Summary Loss and Psychotrauma Lectures
Lecture 1 Grief
Bereavement: the situation of having recently lost a significant person through death.
Grief: the mainly emotional reaction of bereavement. It is a complex emotional syndrome
accompanied by physical changes and physical symptoms. It also involves a wide range of possible
cognitive and behavioral reactions.
Four dimensions of grief:
- Emotional/Affective (sorrow, loneliness, anxiety, guilt, anger etc.)
- Cognitive (loss of concentration, lowered self-esteem, confusion, hopelessness etc.)
- Physical/Somatic (sleep-related problems, loss of appetite, stress headaches etc.)
- Behavioral (agitation, withdrawing, seeking behavior, avoidance etc.)
Mourning: the actions and manners expressive of grief which are shaped by social and cultural
practices, and by societal expectations which serve as guidelines for how bereaved people are to
behave (which also differ across individuals and/or groups). Mourning covers different customs and
rituals, including various funeral practices.
Kubler-Ross has made a popular five stage model of grieving: denial, anger, bargaining, depression,
and ultimately acceptance (DABDA). Kubler-Ross stated that someone would have to go through the
first stage in order to go to the second stage and so forth. This model has been used a lot in research
on grieving. It is however now known that this model is not fixed, and that not every person goes
through these five stages. For example, not everyone experiences anger in their grieving process. It is
also harmful to set an expectation for people that they have to go through these stages in their
grieving process: they could feel bad for, for example, not feeling anger, even though in reality not
everyone goes through that stage.
Most research has been done on spousal bereavement (someone dying that you are in a romantic
relationship with), since this is easiest to research. Spousal bereavement has shown to have early
risks of mortality (basically someone dying of a broke heart), and sometimes even later risks, six
months after the death.
People who have been bereaved are more likely to have physical health problems in comparison to
people who have not been bereaved, particularly those who have been bereaved recently. Bereaved
individuals also have higher rates of disability, medication use, and hospitalization than non-
bereaved counterparts. Although widowed people in general go to the doctors more frequently,
most likely because of symptoms of anxiety and tension, findings suggest that many of those with
intense grief actually do not see a doctor.
Changes in symptoms of bereavement over time were originally described in terms of stages or
phases of shock, yearning and protest, despair, and recovery, and lately in terms of tasks. This so-
called Grief Task Model is used in guiding counselling and therapy. This model is nowadays used
more than the Kubler-Ross model. The four tasks of grieving are:
- Accepting the reality of the loss
- Allowing yourself to experience the emotions
- Adjusting to life without the deceased
- Relocating the deceased emotionally and moving on.
It should however be noted that not all grieving individuals undertake these tasks, nor, if they do, do
they undertake them in a fixed order. Both individual and cultural differences may play a role.
,Complicated grief: when someone responds differently to a death than most people. Someone can
for example completely ignore the loss or because of other mental disorders have different
responses.
Major determinants of the process of grieving:
- Background bereaved person: gender, age, personality, attachment, health, history etc.
- Characteristics of the death: sudden, unexpected, premature death, traumatic
circumstances etc.
- Characteristics of the deceased: kinships relationship, quality of the relationship with the
deceased etc.
- Situation after loss: lack of support, secondary losses, ways of coping etc.
Interesting to note is that men have a higher mortality rate when their married partner dies
compared to women. Also, the younger people are the more they die after bereavement. The reason
for this is still not known, but there are explanations for the gender differences:
- Differences in social support: men more often have less friends which means that they have
less people to rely on after the death of their partner
- Differences in coping strategies: generally speaking, men are more problem focused and
women are more emotion focused.
- Differences in types of bereavement: perhaps marriage is different for men than for women,
which could be why losing their partner is heavier for men than for women
Another aspect that can influence grieving is religion. Through religion people have a life philosophy:
a system of meaning. They also have a religious social community which could be helpful for them.
Situational, intrapersonal, interpersonal, and coping factors affect bereavement outcomes (how
heavy someone griefs). They do so in complex ways and there could be interactions between factors
(like between personality and circumstances of death) that operate to affect the outcome. Many
potential risk factors have been under-researched. The ways that risk factors relate precisely to the
different health outcomes also remains to be seen, like why one person can succumb to mental-
health disorders while another might die prematurely after bereavement.
Causes of death: natural, accident, suicide, and homicide.
- Bereavement is most hurtful to people when the death is sudden, untimely, intentional,
painful, or violent.
- Debilitating and exhausting (terminal) conditions are a risk factor too.
- Talking about and acting in preparation of imminent death predicts less intense grief.
Unacknowledged losses or “disenfranchised grief”: losses that a lot of the times are not recognized
by people and researchers:
- Ex-partners
- Miscarriage, perinatal deaths (in the past)
- Homosexual partners (in some circles)
- Extramarital affairs
These types of disenfranchised grief can make the grieving process ever harder for a person since
they do not get acknowledgement/support from their environment.
Conclusions on grief and bereavement:
- From a societal perspective, the concepts of death and dying, and surviving relatives, are
surrounded by a complicated context of denial and fascination
- Death in most Western societies becomes more normalized, more than it is in many
countries elsewhere.
