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DistinguishingGrief,ComplicatedGrief,andDepression
RonaldW.Pies,MD,M.KatherineShear,MD,SidneyZisook,MD December26,2014
Editor'sNote:Depression,grief,andcomplicatedgriefcanbedifficulttodistinguishfromoneanother.However,a
study[1]recentlypublishedinJAMAPsychiatrythefirstrandomizedtrialtoexplorethetreatmentofcomplicatedgrief
(CG)inanelderlypopulationemphasizeshowimportantitistorecognizewhengrievingpatientsarealsosuffering
fromcomorbidpsychopathology,sothatappropriatecarecanbedelivered.MedscapecontributorRonaldW.Pies,MD,
professorofpsychiatryatSUNYUpstateMedicalUniversityinSyracuse,NewYork,recentlymoderatedanemail
discussionbetweenleadauthorM.KatherineShear,MD,programdirectorforColumbiaUniversity'sCenterfor
ComplicatedGrief,andSidneyZisook,MD,distinguishedprofessoranddirector,DepartmentofPsychiatryatthe
UniversityofCaliforniaSanDiego,LaJolla,California,onwhatcomplicatedgriefis,howtotreatit,andhowto
distinguishitfromgriefanddepression.

DepressionvsGriefvsComplicatedGrief
DrPies:I'mdelightedtohavemycolleagues,DrSidZisookandDrKathyShear,joinmeinadiscussionofgrief,
depression,andsomeofthecontroversiessurroundingthesetopics.

SidandKathy,asweknow,theconceptsofgrief,complicatedgrief,anddepressionaresometimestoughforclinicians
tosortout.Thisisespeciallytrueinthecontextofrecentbereavement:thatis,followingthedeathofalovedoneor
significantother.Sometimesourcolleaguesinprimarycareandinpsychiatry,toofindithardtotellwhethera
patientwhohasjustsufferedthedeathofalovedoneisexperiencinggriefordepression,both,orneither.
Unfortunately,thesetermsareoftenusedinconfusingways,bothinthepopularmediaandinsomeofthe
professionalliterature.

So,togettheballrolling,canweprovidesomebrief,basicdefinitionsordescriptionsoftheterms"grief,""complicated
grief,"and"depression"?

DrZisook:"Depression"isabroadlyusedtermfortheselflimitingandgenerallybenigneverydaybluesthatweall
experiencefromtimetotime,aswellasacatchallforagroupofserious,oftenquitemalignantmentalillnesses,
hereingroupedundertherubric"majordepression."Thelatter,inturn,encompassesagroupofimportantclinical
conditions:majordepressiveepisodes(MDEs)seeninbipolarmooddisorders,majordepressivedisorder(MDD,or
"unipolar"depression)andpersistentdepressivedisorder,whichmayormaynothavefewerorlessintensesymptoms
thanMDD,butismarkedbyitspersistence(atleast2years'duration).

Eachoftheseclinicalconditionsarethemselvesheterogeneous,comprisingaspectrumofseverityfromrelativelymild
toquitesevere.Andtheymay(butnotnecessarily)beassociatedwithanxious,mixed,melancholic,atypical,or
psychoticfeatures,andmaybeinfullbloomorinpartialorfullremission.

Tohelpcliniciansdifferentiatethenonclinicaltypeofdepressionsadnessorthebluesfromtheclinicalconditions,it
isimportanttorememberthatnoneoftheseclinicalconditionsshouldbediagnosedabsentthreekeycharacteristics:

Severity(atleastfiveofthecharacteristicsymptoms)

Duration(mostoftheday,nearlyeveryday,foratleast2weeks)and

Pathology(clinicallysignificantdistressorimpairment).

InkeepingwiththeacknowledgmentintheDiagnosticandStatisticalManualofMentalDisorders,fifthedition(DSM
5),thatclassificationofmentaldisordersisaworkinprogress,andthatthecurrentclassificationsystemisintendedto

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serveasa"practical,functional,andflexibleguidefororganizinginformationthatcanaidintheaccuratediagnosisand
treatmentofmentaldisorders,"wefavoralsoaddingclinicaljudgmentandcautiontothediagnosticmenu.

Thus,ifapersonmeetscriteriaforoneoftheclinicalconditions,butitisafirstepisodeandrelativelymild(eg,only
fiveorsixsymptomsaremetandthesedonotincludefeelingsofworthlessnessorsuicidalideation),brief(lessthan1
or2months)andonlyminimallyimpairing,itmaymakesensetodelaymakingaformalordefinitivediagnosiswhile
moreinformationisgatheredandatinctureoftimeisalloweditsdue.

