Traumatic and complicated grief?


Luto traumático e complicado?



Joao Paulo Consentino Solano

Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Eneias Carvalho Aguiar, 155 - PAMB, 8º. Andar, bloco 3. 05403-000  São Paulo SP. joaopaulocsolano@uol.com.br



A recent article from Duarte et al. focused on the assessment of child mental health problems related to exposure to violence. The authors also referred to the process of grief among children and to its potential to trigger abnormal reactions, or psychopathology1. Relating to the topic, the article lacks consistency, what deserves to be pointed out.

The authors mentioned (1st paragraph of section "Traumatic grief: new diagnostic category?") that "traumatic grief...is often confused with complicated grief", leaving one to understand that they are both separate categories. Moreover, by considering "complicated grief" as "another newly developing diagnosis" (same sentence), the article warrants confusion to escalate.

Since the work of Lindemann2, authors have variously, interchangeably referred to traumatic grief, complicated grief or pathologic grief as to mean the same concept: a pattern of abnormal, non-adaptive grieving reaction which is associated with present distress or disability. Literature fully supports that traumatic (or complicated or pathologic) grief can follow any kind of death, including the ones by a chronic long-lasting disease of a loved one. Conversely, traumatic death can have anteceded a plea of reactions among survivors, since from the most adaptive to the (probably pathologic) less adaptive ones3-10. Such less adaptive processes of mourning are associated with some risk factors, being traumatic death one of them11. Part of the alluded confusion may be attributable to that, and another part is probably due to an understandable linguistic association - the one between "traumatic death" and "traumatic grief".

Having agreed that "traumatic death" must be disentangled from "traumatic grief", one is expected to step forward to consider, as to say, "abnormal grief reactions" as a new diagnostic category. The question has merited debate among the professionals recruited to prepare the forthcoming DSM-V and ICD-11. But the sometimes controversial and hot discussions have much evolved since the 1999 article from Prigerson et al.4, cited by Duarte et al. One of the stages for such debates have been the annual meetings of the International Work Group on Death, Dying and Bereavement (held in Sao Paulo in 2007). During the last 10 to 15 years leading authors on the field have been struggling with the task of validating consensus criteria for a construct that was ultimately called Prolonged Grief Disorder (PGD)6,10-12. In a recent panel, expert authors have agreed that PGD is a new diagnostic category that deserves to be included in the next official diagnostic classifications10. From now on, such terms as traumatic grief, complicated grief and pathologic grief are likely to belong to the history of how a scientific matter was identified and managed - what will hopefully prevent misconceptions and inconsistencies to surface now and there, like, again, in the last paragraph of the here discussed text.

A final remark must be done regarding the cited measure to assess "traumatic grief", "Inventory of Traumatic Grief" (ITG). The ITG is not the only, either the main method to assess grieving reactions. A recent review identified 14 assessment tools that have been elaborated and used13.One of the most widely used, the Texas Revised Inventory of Grief, deserves to be mentioned, as it has been recently translated, adapted and validated to Brazilian context14. It may be a question of the very interest of Duarte, Bordin and colleagues to investigate which of those existent assessment tools would fit best to Brazilian grieving children.

Assisting grieving children poses additional challenges to health professionals - which are beyond the scope of a letter. It´s recognized that there are differences between the grieving process for children and the grieving process for adults11. Duarte, Bordin and her colleagues represent prominent groups of researchers and clinicians on the field of Child and Adolescent Psychiatry. I feel very confident that, given their interest in grief and bereavement, Brazilian grieving children will increasingly be better and better cared for, what will eventually result in prevention of a considerable burden of mental ailments among our children and adults.



1. Duarte CS, Bordin IAS, Green GR, Hoven CW. Measuring child exposure to violence and mental health reactions in epidemiological studies: challenges and current issues. Cien saude Colet 2009; 14 (2):487-496.         

2. Lindemann E. The symptomatology and management of acute grief. Amer J Psychiat 1944; 101:141-148.         

3. Horowitz MJ, Wilner N, Marmar C, Krupnick J. Pathological grief and the activation of latent self-images. Am J Psychiatry 1980; 137(10):1157-1152.         

4. Prigerson HG, Maciejewskib PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, Franka E, Domana J, Miller M. Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research 1995; 59(1-2):65-79.         

5. Prigerson HG, Bierhals AJ, Kals SV, Reynolds CF, Shear MK, Day N, Beery LC, Newsom JT, Jacobs S. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997; 154(5):616-623.         

6. Prigerson HG, Shear MK, Jacobs SC, Reynolds CR, Maciejewski PK, Davidson JRT, Rosenheck R, Pilkonis PA, Wortman CB, Williams JB, Widiger TA, Frank E, Kupfer DJ, Zisook S. Consensus criteria for traumatic grief: a preliminary empirical test. Br J Psychiatry 1999; 174(1):67-73.         

7. Shear MK, Frank E, Foa E, Cherry C, Reynolds CF, Bilt JV, Masters S. Traumatic grief treatment: a pilot study. Am J Psychiatry 2001; 158(9):1506-1508.         

8. Center for the Advancement of Health. Report on bereavement and grief research. Death Studies 2004; 28(6):491-575.         

9. Shear K, Frank E, Houck PR, Reynolds CF. Treatment of Complicated Grief: A Randomized Controlled Trial. JAMA 2005; 293 (21):2601-2608.         

10. Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Beverley R, Samuel JM, Wortman C, Neimeyer RA, Bonanno G, Block SD, Kissane D, Boelen P, Maercker A, Litz BT, Johnson JG, First MB, Maciejewsk PK. Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11. PLoS Med 2009; 6(8): e1000121. [acessado 2009 out 25]. Disponível em: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371% 2Fjournal.pmed.1000121        

11. National Cancer Institute. Bereavement, mourning and grief (PDQ). [acessado 2009 out 31]. Disponível em: http://www.cancer.gov/cancertopics/pdq/supportivecare/bereavement/HealthProfessional/page4        

12. Prigerson HG, Vanderwerker LC, Maciejewski PK. A case for inclusion of prolonged grief disorder in DSM-V. In: Stroebe MS, Hansson RO, Schut H, Stroebe W, editors. Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association; 2008. p. 165-186.         

13. Agnew A, Manktelow R, Taylor BJ, Jones L. Bereavement needs assessment in specialist palliative care: a review of the literature. Pall Medicine 2009; 0(00):1-14. [acessado 2009 out 31]. Disponível em: http://pmj.sagepub.com/cgi/rapidpdf/0269216309107013v1        

14. Barros EM. Tradução e validação do Texas revised inventory of grief (TRIG): aplicação em pais enlutados pela perda de um filho por câncer pediátrico [dissertação]. São Paulo: Fundação Antonio Prudente/CAPES; 2008.         

ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil