شیوع و ارتباط هم ابتلایی در افراد با سوگ و داغداری پیچیده

Abstract Background Complicated grief (CG), variously called pathological or traumatic grief, is a debilitating syndrome that is not currently included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) nomenclature. One issue that remains under debate is whether this condition can be clearly distinguished from other psychiatric disorders, such as major depression and posttraumatic stress disorder, with which CG frequently coexists. Methods Using a structured clinical interview for CG and the Structured Clinical Interview for DSM-IV, trained experienced raters conducted careful diagnostic assessments of individuals seeking treatment of bereavement-related distress. All study participants met criteria for a current CG syndrome. Liberal criteria were used to diagnose DSM-IV disorders, making no attempt to decide if symptoms could be explained by grief. Results Of 206 who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder. When present, psychiatric comorbidity was associated with significantly greater severity of grief; however, even after adjustment for the presence of comorbidity, severity of CG symptoms was associated with greater work and social impairment. Limitations It is likely that our study underestimated the rate of CG without comorbidity because fewer DSM diagnoses would have been made if a judgment about grief had been taken into consideration. Conclusions Our data provide further support for the need to identify CG as a psychiatric disorder.

1. Introduction The syndrome of complicated grief (CG), variously called pathological or traumatic grief, is chronic and debilitating, results in substantial distress and impairment [1], [2] and [3], worsens quality of life [4], and has been linked to excess medical morbidity [5] and [6] and suicidality [5], [7], [8] and [9]. As currently defined, CG consists of symptoms at least 6 months after the loss of a loved one that include a sense of disbelief regarding the death; persistent intense longing, yearning, and preoccupation with the deceased; recurrent intrusive images of the dying person; and avoidance of painful reminders of the death [10], [11], [12], [13] and [14]. Individuals with the syndrome of CG often report anger and bitterness related to the death, feel estranged from other close friends and relatives, and cannot find satisfaction in ongoing life [1], [15] and [16]. Complicated grief has been distinguished from other co-occurring psychiatric disorders such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) [2], [17], [18], [19] and [20]. For example, CG symptoms have been shown to contribute to impairment beyond that associated with PTSD and major depression [2], [3] and [4]. Nonetheless, there is still controversy regarding the distinctiveness of the syndrome [21]. There are limited data available examining the co-occurrence of CG disorder and other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) conditions in clinical populations with CG. In addition, little has been done to evaluate the impact of psychiatric comorbidity on the course or severity of CG. In our pilot study of psychotherapy for 23 individuals with CG [22], current MDD was present in 52%, PTSD in 30%, panic disorder in 26%; 48% had more than one comorbid psychiatric disorder. Coexisting psychiatric disorders were associated with greater grief severity [17]. The current article reports secondary analyses conducted to examine both the question of coexisting psychiatric disorders and CG symptoms together with the impact of current psychiatric comorbidity in 206 individuals recruited for participation in a randomized controlled treatment study [1]. We hypothesized that (1) a substantial subgroup of individuals with CG would have no DSM-IV comorbidity, (2) grief severity would be linked to greater work and social impairment after controlling for the presence of psychiatric comorbidity, (3) individuals with psychiatric comorbidity would have more severe CG symptoms, and (4) comorbid disorders would commonly be preexisting, supporting the possibility that mood and anxiety disorders may elevate risk for CG