Justasitisimportantnottooverdiagnosethebluesofeverydaylifeasmajordepression,itiseverybitasvitalnotto
overlookmajordepressionwhenitisthere.Nodisorderismorepainfulorhasamoreprofoundeffectonthewaya
personrelatestoothers,feelsaboutthemselvesortheirworthasahumanbeing,functionsineverydayactivities,or
maintainshopeofabetterfuture.

Here,IthinkaquotefromInfiniteJest,byDavidFosterWallace,beautifullydescribesseveremajordepression:

Itisalevelofpsychicpainwhollyincompatiblewithhumanlifeasweknowit.Itisasenseofradicaland
thoroughgoingevilnotjustasafeaturebutastheessenceofconsciousexistence.Itisasenseofpoisoningthat
pervadestheselfattheself'smostelementarylevels.Itisanauseaofthecellsandsoul.

Sometimesmajordepressionseemstooccuroutoftheblue,withnowarningsometimesitsonsetisgradualand
almostunnoticeableandsometimesitseemstobebroughton,orintensified,bystressfullifeevents,suchasthe
deathofalovedone.Whenthathappens,areverberatingcyclesetsin:Thedepressionincreasesthestress,
intensifiesthegrief,andmayeveninterferewithgrief'sresolution,settingthestageforaconditionwecall
"complicatedgrief."

Whetherornottriggeredbyadversity,majordepressiontendstobebothchronic(atleast20%ofallepisodeslast2or
moreyears)andrecurrent(atleast90%ofacuteepisodesrecur).Initsmoresevereforms,thesuffereriswithdrawn
andinconsolable,andongoinglifemayfeeluntenable.Inshort,itisamiserablestate.

PresidentAbrahamLincolnsaidofbeingdepressed:

Iamnowthemostmiserablemanliving.IfwhatIfeelwereequallydistributedtothewholehumanfamily,there
wouldnotbeonecheerfulfaceontheearth.WhetherIshalleverbebetterIcannottellIawfullyforebodeIshall
not.ToremainasIamisimpossibleImustdieorbebetter,itappearstome.

Insuchastate,itisnosurprisethatthoughtsofdeathordyingarecorefeaturesofmajordepressionandthatsuicide
isanalltoofrequenttragicoutcome,especiallywhenthedepressionisunrecognizedoruntreated.

TreatmentsandTerminology
DrPies:Andyet,asbadastheillnessis,wehaveeffectivetreatmentsformajordepressionwouldn'tyouagree,Sid?

DrZisook:Althoughtreatmentsareimperfectandthereisampleroomforbetter,morerapidlyacting,safer,and
moresustainabletherapiesthereisstrongevidencethatbothantidepressantmedicationsanddepressionfocused
psychotherapieswork.Theyreducesymptoms,enhancefunctioning,improvewellbeing,reducesuiciderisk,andcan
reducerelapseandrecurrence.Formanyindividualswithmajordepression,combiningantidepressantswith
psychotherapyismoreeffectivethaneitheralone.

Therealsoisaroleforexercise,light,goodnutrition,andahostofotherhealthpromotingbehaviors,butthesemay
becomefeasibleonlyafterthedarkestperiodsbegintolift.

Forthosewhohavedweltindepression'sdarkwood...theirreturnfromtheabyssisnotunliketheascentofthepoet,
trudgingupwardandupwardoutofhell'sblackdepthsandatlastemergingintowhathesawas"theshiningworld."

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WilliamStyron,DarknessVisible

DrShear:Terminologyisusedinconsistently,soIwillstartbydefininghowweusekeyterms.

"Bereavement"isthesituationofhavingexperiencedthedeathofsomeoneclose,nottheresponsetotheloss."Grief"
istheresponsetoloss,notsimplyanemotion.Theword"grief"isasimpleshorthandforacomplex,multifaceted
experiencethatchangesovertimeandvariesfromlosstoloss.Griefisanautomaticreaction,presumablyguidedby
braincircuitryactivatedinresponsetoaworldsuddenly,profoundly,andirrevocablyalteredbyalovedone'sdeath.

