Previously held findings on complex grief include:
• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.
• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.
• Low perceived social support associated with depression after disaster-related bereavement.
• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.
• Finding meaning in the loss is related to lower mental distress and grief after violent losses.
• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.
After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.
An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.
In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).
Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).
DSM-5 diagnosis of persistent complex bereavement disorder
How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).
PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.
Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.
In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.
Summary of proposed PCBD in DSM-5
• Criterion A requires that the individual has experienced the death of a loved one.
• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.
• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.
• Criterion D requires clinically significant distress or functional impairment.
• Criterion E requires that distress or impairment is outside of sociocultural norms.
Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.