Grief and Trauma: The Confusion-The Difference

Grieff and Trauma

Grief and Trauma: The Confusion - The Difference
Normal Grief	Bereavement
Neurotic Grief	Traditional Mourning
Inhibited Grief	Distorted Mourning
Acute Grief	Psychoanalytical Mourning
Morbid Grief	Unanticipated Mourning
Complicated Grief	Chronic Mourning
Pathological Grief	Complicated Mourning
Traumatic Grief	Traumatic Mourning

Post Traumatic Stress Disorders (PTSD)
Type I, II, III

Associated Disorders
Major Depressive Episode
Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Panic Disorder
Associated Complications
Suicide	Substance Abuse	Self-Medication

Type I Single Incident	Type II Single Incident (like abuse) Repeated over a period of time or multiple incidents	Type III Complex Cumulative Trauma
Single Exposure	Single incident, like abuse, repeated chronically over a period of time, or multiple incidents	Multiple incidents
Posttraumatic Growth (PTG) possible	Can separate incidents	Cannot separate incidents
	Trait anxiety	State anxiety
	Resiliency accessible	Resiliency lost
	Impaired functioning (but manages in some areas)	Impaired functioning in all areas (daily)
	PTG accessable	Psychiatric manifestations
	PTG is possible in Type I & II in the face of continuous exposure when there exists: • Low trait anxiety • High self potency • High social support	Generally absent in Type III: • Anxiety • Low self potency • Minimal social support

     There are a minimum of fifteen different terms describing grief, and mourning. Further complicating our understanding of grief and mourning is trauma.
     As our understanding of trauma has improved, new terminology has emerged to describe new findings in the field of grief and trauma yet older terminology lingers. Terms are used interchangeably sometimes appropriately but also, at times, inappropriately. The meaning of some of the older terms can be narrowly and vaguely defined. This transition between old and new can be confusing at times.
     The definition of Bereavement and its criteria has remained one of the more constant classification. However, criteria related to other than normal bereavement and criteria related to mourning has changed considerably. Traumatic Grief is now becoming the term of choice over other terms used in the past to define other than normal bereavement.
     Posttraumatic Stress Disorder has also become a more familiar classification which is now evaluated for its presence following death of a traumatic nature. PTSD and Traumatic Grief do share common reactions yet each classification stands alone. At the same time both classifications can coexist with or without additional disorders.
     The questions many now ask are “What is the difference between grief and bereavement and grief and trauma? What is the difference between Traumatic Grief and PTSD? What are the disorders most often associated with ongoing Traumatic Grief?”

Grief and bereavement are terms often used interchangeably when in fact there is one major difference between the two. Bereavement is reserved specifically for the response to the death of a significant other whereas, grief can be the result of incidents of loss not involving death such as loss of job, loss of a limb, loss of status.

Bereavement and mourning are also sometimes used interchangeably when in fact a distinct difference also exists between these two classifications. Bereavement identifies the specific reactions experienced following the death of a significant other whereas, mourning speaks to the way the individual displays his/her grief.

Complicated Mourning and Pathological Grief both refer to a description of the normal mourning process that leads to chronic or ongoing mourning. Psycho-analytically, mourning refers to the conscious and unconscious processes and behavior related to:

a) development of new ties
b) adapting to the loss (the internal process of redefining one’s view of self and the world) and
c) adaptation to the loss (the external process of relating to the world, people, one’s roles, responsibilities etc.)

It has been in this area of complicated mourning and pathological grief that numerous terms came into existence to further clarify different factors of complicated mourning or pathological grief. As stated previously many of these terms were narrowly defined.

The classification of Traumatic Grief accomplishes several objectives. It does the following:

Avoids confusion with previous terminology-pathological grief, neurotic or morbid grief, complicated grief, etc.
Succinctly defines a mourning process that can be traumatic without being triggered by a traumatic death.
Delineates traumatic grief from PTSD which can coexist with traumatic grief.
Requires that criteria be present for two months thereby giving individuals time to process traumatic aspects of the actual death prior to moving too quickly in assigning their reactions/responses as problematic.

The following schematic identifies the relationship between grief, bereavement, traumatic grief and associated depressive disorders and behaviors and anxiety disorder.