Atanygiventime,griefsymptomsareamanifestationofongoingpsychobiologicalprocessesasmodifiedbyan
evolvingprocessofadaptation.Adaptingtoanimportantlossoftenentailsreevaluationofone'sselfconcept,and
revisingexpectationsandpredictionsofselfandothers,especiallythedeceased.Adaptationentailsunderstandingthe
meaningofthefinalityandconsequencesofthelossandreenvisioninglifegoalsandplans.Asadaptationprogresses,
thefrequencyandintensityofgriefsymptomsattenuate.

Deathispermanent,andsotooistheresponsetotheloss,thoughthemanifestationsofgriefusuallyevolveand
changeovertime.Griefcanbeconsideredastheformlovetakeswhensomeonewelosesomeonewelove.Likeother
formsoflove,griefcanbeanavenueforpersonalchangeandgrowth.

DrPies:Kathy,whataboutthenotionthatpeoplecanandshould"getover"grief?

DrShear:AsWortmanandSilver[2]haveargued,returntoapriorstateafterasignificantlossdoesnotoccur.They
suggestthattheideaofresolvinggriefisoneofanumberofcommonmisconceptionsnotsupportedinsurveystudies
ofbereavedpeople.Anotheristheideathatsuccessfuladaptationmeans"lettinggo"or"sayinggoodbye"inorderto
"moveon."

Anothermisconceptionisthebeliefthatexperiencingandexpressingstrongemotionsisthekeytosuccessful
adaptationandthatthosewhodonotexperienceandexpresstheiremotionsrightaftersomeonedieswillpaylater,or
thecorollariesofthisthatthemoreintenseaperson'semotions,themoreeffectivelysheorheisgrievingandthat
onceyouhavegrievedeffectively,youneverhavetogrieveagain.

Manycliniciansbelievethatproblemswithgriefareseenprimarilyinpeoplewhohaveanambivalentrelationshiptothe
personwhodied.However,complicatedgriefisseenprimarilyinpeoplewhohaveenjoyedaveryrewardingandloving
relationshipwiththedeceased.

Acutegriefistheinitialresponsetoapainfullossthatusuallyentailspainfulemotionsasenseofdisbeliefaboutthe
finalityofthelosspreoccupationwiththoughts,images,andmemoriesofthedeceasedandaninclinationtosocial
withdrawal.Longing,yearning,andsorrowarethemostprominentemotions,oftenaccompaniedbyasenseof
disbeliefeventhoughthebereavedpersonknowsthattheirlovedonehasdied.

Astimepasses,thedisbeliefwanesacutegriefisreshaped,anditsdominancesubsides.Asthefinalityand
consequencesofthelossareunderstood,griefisintegratedintomemorysystems,emotionalreactivity(bothpositive
andnegative)toremindersofthedeceasedisextinguished,andwaysarediscoveredtousethisrelationshiptofoster
continuedpsychologicalgrowth.Thoughgriefismorethanafeelingstate,emotionsformanimportantcomponentof
theresponsetobereavement.

DrPies:What,then,characterizestheperson'semotionsingrief?

DrShear:Griefisnotasingleemotion,butrathercontainsacompendiumofemotions,bothnegativeandpositive.
Yearningandsorrowaretheemotionsthatdefinegrief.Inaddition,almosteveryoneexperiencessomeanxiety,guilt,
anger,orshameinresponsetoasignificantloss.

Mostgrievingpeopleareanxiousaboutthemeaningoftheloss,theexperienceofgrief,ortheshapeofthefuture
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withouttheirdeceasedlovedone.Somepeopleareafraidthattheywillneverstopfeelingwrenchingpain,anxious
aboutwhethertheycaneverbehappyagain,orwhethertheycaneverfeelcomfortablewiththemselveswithoutthe
persontheylost.

Manybereavedpeopleexperiencesomeremorseorguiltabouthowtheytreatedtheirlovedone.Manyfeelsome
survivorguiltbecausetheygettoliveandenjoylifewhenthepersontheylovedcannolongerdothis.

Angerisalsocommon.Itiseasytofeelcheated,tothinkitisunfairthatthepersondied,orthatsomeonefailedin
caringforthepersonwhodied.Sometimesangerisdirectedtowardthepersonwhodied.

Griefcreatesfeelingsofextremevulnerability,andpeoplewhopridethemselvesonbeingstrongandcapablecanfeel
ashamedoftheweaknessthataccompaniesgrief.Peoplewhovalueemotionalcontrolmightbeashamedof
uncontainableanguish.

