13.5 (17.7) Bereavement Flashcards
Define the following terms:
1. Bereavement
2. Grief
3. Mourning
4. Anticipatory grief
5. Pathological grief (list 2 variants)(!!!)
6. Disenfranchised grief
- Bereavement - STATE of loss (usually referring to loss of life)
- Grief - RESPONSE associated with loss (emotional, physical, cognitive, behavioral)
- Mourning - process of adaptation including cultural and social RITUALS prescribed as accompaniments
- Anticipatory grief: precedes the death and results from expectation of that event
- Pathological grief: abnormal outcome involving psychological, social, or physical morbidity
(variants: COMPLICATED grief, PROLONGED grief) - Disenfranchised grief: HIDDEN sorrow of the MARGINALIZED where there is less social permission to express many dimensions of loss
List four types of theory to explain the phenomenon of bereavement*
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
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?
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)
List 4 dimensions of grief
- Emotional
- Physical
- Cognitive
- Behavioural
List four emotional displays of normal grief
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
List 1 common cognitive manifestation of grief
Cognitive processes dominated by MEMORIES (reflected in storytelling, reminiscences, conversations about the deceased)
List four physical manifestations of grief
numbness
restlessness
tension
tremors
sleep disturbance
anorexia
weight loss
fatigue
aches and pains
FS: physical aspect of MSIGECAP and BE SKIM (anxiety)
list three behavioural manifestations of normal grief
social withdrawal
seeking company and consolation
wandering
searching
Beside loss of life - list four other domains where loss is expected
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
List four emotional indicators for risk of complicated grief in a person/family experiencing anticipatory grief
intense distress
Anger
denial of the seriousness of the threat
protective avoidance
withdrawal from involvement
FS: DADA
Distress, anger, denial, avoidance
List 2 ways clinicians can help a family experiencing anticipatory grief
- Encourage them to openly share their feelings
- 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
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
- comment on the process of dying explaining breathing patterns etc
- normalize experience empathetically
reassure family when a concern develops - discuss pain
- discuss reasons for medications
- skilled prediction of events
- ask about and facilitate religious rituals
- expression of sympathy
FS
1) signs of dying
2) symptoms (pain)
3) meds
4) rituals
5) empathy
List 3 post-mortem practices that MD can provide to be supportive for family/friends of the deceased (immediately after death)
- Respecting post-mortem cultural approaches
- If relatives not present at time of death, invite to attend based on a deterioration and shares news on arrival
- Unless there is a legal requirement for coroner’s postmortem, respect family’s views on autopsy
- 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
List 4 scenarios in which grief could be marginalized or disenfranchise the bereaved from usual supports
- Ageism (death is normalized because it appears in step with life cycle & family members given less support)
- Suicide
- Homicide
- Euthanasia
The duration of grief is based on what two major factors
strength of attachment to the lost person
cultural expression
What are the four general phases of acute grief
- initial numbness and sense of unreality
- waves of distress begin to occur as the bereaved yearn for lost loved one
- 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) - phase of reorganization and recovery - altered world view constructed + personal growth
FS:
Numb
Distress
Disorganized
Reorganize
List 3 factors that help to differentiate normal from pathological grief
- time course
- intensity of reaction
- presence of range of grief related behaviours
FS: think of DSM
List four common psychiatric conditions that accompany grief and are separate entities from complex grief
- PTSD
- EtOH or other substance abuse/dependence
- MDD
- anxiety disorders
- psychotic disorders
- Name the diagnosis proposed by DMS-5 for complex grief
- What are the general diagnostic criteria for this
- Persistent Complex Bereavement Disorder
- 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
Prolonged grief can lead to a range of health problems - list 4
- cardiac distress
- hypertension
- increased ETOH and cigarette consumption
- suicidal ideation
List 5 signs of pathological grief*
- greater degrees of separation distress
- emotional numbing and dissociation
- mood symptoms
- impaired social functioning
- maladaptive coping styles
FS: think of DSM 5 criteria
List 2 maladaptive coping strategies seen in pathological grief
avoidance or denial*
distortion through excessive anger*
despair
guilt
idealization or somatization
prolongation that culminates in chronicity
FS: think of DSM
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?
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)
What is 1 major risk factor for chronic grief
Chronic grief - particularly associated with overly dependent relationships (!!!) in which a sense of abandonment is avoided by perpetuation of relationship through memorialization of deceased
What causes traumatic grief?
List 2 unique symptoms of traumatic grief
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?
At what point after a death is MDD most likely to develop?
Within initial 2 months (per 5th edition)
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?*
See Table 13.5.2:
supportive
conflict resolving
conflictual
uninvolved
low communicating
loss of cohesiveness
communication breakdown
increased conflict
List 4 risk factors for pathologic grief (!!!)
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)
List 3 health related consequences of bereavement
-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
What are two types of bereavement follow up that can be offered by the treatment team to a bereaved family
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
Who should be offered grief therapies?
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)
List 3 therapy models for grief support
CBT*
complicated grief treatment*
family focussed grief therapy*
supportive-expressive therapy
interpersonal psychotherapy
What are the four major tasks of mourning?
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
List four risk factors for suicide in bereavement
- Self
those who abuse EtOH
current or past hx of MDD - Relationship with deceased
elderly widowers - Relationship with others
socially isolated
At what age do children start to understand the concept of death and what age do they grasp finality of death
5-6 years understand
9-10 years old - finality
Personal growth and positive outcomes can be experienced after successful grief and bereavement. List 2 such outcomes
renewed sense of meaning
self-awareness
increased empathy*
appreciation of family and relationships*
independence
reprioritized goals and values
deepened spirituality
increased altruism
List four bereavement symptoms in children
fear
insecurity
Guilt
Sadness
Behavioural problems
FS: FIGS
Other than the family environmental scale. What tool can be used to screen families for risk of complicated reactions to stressful events?*
Inventory of complicated grief
List four types of meds used for bereavement
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
Clinician exploration of spirituality with the patient and family may help address bereavement.*
- How might patients/families express their spiritual dimensions or philosophy of life. List 3 ways
- How can clinician understanding of this be helpful to the bereaved? List 2 ways
- religious beliefs, cultural customs, traditions
- 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
