Traumatic Loss

What is traumatic loss? [1] [2]

  • An individual may have a traumatic reaction after a death that was sudden and unexpected (e.g., through violence or an accident) or a death that was anticipated (e.g., due to illness).
  • Traumatic loss is comprised of separation distress (yearning, searching, and loneliness) and traumatic or emotional distress (numbness, disbelief, distrust, anger, emptiness, and sense of futility about the future).
  • When individuals experience a traumatic loss, the trauma symptoms interfere with their ability to navigate the typical bereavement process.

Common symptoms: [2]

  • Intrusive memories about the death: Commonly expressed through nightmares, guilt, or self-blame about how the person died or recurrent or intrusive thoughts about the horrifying manner of death.
  • Avoidance and numbing: Common characteristics of the individual may include withdrawal, the individual acting as if not upset, or avoiding reminders of the person, the way she or he died, or the event that led to the death.
  • Physical or emotional symptoms of increased arousal: Individuals may display irritability, anger, trouble sleeping, decreased concentration, drop in grades, stomachaches, headaches, increased vigilance, and/or fears about safety for oneself or others.

Grief symptoms: [5] [6]

  • Normal grief symptoms: Intense yearning for the lost loved one with grief beginning to abate over the months following the loss. The individual gradually reengages in pleasurable activities and reattaches to significant others.
  • Problematic grief symptoms (complicated grief or prolonged grief):
    • Intense and long-lasting longing for the deceased
    • Distressing intrusive thoughts
    • Anger and bitterness over the death
  • Problematic grief symptoms may result in Prolonged Grief Disorder (PGD; ICD-11) or Persistent Complex Bereavement-Related Disorder (PCBD; DSM-5).
    • Prolonged Grief Disorder: Bereavement difficulties persist rather than diminish with time. Fewer than 10% to as many as 20% of bereaved individuals develop this disorder.
  • The International Classification of Diseases (ICD) describes Prolonged Grief Disorder:
    • “A disturbance in which, following the death of a person close to the bereaved, there is persistent and pervasive yearning or longing for the deceased, or a persistent preoccupation with the deceased that extends for an abnormally long period beyond expected social and cultural norms (e.g., at least 6 months, or longer depending on cultural and contextual factors) and that is sufficiently severe to cause significant impairment in the person’s functioning. The response can also be characterized by difficulties accepting the death, feeling one has lost a part of one’s self, anger about the loss, guilt, or difficulty in engaging with social or other activities.”
  • The Diagnostic and Statistical Manual of Mental Disorders (DSM) lists the following criteria for Persistent Complex Bereavement-Related Disorder:
    • “Since the death, at least one of the following [symptoms] on most days to a clinically significant degree for at least 12 months after the death: (1) persistent yearning for the deceased, (2) intense sorrow and emotional pain in response to the death, (3) preoccupation with the deceased, and/or (4) preoccupation with the circumstances of the death. Since the death, at least six of the following [symptoms] on most days to a clinically significant degree, for at least 12 months after the death: (1) marked difficulty accepting the death, (2) disbelief or emotional numbness over the loss, (3) difficulty with positive reminiscing about the deceased, (4) bitterness or anger related to the loss, (5) maladaptive appraisals about oneself in relation to the deceased or death (e.g., self blame), (6) excessive avoidance of reminders of the loss, (7) a desire to die in order to be with the deceased, (8) difficulty trusting other people since the death, (9) feeling alone or detached from other people since the death, (10) feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased, (11) confusion about one’s role in life or a diminished sense of one’s identity, and/or (12) difficulty or reluctance to pursue interests or to plan for the future (e.g., friendships, activities) since the loss. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bereavement reaction must be out of proportion or inconsistent with cultural or religious norms.”
  • In the case of traumatic bereavement, grief symptoms commonly result in symptoms of posttraumatic stress disorder (PTSD) as well, including flashbacks, sleep difficulties, and concentration problems. These individuals are particularly at risk because they are battling both grief and trauma symptoms concurrently.

Prevalence:

  • Bereavement carries a degree of risk when severe. Severe reactions affect approximately 10-15% of bereaved individuals [3].
  • Severe reactions of grief can be debilitating and the effects can last from one to two years or longer [4].
  • Grief symptoms are commonly associated with functional impairment [4].
  • Sudden, traumatic deaths are the most prevalent type of death in all age groups younger than 44 [5].

Domains of life affected by traumatic loss: [5]

  • The Nuclear Family: Family relationships may become strained after the loss. Most people report a dramatic change in the atmosphere at home.
  • Marriage or Primary Partnership: Death places strain on partnerships. Spouses often report that they have difficulty establishing the closeness that they had before the loss.
  • Parenting: When one parent dies, the surviving parents may worry about the absence of a role model for their children. Parents may also have difficulties with enforcing discipline, overprotective behavior, and placing new restrictions on their children.
  • Work: Individuals who have experienced traumatic loss may face serious difficulties with concentration and memory, leading to a reduced ability in functioning. Physiological changes, including hyperarousal, headaches, stomachaches, and sleep difficulties, may lead to problems with tardiness, attendance, and productivity at the workplace.
  • Leisure and Recreation: The grieving individual may no longer participate in activities that they used to enjoy. Mourners also sometimes find it challenging to relax while watching TV or films because they never know when they will encounter reminders of their loss.
  • Social Support: Survivors of traumatic loss rarely receive effective support. It is especially difficult for the bereaved if the deceased was the main source of social support. Many survivors tend to socially withdraw themselves after the tragedy, thus potentially cutting off healing interactions.

Risk factors: [5]

  • Characteristics of the death (e.g., suddenness, accident, disaster, military combat, suicide, homicide)
  • Personal characteristics of the survivor (e.g., religion, spiritual beliefs, relationship with the deceased, childhood adversity)

Prevention and intervention: [5]

  • Build survivors’ internal and interpersonal resources, including coping skills and social support.
  • Process the traumatic death both cognitively and emotionally.
  • Facilitate the process of mourning: recognize the loss, react to the separation, relinquish old attachments to the loved one, readjust to daily living, and reinvest in activities and relationships that are supportive and enjoyable.

Helpful websites:

  • It’s Okay to Remember: This video illustrates how a family can cope with the pain of death and eventually heal. This video may help parents, educators, pediatricians, and others who care for children to understand childhood traumatic grief.
  • Ask Mary Mac: Extensive website and blog for those grieving the death of a loved one.

[1] Tay, A. K., Rees, S., Chen, J., Kareth, M., & Silove, D. (2015). Factorial structure of complicated grief: Associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees. Social Psychiatry and Psychiatric Epidemiology, 1-12.

[2] The National Child Traumatic Stress Network. (2015). Childhood traumatic grief. Retrieved from http://www.nctsn.org/trauma-types/traumatic-grief

[3] Bonanno, G. A. (2008). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 101-113. 

[4] O’Hare, T., Sherrer, M. V., & Shen, C. (2014). Sudden losses and negative appraisal in people with severe mental illness. American Journal of Orthopsychiatry, 84(6), 664-673. 

[5] Barlé, N., Wortman, C. B., & Latack, J. A. (2015). Traumatic bereavement: Basic research and clinical implications. Journal of Psychotherapy Integration, Advance online publication, 1-12. 

[6] Jordan, A. H., & Litz, B. T. (2014). Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice45(3), 180-187.