Sometimespeoplealsofeelguiltorshameabouthavingpositiveemotions.However,griefusuallycontainspositive
feelingsinterspersedwiththenegativeones,evenintheearlyperiodofbereavement.SusanFolkmanandher
colleagues[3]foundthatbereavedpeoplereportedpositiveemotionsasfrequentlyasnegativeonesasearlyas1
monthafterthedeathofsomeoneveryclose.Itfeelsgoodtorecallhappymemories,tellfunnyanecdotes,feelpride
inhonoringthepersonwhodied,orfeelwarmthinrecollectingclosenesstoalovedone.

Ifthepersonwhodiedwasillandburdensome,itisverynaturaltofeelreliefwhentheydie.Peoplemightfeelrelief
afterthedeathofapersonwhowasdifficulttolivewith.

Inadditiontoevokingstrongemotions,bereavementpresentsmajorcognitiveandbehavioralchallenges.Bereaved
peopleneedtochangethewaysinwhichtheythinkaboutthemselves,otherpeople,andtheworldatlarge.Behavioral
changesmaybeneededtoachievenewrolesortoformnewrelationships

Overall,manycomplexandvaryingemotional,cognitive,andbehavioralchangesareentailedinmakingtheadaptation
neededtocometotermswiththelossandtoreenvisionthefutureafterbereavement.

ComingtoTermsWithLoss
DrPies:Canyousaywhathelpsthegrievingpersonadaptandcometotermswiththeloss?

DrShear:Adaptationislargelyalearningprocess.Bereavedpeopleneedtoassimilateinformationaboutthefinality
andconsequencesofthelossintolongtermmemoryandlearnnewwaystoenvisiontheirownliveswithoutthe
deceasedperson.

TheprocessofadaptationtoadeathhasbeendescribedbyBowlby[4]asoneinwhichwemustchangeamental
model,andhepointsoutthatsuchachangeisalwaysresisted.Bowlbyassertsthatourmindsmercifullymovetoward
andawayfromacknowledgingthepainfulreality,providingboutsofgriefinterspersedwithperiodsofrespite.Inother
words,adaptationtypicallyprogressesinfitsandstarts,inwhichweoscillatebetweenconfrontingandreflectingon
painfulinformationabouttheloss,andthensettingitaside.StroebeandSchut [5]pointoutthatlossbringsdualcoping
challengesrelatedtodealingwiththelossontheonehand,andrestoringameaningfullifeontheother.

Differentfeelingsassociatedwithacutegriefcanguideandmotivatechangesthathelppeopleadjusttothedeath.At
thesametime,preoccupationwiththepersonwhodiedhelpsweaveintoadaptationwaystostayconnectedtothe
personwhodied,andtofeeltheirpresenceasthebereavedbegintoengageintheirownlivesagain.

Forexample,ifthereisachoretobedone,memoryofhowthedeceaseddidthischoreislikelytobeeasily
accessible.Thisisusefulforthebereavedperson,whocanthenconsiderwhetherthiswouldbeagoodwaytodoitor
not.Ifnot,itwillhelptoseewhynot.Ifthereisnoideahowthepersonactuallydidthechore,easilyaccessible

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memoriesmightstillmakeitpossibletorecallwhatadvicethedeceasedmighthaveprovided.Manypeoplemakeita
habitto"talk"toalovedonewhohasdied,especiallywhentheyaresolvingaproblemormakinganimportant
decision.

DrPies:Whataboutcomplicatedgrief,Kathy?Whatcontextdoesthatoccurin?

DrShear:Sometimes,maladaptivefeelings,thoughts,orbehaviorscangetafootholdduringgrief.Apersonmight
becomecaughtupintroublingthoughtsaboutthecircumstancesorconsequencesofthedeath,oraboutaspectsof
theirrelationshipwiththedeceased.Sometimes,remindersofthelossaresopainfulthatthebereavedpersongoesto
greatlengthtoavoidthese,andthoughtsaboutthedeatharesointenselypainfulthatitisdifficulttoreflectonitand
makepeacewiththeloss.Ortheremaybeanexternalsituation:hostilityorsevereneglectbyotherpeople,
devastatingfinancialconsequences,orotherhighlystressfulchangesinabereavedperson'ssituation.

Complicatedgriefoccurswhensomethinginterfereswithlearningthatisthecoreprocessofhealing.Theresultisa
situationinwhichthebereavedpersonseems"stuck"inacutegrief,tryingtodealwiththecomplicationsthatblock
acceptanceandadaptationtotheloss.Initiallyidentifiedusinga19itemselfreportquestionnairecalledtheInventory
ofComplicatedGrief,complicatedgriefcanbeadisablingproblem.Complicatedgriefisbestunderstoodasasevere
formofgrief,similarinmanyrespectstotheexperiencealmosteveryonehaswhenalovedonedies.

