#MentalHealthAwareness
Bereavement — part of Post traumatic stress disorder (PTSD)
by Rashi Jain, Farooq Ali Khan, Abhishek Kumar, Raamesh Gowri Raghavan, and Sukant Khurana
Bereavement is the state of loss when someone close to you has died. The death of someone you love is one of the greatest sorrows that can occur. However, feelings of bereavement can also accompany other losses, such as the decline of your health or the health of someone you care about, or the end of an important relationship. Grief is a normal, healthy response to loss.
Everyone feels grief in his or her own way, but there are certain stages to the process of mourning. It starts with recognizing a loss and continues until that loss is eventually accepted. People’s responses to grief will vary depending upon the circumstances of the death.
If the person died of a chronic illness, for example, the death may have been expected. The end of the person’s suffering might even come as a relief. If the death was accidental or violent, coming to a stage of acceptance could take longer.
Symptoms
A wide and confusing range of emotions may be experienced after a loss. There can be five stages of grief. These reactions might not occur in a specific order, and can (at times) occur together. Not everyone experiences all of these emotions:
· Denial, disbelief, numbness
· Anger, blame
· Bargaining (for instance, “If I am cured of this cancer, I will never smoke again”)
· Depressed mood, sadness, and crying
· Acceptance, coming to terms
People who are grieving will often report crying spells, some trouble sleeping, and lack of productivity at work. At first, you may find it hard to accept that the loss has actually occurred.
Once the initial shock has worn off, denial of the loss is often replaced by feelings of anger. The anger may be directed toward doctors and nurses, God, other loved ones, yourself, or even the person who has died. You may experience feelings of guilt, with sentiments such as “I should have… “, “I could have… “, or “I wish I had…. “ Such thoughts are common. Your emotions may be very intense, and you may have mood swings. These are all normal reactions to loss. Mourning is the process by which people adapt to a loss; mourning is also influenced by cultural customs, rituals, and society’s rules for coping. Bereavement is the period after a loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached one was to the person who died and how much time was spent anticipating the loss. If you feel that you are not coping with bereavement, it is important to seek help. Although it may seem easier to bury your pain than to face it, unresolved grief can cause long-term physical or emotional illness.
Causes
Your reaction to loss will, in part, be influenced by the circumstances surrounding it. The death of a loved one is always difficult, particularly when it is sudden or accidental. Your relationship to the person who has died will greatly influence your reaction to the loss.
A Spouse’s Death A Loss Due to Suicide
A Child’s Death
A Pet’s Death
A Parent’s Death Anticipatory Grief (expected death)
Treatments
Grieving is extremely tiring, both physically and emotionally. The grief one is feeling is not just for the person who died, but also for the unfulfilled wishes and plans with the person. Death often reminds people of past losses or separations. Mourning may be described as having the following three phases:
· The urge to bring back the person who died
· Disorganization and sadness
· Reorganization
Depression shares common features with grief, but can completely take over the way you think and feel.
The goals of grief counseling include:
· Describing normal grieving and encouraging the bereaved to accept the loss by talking about it
· Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt, anxiety, helplessness, and sadness)
· Helping the bereaved to separate emotionally from the deceased, as well as to make independent decisions and live alone
· Helping the bereaved to understand his or her methods of coping
· Describing the differences in grieving among individuals
· Providing continuous support
· Providing support at important times, such as on birthdays and anniversaries
· Identifying coping problems the bereaved may have and making recommendations for professional grief therapy, if necessary
Humans tend to make strong bonds of affection or attachment with others. When these bonds are broken, as in death, a strong emotional reaction occurs. After a loss, a person must accomplish certain tasks to complete the process of grief. These basic tasks of mourning include accepting that the loss happened, living with and feeling the physical and emotional pain of grief, adjusting to life without the loved one, and emotionally separating from the loved one and going on without him or her. It is important that these tasks are completed before mourning can end.
In grief therapy, six tasks can be used to help mourners work through their grief:
1. Develop the ability to experience, express, and adjust to painful grief-related changes.
2. Find effective ways to cope.
3. Establish a continuing relationship with the person who died.
4. Stay healthy and keep functioning.
5. Reestablish relationships and understand that others may have difficulty empathizing with the grief being experienced.
6. Develop a healthy image of themselves and their world.
Diagnostic and Statistical Manual of Mental Disorders (DSM) and Grief
The Diagnostic and Statistical Manual (DSM) does not define bereavement as a disorder, but preexisting conditions like major depression, or repercussions associated with the trauma of a death, such as acute stress or posttraumatic stress, can complicate bereavement. Normal symptoms of bereavement can mimic those of depression, but these symptoms typically pass within two months of the loss. For those who may be vulnerable to depression, grief has the potential to precipitate a depressive episode, and for those who already experience depression, the bereavement process can be prolonged and worsened by the depression. What distinguishes grief from depression is that the feelings of grief are specifically related to the loss or death, and depression is characterized by a general sense of worthlessness, despair, and lack of joy.
