Some experts are calling for complicated grief to be registered as a serious psychiatric illness, writes Gerry Byrne
WHEN JUNE Carter, Johnny Cash's wife, close friend and songwriting partner, died unexpectedly of complications following heart surgery on May 15th, 2003, Cash was devastated. Carter had co-written one of Cash's most enduring hits Ring of Fire.
Four months later, Cash followed her into the grave. Fans readily assumed that he had died of grief.
Was this just another Nashville legend taking its resonance from Cash's own earlier country hit, Story of a Broken Heart, or is there a link between the death of a loved one, and one's own rapid descent into fatal illness? If Carter had survived that operation, would Cash have lived?
We can easily come up with examples of friends and relatives who also "died of a broken heart". Of course there is no such cardiac condition yet psychiatrists are now verifying what was once thought myth.
Statistics show you have a higher chance of dying after a partner dies. For some personality types that risk increases to almost epidemic proportions.
Indeed, one Harvard psychiatrist researcher, Dr Holly Prigerson, is so alarmed at the statistics she has recently uncovered that she has called for the condition we might call a broken heart, but which psychiatrists call complicated grief, to be registered as a serious psychiatric illness.
In the US the official bible of mental conditions is the Diagnostic and Statistical Manual of Mental Disorders (DSM). In 1994, its fourth revision DSM-IV was published; it lists 297 mental disorders on 886 pages. Prigerson says it deals with grief disorders in just one paragraph, mostly alluding to depression, and she wants major changes in the next edition, due in 2012.
But other experts, including Prof Patricia Casey, professor of psychiatry at the Department of Psychiatry, UCD and at the Mater Misericordiae Hospital, urge caution. They warn that rushing into making a disease out of something natural may be counterproductive.
People suffering from "normal" or uncomplicated grief, says Prigerson, are able to feel that life still holds meaning.
"Despite their pain, they are also able to maintain a sense of self-efficacy and trust in others. Their identity remains intact, they are willing and able to explore new roles and relationships and derive new or renewed sources of satisfaction in their lives."
After six months, she adds, they are getting on with their lives.
Things are different with a minority of the bereaved; those suffering from disordered or complicated grief. They are at greater risk of dying earlier, of suffering a wide range of illnesses, even committing suicide. Their grief symptoms last far longer.
According to Prigerson, complicated grief sufferers lack a sense of identity, and they wonder how they will survive in the absence of the deceased person. They are acutely distressed with intense pangs of yearning or longing; there's a sense of emptiness and lack of purpose.
And they feel numbed after their bereavement. Yet, taken one at a time, their symptoms do not ring alarm bells.
"When someone you love dies, that's how you're expected to feel. But these people sometimes want to kill themselves, and they are more likely to have a heart attack. It's not that the symptoms of grief are unusual and unexpected, it's a question of severity.
"Six months afterwards they are still thinking all day about this loss and how their life used to be so great and now it's awful," she adds.
A 1969 British study found almost one in 20 men died within six months of their wives' deaths. A much larger Finnish study published in 1996 revealed that the recently bereaved were one-third more likely to die of a heart attack within six months.
They were even more likely to have an accident, commit suicide or develop a fatal drink problem.
But a person suffering from complicated grief for six months is 14 times more likely to consider suicide than a "normally" bereaved person, according to more recent research by Prigerson and several of her colleagues. And, rather than things improving with time, the same group was 22 times more likely to think of killing themselves almost a year after bereavement.
And they are not just at risk of suicide. They face the early onset of serious physical illness such as cancer, hypertension, cardiac illness and psychiatric ailments. They are also more likely to be hospitalised.
"These are people who take bereavement that much harder and we are now finding out who they are," says Prigerson. "Usually they are people who have trouble with change.
"They like having their meals at the same time each day and they are usually very dependent on the person who has died. They are also sometimes people who were physically or sexually abused."
Prigerson realises that many complicated grief sufferers have suffered from a psychiatric condition known as childhood separation anxiety where they were separated from their parents, or received poor parenting at a critical period of their early childhood.
It is a condition which, if not remedied, can leave sufferers prone to a range of other disorders, not the least of which are anxiety, depression and difficulty in sustaining long-term relationships.
"Typically there has been an insecure attachment to a parent in childhood, then they find someone later in life who makes them feel safe and protected. But if that person dies, it's like a wound opened up and they are vulnerable and waif-like again."
Attachment disorders were first comprehensively described by the British psychoanalyst John Bowlby and one of those who worked with him was Colin Murray Parkes, now a world-renowned expert on bereavement at St Christopher's Hospice, Sydenham, London.
He supports Prigerson's quest to have complicated grief made an official mental disorder. Attachment theory is all about security, or the lack of it, Parkes explains.
Estimates of the incidence of complicated grief range from 5 per cent to 50 per cent of the bereaved, says Parkes but this uncertainty is largely because there is so far no accurate definition of the disorder.
He hopes some agreement on a diagnosis can be reached. Prigerson suggests a diagnosis should be based on patients suffering from significant impairment and displaying four or more bereavement-related symptoms for more than six months.
But they are meeting some resistance, especially from Nancy Hogan, a professor of nursing specialising in bereavement care at Loyola University, Chicago. Hogan and Prigerson have clashed on the issue with Hogan also saying not enough research has been done to warrant the recognition of complicated grief as a separate ailment.
It's possible, says Hogan, that Prigerson's research is mistaking major trauma and serious depression associated with bereavement with complicated grief. Prigerson rejects this and says far more research has been conducted than Hogan credits her with.
Prigerson is also under fire from bereavement counsellors who say widows and widowers will resent being labelled mentally ill. But Prigerson disagrees and quotes a survey which she says shows that more than 97 per cent of complicated grief sufferers said they would be interested in receiving treatment if they were to be diagnosed with a mental illness.
"They are glad to be labelled, in fact they were reassured by it. At least now they know there's some reason for what's going on in their lives," says Prigerson.
Parkes explains. "This is a psychiatric disorder when sufferers say 'I cannot enjoy life, I need help, I need to take time off work, I need the privileges of illness if you like'."
Casey agrees that complicated grief has life-threatening consequences, not the least of which is an increased risk of suicide but she urges caution in designating it as a major disorder.
"Otherwise many people could be defined as having it when in fact their grief is relatively normal.
"There's little evidence of benefit in grief intervention for people going through normal grieving," she says.
"It could be rather like debriefing for traumatic stress disorder after a major accident; in some cases it might be harmful and actually prevents the healing. This is not something to be rushed into. Rather than defining sufferers as displaying symptoms for six months I would say you should wait at least a year."