BereavementDoesn't"Immunize"AgainstDepression
DrPies:Thankstoyoubothfortheseexcellentdescriptions.

OneofthemostcontroversialdecisionstheDSM5madewastodropthesocalled"bereavementexclusion"when
diagnosinganMDE.Essentially,theDSMIVhadinstructedcliniciansnottodiagnosemajordepressionwithinthefirst
2monthsafterthedeathofalovedone,unlesscertainputativemarkersofseveritywerepresent,suchassuicidal
ideation,markedfunctionalimpairment,psychomotorretardation,senseofworthlessness,orpsychosis.

TheDSM5,incontrast,tellsusthatthesubsetofpersonswhomeetthefullsymptom/duration/severitycriteriafor
majordepressionwithinthefirstfewweeksafterbereavementshouldnotbeexcludedfromthesetofallpersonswith
majordepression.Toputitmoresimply:TheDSM5recognizesthatbereavementdoesnot"immunize"thegrieving
personfrommajordepression,andisinfactafrequentprecipitantofmajordepression. [6]

DespitesomeguidanceintheDSM5regardingthedifferencesbetweengriefandmajordepression,manyclinicians
remainpuzzledoruncertainastohowthetwoaredistinguished.

Sid,thisisanareayouhaveexploreddeeply.Canyougivetheprimarypracticephysician,andpsychiatristsaswell,
fourorfivekeyfeaturesthatyoulookforwhendistinguishinggrieffrommajordepression,inthecontextofrecent
bereavement?And,then,Kathy,canyouaddabitonhowcomplicatedgriefdiffersfrommajordepression?

DrZisook:ThefirststepistorememberpreciselywhatgriefandmajorMDDrepresent.Thedeathofalovedone
almostalwaystriggersgriefbut,anexquisitelystressfulandsometimestraumaticlifeeventmayalsoprecipitatea
numberofadversehealthconsequences,including(butnotlimitedto)MDD.

Griefisthenormal,expected,generallyadaptivepsychological,biological,interpersonal,andsocialresponsetoloss.
MDD,ontheotherhand,isaserious,sometimesmalignant,lifethreatening,mentaldisordermarkedbyintense,
persistentandpervasivesadnessoranhedonia.MDDgenerallyisarecurrentconditionandoftenisquitechronic.

Thus,IwouldrephrasethequestionIwasaskedtodiscuss.Themoremeaningfulquestionisnotsomuch,"Howcan
griefandMDDbedifferentiated?"asitis,"HowcananMDEbediagnosedwhenitoccursinarecentlybereaved
personwhoisstillactivelygrieving?"Thatcanbeachallengingandtrickyclinicalconundrum,evenforthemost
experiencedclinician.

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TheDSM5doesagoodjobinhelpingclinicianstounderstandwhengriefmaybecomplicatedbyacooccurringMDE.
InthefootnoteforthediagnosticcriteriaofanMDD,theDSM5notes:

Keyissue:ThepredominantaffectingriefthatisnotcomplicatedbyanMDEasenseofemptinessandloss.When
thereisalsoanMDE,persistentandpervasivedepressedmoodandtheinabilitytoanticipatehappinessorpleasure
predominate,evenintheabsenceofreferencetothedeceased.

Natureofdysphoria:IngriefthatisnotcomplicatedbyanMDE,thedysphoriatendstodecreaseinintensityover
daystoweeksandoccursinwavesthatareassociatedwiththoughtsorremindersofthedeceasedsocalled"pangs
ofgrief."WhenanMDEintervenes,thedysphoriatendstobemorepersistentandnottiedtospecificthoughtsor
preoccupations.

Positiveemotions:Ingrief,thepainmaybeaccompaniedbypositiveemotions,suchashumor,relief,warmth,and
evenpleasureintheclosenesswithsignificantothers.Incontrast,whenaMDEalsoispresent,morepervasive
unhappinessandmiseryarelikelytoleavenoroomforwarmth,joy,orhumor.

Preoccupations:Thoughtsandmemoriesofthedeceasedpredominateingrief.Whenthegriefisaccompaniedbya
coexistingMDE,thoughtsalsoarefocusedononeselfbeingbad,undeserving,orunworthy.