Psychotherapy
Complicated grief is sometimes treated with a type of psychological counseling (psychotherapy) called complicated grief therapy. It’s similar to psychotherapy techniques used for post-traumatic stress disorder (PTSD). Other counseling approaches also may be effective.
During therapy, you may:
· Explore such topics as grief reactions, complicated grief symptoms, adjusting to your loss and redefining your life’s goals
· Hold imagined conversations with your loved one and retell the circumstances of the death to help you become less distressed by images and thoughts of your loved one
· Explore and process emotions
· Improve coping skills
· Reduce feelings of blame and guilt
Medications
There’s little solid research on the use of psychiatric medications to treat complicated grief. However, antidepressants may be helpful in people who have clinical depression as well as complicated grief.
Epidemiology
A household survey of UK adults estimated a prevalence of 2.6% in men and 3.3% in women. Everywhere in the world, women can have higher percentage of prevalence than in men maybe due to social, economical, religious issues. Depression is a common symptom, with more than 300 million people affected every year worldwide.
Traumatic events and loss are common in people’s lives. In a previous WHO study of 21 countries, more than 10% of respondents reported witnessing violence (21.8%) or experiencing interpersonal violence (18.8%), accidents (17.7%), exposure to war (16.2%) or trauma to a loved one (12.5%). An estimated 3.6% of the world’s population has suffered from post-traumatic stress disorder (PTSD) in the previous year, the study showed.
Prevalence of PTSD in the Community
U.S. National Comorbidity Survey Replication
The National Comorbidity Survey Replication (NCS-R), conducted between February 2001 and April 2003, comprised interviews of a nationally representative sample of 9,282 Americans aged 18 years and older. PTSD was assessed among 5,692 participants, using DSM-IV criteria. The NCS-R estimated the lifetime prevalence of PTSD among adult Americans to be 6.8% (1). Current past year PTSD prevalence was estimated at 3.5% (2).The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%. The twelve month prevalence was 1.8% among men and 5.2% among women (3).
These findings are very similar to those of the first National Comorbidity Survey. The original survey was conducted in the early 1990s and comprised interviews of a representative national sample of 8,098 Americans aged 15 to 54 years. In this earlier sample, the estimated prevalence of lifetime PTSD was 7.8% in the general population. Women (10.4%) were more than twice as likely as men (5%) to have PTSD at some point in their lives
In general, the estimates for lifetime PTSD prevalence range from a low of 0.3% in China to 6.1% in New Zealand. However, statistics reported from various countries are not directly comparable due to methodological differences in survey administration and sampling strategies.
Availability of cure/medicine
The best treatments include different talk therapies (or psychotherapy) and meditations.
If all the aspects of psychotherapy fails, then we take help of medications only to some extent along with ongoing psychotherapy. SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are among the effective treatments. SSRIs and SNRIs are types of antidepressant medication used to treat PTSD. They include:
· Sertraline (Zoloft)
· Paroxetine (Paxil)
· Fluoxetine (Prozac)
· Venlafaxine (Effexor)
Mood stabilizers like topiramate could provide a useful option for clinicians in treatment of PTSD symptoms in patients who fail first-line pharmacotherapy
TABLE OF MEDICATIONS
Medications to be avoided: Addictive, tend to make depression worse
§ Alcohol: to be avoided when used as a medication, e.g. for sleep or to ease stress and anxiety and when drunk in larger quantities than previously.
§ Barbiturates (Nembutal, Seconal, (Phenobarbital): older drugs, seldom used but extremely dangerous when used as sleep aids.
Medications to be used with caution: potentially addictive, may make depression worse
§ Benzodiazepines: Xanax (Alprazalam), Valium (Diazepam), Ativan (Lorazepam), Librium (Chlordiazepoxide), Klonopin (Clonazepam): May be used for short term relief of anxiety and agitation.
Newer antidepressants: non-addictive, safe, generally have few side effects
§ Prozac, Paxil, Zoloft, Wellbutrin, Effexor, Lexapro, Lamictal
§ Remeron and Trazadone are often used as sleep aids and are safe and non-addictive.
Older antidepressants: non-addictive, significant side effects, may aggravate heart or prostate conditions, used primarily when there is no response to the newer antidepressants
§ Elavil (Amitriptyline), Sinequan (Doxepin), Norpramin (Desipramine), Pamelor (Nortriptyline)
§ Nardil and Parnate are a class of antidepressants that can have severe and potentially fatal side effects, require extreme caution with other medications and diet, and should be used only under the supervision of a specialist familiar with their use.
Among all the medicines, Zoloft is most popular and available anti depressant all over the world.
Affordability for people
The cost to treat PTSD can vary significantly — some veterans can get very low-cost care from the VA, for example, but many choose to get private care and pay out of pocket — but that can easily add up to thousands in a year. “PTSD has one of the highest costs to treat of any disorder,” says Barbara Rothbaum, a professor of psychiatry and the director of the trauma and anxiety recovery program at Emory University School of Medicine.