The following charts identify the difference between grief and bereavement, bereavement and major depressive episodes and major depressive disorder, grief/bereavement and traumatic grief and post-traumatic stress disorder, post-traumatic stress disorder and generalized anxiety disorder and panic disorder.

An asterisk (*) represents criteria that are not present in the previous category thereby identifying the difference.

Grief / Bereavement	Traumatic Grief	PTSD
Sadness	*Death of significant other (Death need not be violent to induce traumatic grief)	*Injury to self/others including fear, horror or helplessness
Desperation	*Reactions exist for 2 months following death	*Violent or non-assaultive death that includes fear, horror, helplessness
Irritability	*Intrusive distressing preoccupation with deceased	*Reactions exist for one month following incident
Insomnia	*"Hypervigilant: scanning of environment for cues of deceased	*Intrusive distressing preoccupation with terror/horror inducing elements of incident
Crying/sighing	Wish to be reunited with deceased (separation anxiety focus)	Hypervigilant scanning of environment for potential threat/danger
Pangs of grief	Avoidance not prominent	*No separation anxiety manifestation
Intense yearning	*Feeling of futility about future	*Avoidance prominent
Separation distress	Difficulty acknowledging death	*Omen formation
Seeking out familiar places/persons related to...	*Shattered world view	Feelings of futility about future
Pain acknowledges loss	Excessive irritability, bitterness or anger about unfairness of death	*Focus on elements of horror and terror more than absence of deceased
Able to maintain interest, experience pleasure	*Prolonged impaired social/occupational functioning	Shattered world view
Tactile, visual, auditory illusions/hallucinations of deceased		*Excessive irritability, bitterness, anger/assaultive behavior related to overwhelming sense of powerlessness and/or absence of a sense of safety
No humiliation experienced		*Cognitive dysfunction-difficulty attending, focusing, retaining, recalling, processing verbal information
Not demoralized		*Prolonged impaired social/occupational functioning
Non-suicidal
Seeks help/accepts support
Elicits sympathy
Accepts death
Moves forward

Major Depressive Episode	Major Depressive Disorder
*Reactions persist for at least 2 months or almost every day	*One or more major depressive episodes
*Marked functional impairment	*Can present with severe psychotic features
*Psychomotor retardation (children agitation)	*Can be a single episode or recurrent
*Morbid preoccupation with worthlessness	*Can include catatonic features, melancholic and Atypical features or be associated with Post Partum Depression
*Insomnia everyday	(Dysthemic Disorder: Chronically depressed mood that occurs daily and lasts for at least 2 years. In children their mood may be irritable and need only exist one year to quality.)
*Detached/numb
Repressed emotion
Repressed anger
*Separation anxiety
*Avoiding places/memories
*Diminished ability to think, concentrate, make decisions nearly everyday
*Experiences humiliation
*Demoralized
*Suicidal
*Refuses to seek or accept help
*Elicits frustration
*Stuck/unable to accept death or move on
*Pain is useless/meaningless
*Loss of interest and or pleasure

Acute Stress Disorder	Generalized Anxiety Disorder	Panic Disorder	Agoraphobia
*Occurs within 4 weeks of traumatic incident	*Not incident specific	*Recurrent, unexpected attacks (at least two) followed by 1 month of persistent worry of another attack occurring	*Not a codable disorder
*Disturbance lasts for minimum of 2 days to maximum of 4 weeks	*Anxiety/worry present for six months	*No identifiable situational trigger	Occurs within specific disorder such as Panic Disorder with Agoraphobia
All other reactions found in PTSD	Restlessness	*Significant change in behavior related to attacks	Fear of being in places/situations in which escape might be difficult
	Easily fatigued	*Worry about consequences of attack (having heart attacks, going crazy, etc.)	Avoidance of places, people, situations which may trigger reactions (panic attack reactions)
	Difficulty concentrating	*Four or more of the following are present: palpitations, pounding heart or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, reeling dizzy, unsteady, lightheaded or faint, derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy, fear of dying, paresthesias (numbness or tingling sensations), chills or hot flashes.
	Irritability
	*Muscle tension
	Sleep disturbance
	*Focus of anxiety/worry not specific to any one situation or concern
	Significant distress or impairment in social, occupational or other areas of functioning