal detection Yes Boelen, van den Bout, and de Keijser (2003) CG unidimensional construct distinct from depression and anxiety Principal axis factoring Yes Ogrodniczuk et al. (2003) Three symptoms clusters of CG distinct from two symptoms clusters of depression Factor analysis No Distinctive risk factors/etiology/clinical correlates Beery et al. (1997) Caregiver burden predicted CG but not depressive symptoms Regression analysis No McDermott et al. (1997) Sleep disturbances associated with PTSD and MDD not related to CG ANOVA; correlational and regression analysis No Maercker et al. (1998) Fewer positive themes at 6 months postloss predicted CG-like symptoms at 14 months Regression analysis No van Doorn et al. (1998) Close, security-enhancing relationship and insecure attachment styles predicted CG and not depression Regression analysis Yes Chen et al. (1999) Women reported more CG than men within first 2 years Repeated-measures ANOVA No Carr et al. (2000) High levels of yearning associated with increased marital closeness and dependence Regression analysis Yes Prigerson et al. (2001) Less mental health care service utilization among patients with CG versus MDE Regression analysis No Silverman et al. (2001) Childhood adversity predicted CG, whereas adult adversity predicts PTSD Regression analysis No Barry et al. (2002) Lack of preparedness for death predicted CG but not MDD or PTSD Regression analysis No Prigerson et al. (2002) Pakistani women more likely to meet criteria for CG than men; first-degree relative more likely to meet criteria Regression analysis No Vanderwerker et al. (submitted for publication) Child separation anxiety predicted CG, but not MDD, PTSD, or generalized anxiety disorder Regression analysis No Independent outcomes Prigerson, Frank, et al. (1995) CG but not MDD predicted global functioning, depressed mood, and sleep quality at 18 months Regression analysis Yes Prigerson, Shear, et al. (1996) CG at 6 months independently predicted depression at 12 and 18 months Regression analysis Yes Prigerson, Bierhals, et al. (1997) CG at 6 months predicted cancer, high blood pressure, heart trouble, change in smoking/eating habits, and suicidal ideation at 13 and/or 25 months; CG at 6 months better predictor of morbidity than at 2 months Survival analysis; regression analysis Yes Szanto et al. (1997) Greater CG among suicidal ideators; active ideators had greater CG than passive χ2 tests; ANOVA Yes Chen et al. (1999) CG predicted health events a 13-month follow-up (e.g., cancer, heart attack, hospitalization, and accident); gender differences in predicted outcomes Regression analysis Yes Prigerson, Bridge, et al. (1999) Young adults with CG after losing friend to suicide 5× more likely to report suicidal ideation, controlling for depression Regression analysis Yes Silverman et al. (2000) CG diagnosis related to poorer quality of life; CG better predictor than MDE or PTSD Regression analysis Yes Prigerson et al. (2001) Individual with CG but not MDE had higher functional disability and were 10× more likely to have high blood pressure than those without CG Regression analysis Yes Latham and Prigerson (2004) CG associated with 6.6× greater likelihood of high suicidality at baseline and 11.3× greater likelihood at follow-up; CG at baseline predicted an 8.2× greater likelihood of high suicidality at follow-up Regression analysis Yes Diagnostic discrimination Prigerson, Frank, et al. (1995) 46% with CG did not meet criteria for MDD Contingency table analysis Yes Horowitz et al. (1997) 79% with CG did not meet criteria for MDD Contingency table analysis Yes Silverman et al. (2000) 63% with CG did not meet criteria for PTSD; 50% with CG did not meet criteria for MDE Contingency table analysis Yes Silverman et al. (2001) 18% met criteria for a diagnosis of CG, whereas 7% met criteria for PTSD and 12% for MDE; CG lowest comorbidity rate and most prevalent Contingency table analysis Yes Distinctive course/treatment response Pasternak et al. (1991) Depressive but not CG symptoms improved with nortriptyline treatment ANOVA Yes Pasternak et al. (1993) Grief symptoms more stable than depressive symptoms ANOVA Yes Prigerson, Frank, et al. (1995) Depressive but not CG symptoms improved with nortriptyline treatment Repeated-measures ANOVA Yes Bierhals et al. (1995–1996) CG symptoms stable in first 3 years, but then increase among men and decrease among women ANOVA; t tests No Reynolds et al. (1999) Depressive but not CG symptoms improved with nortriptyline and combination of nortriptyline and IPT χ2 tests Yes Ott (2003) Mental health status of individuals with CG improved less over time than that of individuals without CG over 18 months Repeated-measures ANOVA No

. Conclusion We have argued that the existing diagnostic categories of the DSM-IV-TR (2000) fail to adequately meet the needs of individuals experiencing pathological reactions to bereavement. The symptoms, risk factors, clinical correlates, and responses to interventions are distinct from those of PTSD, MDD, or AD. Furthermore, CG symptoms are associated with enduring psychological and physical dysfunction. Interventions for CG also require specific assessment instruments and treatments to identify effectively the disorder and reduce symptoms. Although consideration must be given to the costs of establishing CG as a distinct diagnostic entity, it is clear that the advantages outweigh the disadvantages. Prigerson and Jacobs (2001a) summarized this perspective by asserting that “…the harm done by not diagnosing those at risk (false negatives) is, in our view, a greater concern than the misdiagnosis of those who are grieving normally” (p. 621). Throughout this paper, solid research evidence has demonstrated that CG is associated with distress, impairment in functioning, and deviates from expected and culturally sanctioned grief reactions. Based on this evidence, it deserves a place in the standardized diagnostic manuals. The American Psychiatric Association (2000) does not expect to publish DSM-V until at least 12 years from the publication of DSM-IV-TR. We have, therefore, a window of opportunity. During this time, research endeavors should continue to refine diagnostic criteria in preparation for inclusion in the nosology of mental disorders. Managed care constraints necessitate the focus of clinical attention on those individuals in greatest need. As mentioned above, the benefits of standardizing diagnostic criteria for CG include helping clinicians to detect and effectively treat these symptoms, and aiding researchers in assessing prevalence, risk factors, neurobiology, outcomes, and preventive interventions (Prigerson, Shear, et al., 1999). Now, more than ever, as the “baby boomers” age and the frequency of loss increases, this movement is imperative.