Cost estimates for treatment of PTSD vary widely. A study by the Congressional Budget Office based on VA data found that the average cost of treatment for PTSD in the first year was roughly $4,100 (treatment trends to get less expensive as the years go on).
A study by Rand found that the annual cost ranges from about $1,160 to $4,724 per person (though this data is from 2008)
What’s more, some patients need years of therapy to cope with this disorder, so it’s possible that patients and their families could spend tens of thousands of dollars just on treatment, experts say. CBO data shows that four years of PTSD treatment would cost $10,000. Cost of manufacture of antidepressants drugs estimate roughly around $8–10 for 30 tablets.
In India, Cost of antidepressant paxil is 12.5mg X 100 pills = M.R.P. 950.00and Zoloft is 100mg x 10 pills = M.R.P. 60.00
Cost of PTSD treatment (therapy + medications) depends on the ranking of the doctor and the hospital in private sector. In government sector, people can still afford cheaper treatment. Each sitting can cost Rs. 100–2000. It gets reduced with the time. Medication is needed in very few cases, severe ones.
Case study
Everyone experiences grief in their own unique way but emotional support for the grieving party is an essential component for overcoming grief. Support comes from family and friends, but can also come from a professional bereavement counsellor who is able to offer non-judgmental understanding, a listening ear, and a practical way forward.
Here is Naheem’s Story.
NAHEEM’S STORY
Naheem was very close to her husband. They had been childhood sweethearts and had been best friends all of their lives. When her husband, Nabill, died at 45 of a sudden and unexpected heart attack, Naheem felt like she had been punched in the stomach. She cried and screamed when the doctor told her that they had done everything possible, but he had not survived. How could she go on with her life?
Naheem sat in her home in stunned silence. She had two children to take care of, all by herself now. Jade and Asia were only toddlers and did not really understand what was happening or why their father was not home. Naheem and Nabill’s families were trying to help her as much as they could, but at the end of the day, she was left to herself in her now empty bed. Naheem would wake in the middle of the night, reaching for her beloved husband, only to find his side of the bed empty. She cried herself to sleep every night for a week.
Naheem had to take care of her husband’s estate and all of the legal issues that accompanied the death of a spouse. She had her children to take care of and raise as a single mother now.
Naheem’s sister suggested was a social worker and suggested she might benefit from seeing a bereavement counsellor. Naheem was quick to take up the suggestion as she felt that her friends were sick of hearing about her despair, and yet she really wasn’t ready to stop despairing. She needed to talk about Nabill, she needed to talk about her grief, she needed to cry. Naheem met her grief counsellor, Rebecca, for the first time about three weeks after Naheem’s death and she continued to see her, each week, for about 2 months.
During this time, Naheem’s sleeping patterns calmed down, she found she was able to find joy in her children and even go out with friends for dinner now and again.
Naheem continued to touch base with Rebecca on an intermittent basis for about 18 months.
After about a year, and with Rebecca’s encouragement, Naheem found that eventually she could look back on her life with Nabill with happiness and wistfulness at what she had lost and what might have been.
Naheem found that seeing a grief counsellor within a few weeks after losing Nabill really assisted her to overcome the initial shock, and adjust herself to a new life without him. Naheem found grief counseling valuable because it gave her an opportunity to reveal her emotions and talk about her loss in an environment separate to her family and friends. In the counseling room, Naheem felt able to talk freely about her fears of a life without Nabill — fears for her children, fears about financial insecurity, fears about loneliness. Rebecca listened with empathy and without judgment. She helped Naheem to make sense of her emotions and gave her practical advice, as well as emotional support, to help her find a way forward.
In this case study, Naheem got recovered without any medications. In many cases, it happen so, medicines are needed in severe cases only. A non judgmental understanding, listening ear and a practical idea to move on forward are enough to help a grieving person.
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References
AARP
National Cancer Institute
National Institutes of Health–Bethesda
National Institutes of Health–National Library of Medicine
Canadian Mental Health Association
Mental Health Association
Worden JW: Grief Counseling and Grief Therapy.
Shuchter SR and Zisook S. Treatment of spousal bereavement: a multidimensional approach. Psychiatric Annals
Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living.
Humane Society of the United States
National Funeral Directors Association
http://www.counsellingsydney.com.au/grief-bereavement/grief-counsellor
About:
Dr. Sukant Khurana runs an academic research lab and several tech companies. He is also a known artist, author, and speaker. You can learn more about Sukant at www.brainnart.com or www.dataisnotjustdata.com and if you wish to work on biomedical research, neuroscience, sustainable development, artificial intelligence or data science projects for public good, you can contact him at skgroup.iiserk@gmail.com or by reaching out to him on linkedin https://www.linkedin.com/in/sukant-khurana-755a2343/.