, - There are factors that lead to a higher risk of problems in the grieving process, but the
predictive power of these factors is usually not very high, hence sound explanations are not
generally available
- A small minority cannot cope by themselves and need professional help, and a large majority
of surviving relatives succeed in overcoming the loss
Lecture 2 Introduction psychotrauma
PTSD: Diagnosis and symptoms
There are several criteria for the diagnosis of PTSD in the DSM.
- Criterion A: The DSM-5 requires that a person experiences or witnesses a major traumatic
event (exposure to actual or threatened death, serious injury or sexual violence).
If one has experienced or witnessed such an event, there are four symptom clusters that he/she
should manifest.
- Criterion B: The traumatic event is persistently re-experienced in at least one of the following
ways: intrusive distressing memories, recurrent distressing dreams, dissociative reactions
(e.g., flashbacks), intense or prolonged psychological distress at exposure to reminders of the
trauma, marked physiological reactions to internal or external cues symbolizing or
resembling an aspect of the traumatic event.
- Criterion C: Persistent avoidance of internal (e.g., thoughts, memories) and/or external (e.g.,
situations, conversations) reminders of the trauma.
- Criterion D: Negative alterations in cognitions and mood. At least two “alterations in
cognitions and mood” symptoms are needed, including inability to remember an important
aspect of the traumatic event, persistent and exaggerated negative thoughts about oneself
or the world, persistent distorted cognitions about the cause or consequences of the event,
pervasive negative emotions, markedly diminished interest, feeling detached or estranged
from others, persistent inability to experience positive emotions.
- Criterion E: Trauma-related alterations in arousal and reactivity that began or worsened after
the traumatic event. Someone must present at least two of the following arousal symptoms:
irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance,
exaggerated startle response, problems with concentration, sleep disturbance.
- Criterion F: People are required to manifest the abovementioned symptoms for more than
one month after the trauma exposure.
- Criterion G: The disturbance causes clinically significant distress or impairment in social,
occupational or other important areas of functioning.
- Criterion H: Disturbance is not due to medication, substance use or other illness.
Next to the classification of PTSD from the DSM (which is from the American Psychological
Association) there is another classification from the ICD (which is from the World Health
Organization). The ICD-11 has a more simple classification, it only states two criteria. The ICD is used
in a lot of countries but the DSM is used in The US and The Netherlands. When the DSM and ICD are
compared, there are a lot of differences in diagnosing people: the diagnosing only corresponds for
50%.
Another diagnostic construct that is worth noting is complex PTSD. Complex PTSD is not in the DSM,
it is in the ICD. To receive this diagnosis, one needs to present the core PTSD symptoms, and in
addition experience:
1. Severe and pervasive problems in affect regulation
2. Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep
and pervasive feelings of shame, guilt or failure related to the traumatic event
3. Persistent difficulties in sustaining relationships and feeling close to others.
, Although most commonly seen in the wake of prior prolonged childhood abuse, this disorder also
occurs with refugees and war/concentration camp victims.
There is evidence that some features of a traumatic event are more likely to trigger PTSD. For
example, there are markedly lower rates of PTSD following natural disasters in comparison to sexual
assault. Adjusting for methodological factors, reported torture is the strongest factor associated with
PTSD.
Studies suggest that most people with PTSD have comorbid disorders, particularly depression,
anxiety disorders, and substance use disorder. These high rates of comorbidity may be explained by
psychiatric disorders predisposing people to experience traumatic events, or by traumatic events or
PTSD itself triggering the development of other psychiatric conditions. Greater exposure to traumatic
events is likely to result in greater comorbidity.
Traumatic experiences can lead to PTSD. Complex traumatic experiences, also referred to as complex
trauma, which are worse than “normal” traumatic experiences, can lead to complex PTSD.
Complex trauma contains trauma from situations like war, disaster, domestic violence, or a traffic
accident.
The guidelines for complex PTSD are “exposure to repeated or prolonged instances or multiple forms
of interpersonal trauma, often occurring under circumstances where escape is not possible due to
physical, psychological, maturational, family/environmental, or social constraints”.
So: complex trauma is different than complex PTSD: trauma is the reaction to a certain situation and
PTSD is a disorder that happens because of the trauma.
Very often, trauma occurs from a sudden and unexpected event like for example a terrorist attack.
Characteristics of overwhelming events:
1. Extreme powerlessness
2. Profound disruption
3. Extreme discomfort
There are two types of trauma:
Type 1 trauma: single, intense, unanticipated events
Type 2 trauma: prolonged, repeated, extreme conditions (series of extreme events over time).
There are four significant risk factors that determine whether PTSD will develop after a traumatic
event or not:
- Event characteristics: how traumatic is the event, what are the circumstances
- Personal characteristics: does someone already have a mental disorder etc.
- Social and cultural factors: does the person’s environment acknowledge the trauma, do they
help the person etc.
- Intense emotional reactions during the event: most people that experience fear or terror
during the event have a huge chance of developing PTSD.
A question is whether PTSD can have a latency phase: PTSD occurring a long time after the traumatic
event(s). All people with delayed PTSD had high scores on symptoms checklists. These findings
indicate that delayed PTSD following a traumatic event does not just appear without having any
symptoms in all the time after the event. So all people with delayed PTSD already had symptoms but
just not heavy enough yet to be diagnosed with PTSD before.
Factors that explain delayed PTSD:
- Stressful events
- Lack of social support
- Uncertainty about the future
- Low levels of education
