Traumatic Grief

Diagnosis, Treatment, and Prevention

Selby Jacobs

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317714675
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The loss of a family member, significant other, or friend exposes the afflicted person to a higher risk for several types of psychiatric disorders. In addition to the potential complications that include major depression, anxiety, and PTSD, there is much current (and renewed) interest in pathologic forms of grief. Jacobs, in this innovative new text, introduces the term traumatic grief as description of this diagnostic entity. Here, working criteria, associated descriptive features, and the clinical course of traumatic grief are detailed as the author further verifies the concept of traumatic grief as a disorder. As this is the first discussion of the clinical use of the diagnostic criteria for traumatic grief, this text serves as a foundation for psychiatric diagnosis and treatment of traumatic grief. The format follows the outline for disorders used in the DSM making this a useful tool for the practicing clinician.

1
CHAPTER

Attachment Behavior and Theory

Given the central and pervasive importance of attachment behavior and attachment theory in modern thinking about personal relationships and loss, the text begins with a brief overview of them. The introduction to attachment behavior and theory in this chapter serves as a conceptual framework for the rest of the text. For example, the task of defining Traumatic Grief in chapter 2 builds on this foundation. Similarly, some of the specific criteria used for the diagnosis of Traumatic Grief and discussed in chapter 3 derive from the discussion of separation anxiety introduced her. The discussion of treatments in chapters 5 and 6 also relies in part on concepts introduced here and incorporated into the definition and diagnosis of Traumatic Grief. In addition to the foundation that attachment behavior and theory provide for understanding the diagnosis and treatment of Traumatic Grief, growing knowledge of attachment behavior has been partly responsible for the burgeoning number of neurobiologic studies of affiliation, which are reviewed briefly below.

□ Introduction to Attachment Theory

Attachment theory stems from evolution theory and ethology, which is the scientific study of animal behavior (Darwin, 1872). Ethologic studies document attachment behavior in a variety of animal species, including primates and humans (Carter, Lederhendler, & Kirkpatrick, 1997). The main architect of attachment theory for psychiatry was John Bowlby, a British psychiatrist who worked at the Tavistock Clinic in London from the 1950s through the 1980s. Between 1969 and 1980, Bowlby published three volumes on attachment, separation, and loss (Bowlby, 1969, 1973, 1980). These writings are the foundation for the following overview of attachment behavior. In a recent review, Rutter concluded that empirical support exists for all of the key features of Bowlby’s concepts (Rutter, 1995).

□ Attachment Behavior

Bowlby defines attachment behavior as “any form of behavior that results in a person attaining or retaining proximity to some other differentiated and preferred individual, who is usually conceived as stronger and/or wiser” (Bowlby, 1977 p. 203). He identifies several signaling and approaching behaviors such as crying, non-nutritional sucking, smiling, touching, following, and calling that mediate attachment (Bowlby, 1969). Depending on the circumstances these attachment behaviors are associated with feelings of joy and love or anxiety and sorrow, with associated anger and protest (Bowlby, 1969, Bowlby, 1973). One of the most important insights of attachment theory is the proposition that attachment behavior is a primary drive system and an aggregation of brain functions that confer evolutionary advantage to the individual of a species. Attachment behavior serves as a protection against predators through maintaining a relationship to parents and membership in social groups (Bowlby, 1969).

As a corollary of the view that attachment behavior provides an evolutionary edge for survival, isolation from attachment figures is a situation that is threatening in the perspective of evolution. Attachment behavior stimulated by isolation is accompanied by strong feelings of alarm, anxiety, anger, loneliness, and insecurity (Bowlby, 1969). What is unique about this view is the idea that the absence of an attachment figure can stimulate fear just as strongly and surely as the presence of a frightening stimulus, such as a threatening situation, person, or predator (Bowlby, 1973). In the circumstances of separation and loss, humans experience separation anxiety as an essential part of the reaction that we recognize as grief. A knowledge of normal separation anxiety provides a cornerstone for understanding Traumatic Grief and developing criteria for its diagnosis. Because of its importance for the purposes of this book, separation anxiety is defined and discussed below.

Attachment behaviors are conspicuous in infants and young children in the circumstances of separation from their mothers. In response to the “Strange Situation” procedure employed in studying infants, attachment behavior can be classified into four main types: secure, avoidant, resistant-ambivalent, and disorganized-disoriented (Ainsworth, Biehar, Waters, Wall, 1978; Main & Solomon, 1990). The activation of attachment behavior begins to attenuate in puberty. Still, although attachment behavior is less readily activated in adults, a propensity persists throughout adult life to monitor the environment for attachment figures and seek them out in times of stress. Progressively, investigators have characterized attachment styles in adults that are related to those in infants and probably related to psychopathology in adults (Main, 1996). The strongest and most common stimuli that evoke acute attachment behavior in adults are serious illnesses affecting the self and family members and losses of intimate relationships (Bowlby, 1977; Bowlby, 1980). In adult life, these stimuli arouse attachment behavior that we recognize as grief, including, as one component, separation anxiety. In the absence of losses, attachment behavior in adults is difficult to discern in everyday life as each person’s unique nature mixes with nuturant experience and simple behavior patterns from childhood become overlaid with compensatory behavioral mechanisms.