3. Results 3.1. Characteristics of participants Of 417 patients who received an initial brief prescreening assessment, 217 patients were evaluated; 206 met the study criteria for CG and were included in analyses. The mean (SD) age of the sample was 46.5 (12.4) years, and 81.6% (n = 168) were women. They were 70.1% white, 27% African American, and 2.9% other races (n = 2 missing). The mean ICG score (n = 206) was 47.1 (±9.6), and the mean time since the CG-related death (n = 205) was 5.0 ± 7.5 years (range 0.42-51.7 years, median 2.4 years; 1 patient was included with a duration of only 5 months). 3.2. Presence of psychiatric comorbidity After assigning symptoms to DSM-IV categories with no attempt to decide if these symptoms were better explained by grief, we observed that 51 participants (25%) had no current DSM-IV Axis I disorder and 16% had no lifetime disorder ( Table 1). With respect to specific comorbid disorders, 45% (of the entire sample) did not meet the criteria for current MDD and 28% were free of lifetime MDD. Similarly, 51% failed to meet the criteria for current PTSD and 47% for lifetime PTSD ( Fig. 1). Both conditions share symptoms with CG. Other conditions that were diagnosed in our grief sample include generalized anxiety disorder (GAD) and panic with or without agoraphobia ( Table 1). Although analyses were limited by the high proportion of women and white participants, there were no sex or race differences in comorbidity rates. Patients with at least one current comorbid disorder were younger (45.1 [11.5] years) compared with those without comorbidity (50.6 [14.1] years: t(df) = 2.8(204), P < .01). In addition, those with psychiatric comorbidity tended to present for treatment sooner after the loss at the level of a statistical trend (mean 4.4 [6.2] years vs 6.6 [10.3] years: t(df) = 1.89(203), P = .06). Table 1. Psychiatric comorbidity in treatment-seeking individuals with CG (n = 206) Comorbid disordera Current % (n) Lifetime % (n) MDD 55.34 (114) 71.84 (148) PTSD 48.54 (100) 52.91 (109) Panic disorder 13.59 (28) 21.84 (45) Agoraphobia without panic 0.97 (2) 0.97 (2) GAD 18.45 (38) N/A Social anxiety disorder 7.77 (16) 13.11 (27) Obsessive-compulsive disorder 6.31 (13) 6.80 (14) Any anxiety disorderb 62.62 (129) 69.42 (143) Any comorbid disorder 75.24 (155) 84.47 (174) 1 comorbid disorder 24.76 (51) 21.36 (44) 2 comorbid disorders 30.58 (63) 33.01 (68) 3 comorbid disorders 13.59 (28) 18.45 (38) ≥ 4 comorbid disorders 6.31 (13) 11.65 (24) No comorbid disorder 24.76 (51) 15.53 (32) a Bipolar disorder was an exclusion criterion for randomization in the treatment study, but was diagnosed in 10 individuals at screening assessment (6 bipolar I, 4 bipolar II). b The presence of any anxiety disorder was defined as at least one DSM-IV diagnosis of panic disorder with or without agoraphobia, agoraphobia without panic, obsessive-compulsive disorder, GAD, PTSD, or social anxiety disorder. Table options Current PTSD and MDD comorbidity in treatment-seeking individuals with CG ... Fig. 1. Current PTSD and MDD comorbidity in treatment-seeking individuals with CG disorder (n = 206). Figure options Complicated grief patients with psychiatric comorbidity were more severely ill and more impaired than those without comorbidity (Table 2). This was also the case for those with at least one anxiety disorder compared with those with no anxiety disorder (Table 2). To examine whether the severity of CG contributes to work and social impairment above and beyond the presence of current comorbid anxiety disorders and/or MDD, we examined the prediction of WSAS score by ICG score in a linear regression including covariates for MDD and anxiety disorders. The ICG scores remained significantly associated with greater work and social impairment (B = 0.43, t = 5.57, P < .001) after adjustment for current depression and anxiety comorbidity and also after adjustment for lifetime comorbidity (B = 0.52, t = 6.74, P < .001). Table 2. Impact of current psychiatric comorbidity on current symptom severity in CG Current comorbidity ICG (n = 206) HAM-D 25 (n = 187) IES (n = 170) HAM-A (n = 182) PSQI (n = 165) WSAS (n = 164) MDD (n = 114) 49.5 ± 9.6 (114)*** 30.8 ± 8.4 (106)*** 44.3 ± 14.9 (98)*** 24.3 ± 7.1 (104)*** 10.7 ± 4.2 (94)*** 26.7 ± 9.3 (95)*** Any anxiety disorder (n = 129) 48.5 ± 9.7 (129)** 27.6 ± 9.9 (122)** 42.4 ± 15.0 (111) 22.6 ± 7.9 (119)*** 10.2 ± 4.2 (107) 24.2 ± 10.2 (106) ** Any comorbid disorder (n = 155) 48.1 ± 9.6 (155)** 27.8 ± 9.6 (145)*** 42.7 ± 14.9 (131)** 22.5 ± 7.6 (142)*** 10.2 ± 4.1 (127)** 24.7 ± 10.0 (126) *** No comorbid disorder (n = 51) 44.1 ± 8.8 (51) 19.7 ± 8.3 (42) 34.7 ± 14.1 (39) 16.0 ± 7.8 (40) 8.2 ± 3.3 (38) 15.9 ± 9.6 (38) P values are for t tests comparing the particular disorder group to absence of that disorder classification (ie, MDD vs no MDD, at least one anxiety disorder vs no anxiety disorder, at least one comorbid disorder vs no comorbid disorder). Mean values for the absence of any comorbid psychiatric disorder are also included for reference. Sample size given for each measure to account for missing data (full sample n = 206). ICG indicates Inventory of Complicated Grief; HAM-D 25, 25-item Hamilton Depression Scale; IES, Impact of Events Scale; HAM-A, Hamilton Rating Scale for Anxiety; PSQI, Pittsburgh Sleep Quality Index. *P < .05, **P < .01, ***P< .001. Table options Most individuals with lifetime psychiatric comorbidity (75%, 128 of 175) reported an age of onset for at least one psychiatric disorder before the reported CG-associated loss, with the earliest disorder onset at a mean of 16.7 ± 14.3 (range 0.2-65.6, 95% confidence interval 14.2-19.2) years before the loss. Of note, more than 80% of those with MDD (87%, 127 of 146) and PTSD (82.2%, 88 of 107) reported onset of the DSM disorder before bereavement.