Phenomenology and treatment of bereavement-related distress in the elderly

While brief periods of bereavement-related distress should be neither pathologized nor treated, periods of distress lasting several months that meet criteria for major depressive episode and, in particular, for what we now refer to as traumatic grief reactions, are strongly associated with considerable psychiatric and physical morbidity and deserve careful clinical attention. Our current efforts at treatment development for traumatic grief come directly from treatment for Post-Traumatic Stress Disorder. We conceptualize this as a nine-session intervention with an emphasis on reliving the moment of the death, saying goodbye to the deceased, and in vivo exposure to situations that the subject has come to avoid since the death. As yet, we have no objective data on the outcome of this procedure in traumatic grievers, but clinical outcomes have been consistent with Foa's theory that re-experiencing the trauma and exposure to avoided situations under controlled conditions ultimately leads to reductions in subjective distress. We are currently planning an open treatment development trial of this form of traumatic grief therapy. Assuming outcomes are positive, we plan to test it in a randomized controlled trial comparing the efficacy of this intervention with a more standard form of non-behavioral psychotherapy and with pharmacotherapy.