Individuals vary in their susceptibility to fear in situations that might evoke separation anxiety (Bowlby, 1973). Early experiences with caregivers and an individual’s temperament contribute to the development of attachment styles that persist into adulthood. Attachment styles, particularly anxious forms of attachment, interact with the actualities of current circumstances to determine the occurrence of maladaptive attachment behavior in adults. In addition, separation, loss, and insecure attachment probably predispose to childhood and adult psychiatric disorders (see the section on attachment behavior and psychopathology).

Before discussing the psychobiology of attachment, it is worth noting that attachment theory makes it possible to attempt an answer to the question of why humans grieve after the death of an intimate, an event in a person’s life that is inevitable and irrevocable. The point is that attachment behavior, in this case grief, is a fundamental drive and biologic process evoked by a death. Grief is an expression of the drive to maintain the bond to the deceased person and protect the individual (in an evolutionary sense), no matter how painful, unrealistic, and dysfunctional it may be in a particular situation (Bowlby, 1980). In a sense, it is a vestige of behavior that is more fully developed and functional for the preservation of the species at an early stage of development but serves little functional purpose, or at best is a two edged sword, among adults. Indeed, intense and maladaptive attachment behavior in adults may place them at risk for psychiatric illnesses.

□ Neurobiology of Affiliation

For the Adolf Meyer Lecture of the 135th Meeting of the American Psychiatric Association, MacLean posited that the phylogenetically latest division of the limbic system and the prefrontal cortex, which distinguish mammals and the human brain from other, more primitive, reptilian and amphibian species, developed in concert with the emergence of maternal care, play, the isolation call, and altruism (MacLean, 1990). As evolution conferred advantage to social bonding, brain structures emerged as substrates for affiliative behavior.

Coincident with the development of attachment theory and perhaps spurred in part by attachment theory, there is burgeoning knowledge of the biology and neural substrates of affiliation (Reite and Field, 1985; Carter et al., 1997). Affiliation refers to social behaviors that bring individuals closer together including such forms of positive association as attachment, parent-offspring interactions, pair-bonding, and coalitions (Carter et al., 1997). Affiliations provide a social matrix for reproduction and aggressive behavior. Since 1990, studies of affiliation have increased ten fold, while studies of aggression have declined somewhat, perhaps reflecting the growing acceptance that affifiative behaviors are related to primary drives and are not derivatives of sexual and aggressive behavior (Carter, 1997).

The neuroanatomical areas involved in affiliative behavior include the hypothalamus and limbic systems, which may regulate social approach and avoidance. Specifically, studies implicate systems based in the medial amygdala in avoidance, while those systems integrated by the medial preoptic area and ventral portion of the bed nucleus of the stria terminalis may regulate social approach. Approach is activated and avoidance inhibited for affiliative behavior to occur (Keverne, Nevison, & Martel, 1997). In addition, an evolutionary later system of the vagal nerve is involved in regulating complex social behavior including facial expression (Porges, 1997). Analysis of mechanisms focus on several neuropeptides including the endogenous opiates, oxytocin, vasopressin, the steroid hormones of the adrenal axis, the central nervous system amine systems, and the hypophysio-pituitary adrenal axis (Carter et al, 1997; Porges, 1997; Levine, Lyons, & Schatzberg, 1997).

In mammals, there is an increase in the role of cognition in the control of affiliative behavior in addition to the emotional and hormonal systems exerting control in other animals (Keverne et al., 1997; Snowdon, 1997). Consequently, there is growing appreciation that the organization of the cognitive, hormonal, and emotional systems that regulate social behavior depend on early caregiver-infant attachment rather than developing as an autonomous biological process (Kraemer, 1997). Indeed, not only social behavior but also personal homeostasis is served by relationships, originally with primary attachment figures such as the mother (Hofer, 1984). If these ideas continue to prove true in subsequent research, this may be an example of how the ontogeny of the affiliative, neurobiologic systems, although emerging from a complex interplay of nature and nurture, recapitulates the phylogeny of Maclean’s thesis about evolution of the human brain (MacLean, 1990).

This brief summary is neither a thorough nor critical review of the neurobiology of affiliation or attachment. Rather, it is intended to indicate the enormous interest that now exists and the development of knowledge about how the brain is organized and how it functions to accomplish attachment behaviors. Progressively and perhaps incrementally over the next few years, neurobiologic research in animals that exhibit attachment behavior will inform our understanding of human attachment behavior.

Before leaving this overview of the neurobiology of affiliation, let me make a final note about a byproduct of the new technology for brain imaging. Posatron Emission Tomography ...

Table of contents

• Cover
• Half Title
• Title Page
• Dedication
• Copyright Page
• Table of Contents
• Preface
• Acknowledgments
• 1 Attachment Behavior and Theory
• 2 Definition of Traumatic Grief as a Disorder
• 3 Diagnosis of Traumatic Grief
• 4 Comorbidity: Psychiatric Disorders Associated with Traumatic Grief
• 5 Treatment of Traumatic Grief
• 6 A Diagnosis/Treatment Aigorithm for Traumatic Grief
• 7 Epidemiology and Prevention of Traumatic Grief
• 8 Conclusion and Future Directions
• Index