Selfesteem:Ingrief,selfesteemisgenerallypreserved.WhengriefisaccompaniedbyanMDE,thoughtsof
worthlessnessandselfloathingalsoarecommon.

Consolability:Grievingindividualsoftenfeelsupportedandcomfortedbyfriendsandrelativessharingtimeand
conveyingcondolences.WhenanMDEintervenes,peoplearefarlessconsolableorapproachable.

Suicidalthoughts:Ingrief,thoughtsofdeathordyingaregenerallyfocusedonthedeceasedandpossiblyabout
joiningthem.InabereavedpersonwhoisalsosufferingfromanMDE,thoughtsmaybemorefocusedonendingone's
lifebecauseoffeelingundeservingoflife,feelingunabletowithstandtheseeminglyunendingtortureofdepression,
and/ormistakenlybelievingthatotherswouldbebetteroffwithoutthem.

Evenwiththeseguidelines,isnotalwayseasytodiagnoseanMDEinthecontextofbereavement.Itisclearthata
symptomchecklistisnotenough.Rather,amorenuancedassessment,takingintoaccountsomeofthefeaturesand
phenomenologynotedabove,combinedwiththeuniquehistory,beliefs,andsocial/culturaldimensionsoftheperson
andtheirenvironment,mustbeweighedintothediagnosticprocess.

Sometimesitisusefultowaitbeforemakingadefinitivediagnosis.Thisisespeciallytrueinsomeonewhodoesnot
haveaprevioushistoryofMDD,andifsymptomsarerelativelymildandnotlifethreatening.Whenindoubt,past
historyandfamilyhistory,aswellasatinctureoftime,mayhelpinformclinicaljudgmentanddecisions.

MoreonParsingComplicatedGriefandMDD
DrPies:That'sextremelyhelpful,Sid,andyouremindusonceagainthatgriefandmajordepressionarenotmutually
exclusivethatonecanbegrievingadeathandalsobeexperiencinganMDE.

Kathy,howaboutyourtakeonwhatdifferentiatescomplicatedgrieffrommajordepression?

DrShear:Complicatedgriefisatthehighendofthegriefspectruminbothintensityandduration.Peoplewith
complicatedgriefareoftencaughtupinruminations,avoidance,ormaladaptiveproximityseeking.Complicatedgrief
ruminationsareusuallyfocusedoncounterfactualaccountsofthedeathforexample,"IfonlyIhadmadehimgoto
thedoctorsooner"or"IfonlyIhadnotlefttheroomrightbeforeshedied."

Depressiveruminationisdifferent.Depressedpeoplegetcaughtupinthoughtsaboutbeingworthlessorbeingabad

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personorthoughtsthatnothinggoodeverhappensintheworld,etc.Withdepression,peoplemaybecomewithdrawn
andnotwanttogooutorsocialize.

Withcomplicatedgrief,avoidanceismorespecific,focusedonnotwantingtoconfrontremindersofthepersonwho
died.Peoplewithcomplicatedgriefaredesperatetofeelclosetotheirdeceasedlovedoneandmayspendhours
lookingatphotos,touchingorsmellingtheirclothes,ordaydreamingabouttimestheyweretogether.Thesetimesare
usuallypleasurableuntiltheperson"wakesup"andremembersthatthepersonisgone.

DrPies:Iwanttothankmycolleagues,DrZisookandDrShear,forhelpingusunderstandthiscomplexanddifficult
areaofdiagnosis.

References

1. ShearK,WangY,SkritskayaN,etal.Treatmentofcomplicatedgriefinelderlypersons:arandomizedclinical
trial.JAMAPsychiatry.201471:12871295.

2. WortmanCB,SilverRC.Themythsofcopingwithloss.JConsultClinPsychol.198957:349357.Abstract

3. FolkmanS.Thecaseforpositiveemotionsinthestressprocess.AnxietyStressCoping.200821:314.Abstract

4. BowlbyJ.AttachmentandLoss(vol13).NewYork,NY:BasicBooks1969,1972,1980.

5. StroebeM,SchutH.Thedualprocessmodelofcopingwithbereavement:rationaleanddescription.Death
Stud.199923:197224.Abstract

6. ZisookS,CorrubleE,DuanN,etal.ThebereavementexclusionandDSM5.DepressAnxiety.201229:425
443.Abstract

MedscapePsychiatry2014WebMD,LLC

Citethisarticle:DistinguishingGrief,ComplicatedGrief,andDepression.Medscape.Dec26,2014.

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