Losing a loved one can be a critical life event and one of life's most painful experiences. Competency in grief support is multidimensional, and paramedics not only need to be competent in supporting patients in the initial stages of bereavement, but also in recognising and supporting patients who are experiencing what is referred to as complicated grief. Paramedics should be able to identify the behavioural, physical and cognitive symptoms of someone experiencing complicated grief (Cicchetti et al, 2016).
Grief, complicated grief and depression
The differentiation between grief, complicated grief and depression is essential, as treatment pathways are significantly different (Schneider, 1980).
Complicated grief can include recurrent painful emotions and preoccupation with thoughts of the deceased accompanied by yearning, longing and searching (Boelen and van den Bout, 2005).
Grief is considered a normal reaction to a significant loss; sadness, loneliness and exhaustion are common occurrences. However, these symptoms are generally self-limiting. The initial symptoms of grief are the same as complicated grief; however, unlike normal grief, which gradually subsides, those of complicated grief persist and can be intensified. In comparison, depression is characterised by a broad range of feelings, thoughts and physical manifestations, including low self-esteem, suicidal thoughts, pessimism, and feelings of dejection and hopelessness (Schneider, 1980). Grief and depression have certain similarities; however, Table 1 demonstrates the key differences.
| Grief | Depression | |
|---|---|---|
| Loss | An evident and recognisable loss has occurred | There may not be a recognisable loss |
| Mood states | Variability in mood, activity, communication and interests within the same day/week | Absence of energy, consistent sense of depletion, weight loss, loss of sexual interest and agitation |
| Expression of anger | Open anger and hostility | Absence of externally directed anger and hostility |
| Expression of sadness | Weeping | Difficulty in weeping or in controlling weeping |
| Fantasies and imagery | The capacity for fantasy and imagery, particularly involving the loss | The capacity for fantasy and imagery is low except in self-punitive |
| Sleep disturbance | Disturbing dreams, difficult sleep initiation | Insomnia, early-morning awakening |
| Self concept | Preoccupation with lost object or person |
Experience of worthlessness |
| Responsiveness | Responds to warmth and reassurance | Responds to repeat promises |
| Pleasure | Restrictions of pleasure are variable | Persistent restrictions of pleasure |
| Other people's reactions to the affected person | Sympathy |
Irritation |
Neural mechanisms in complicated grief
Although the neural mechanisms that distinguish non-complicated and complicated grief are unclear, the nucleus accumbens has been of vital interest. The nucleus accumbens is a brain region that mediates various behaviours, including reward and satisfaction (Salgado and Kaplitt, 2015). Sometimes referred to as the pleasure centre of the brain, a more precise way of characterising its function is how it aids in motivationally relevant goals such as promoting efficiency and vigour—manifesting in the procurement of rewards, avoidance of aversive consequences and exploration of novel stimuli (Floresco, 2015). When subjected to eliciting stimuli, those with complicated grief produce significant activations in the nucleus accumbens, in contrast to a reduction in those with non-complicated grief (O'Connor et al, 2008). Understanding this neural response could aid in explaining why reveries about the deceased are hard to resist—this is not to suggest that the reveries are emotionally satisfying but rather a craving response that makes adapting to reality more difficult.
Activation of these neurobiological reward pathways may manifest in addiction-like properties. Attachment-seeking is an intrinsic biological motivational system associated with resistance to separation. Neurological structures that evolved prior to the ability of mammals to comprehend the permanence of separation lead to registering the absence of the deceased as simply missing, failing to acknowledge the irrevocable loss (Field et al, 2005). Activation of thoughts and images are a potential compensation for the profound loss. Preoccupying thoughts further activate the attachment system and produce a feed-forward escalation in distress (Vahia, 2014). Strong urges to unite with the deceased and continued feelings of presence persist as reality fails to match the assumptive world.
A paramedic's role in grief
Comprehensive treatment of complicated grief is beyond the scope of a primary care professional such as a paramedic and frequently requires the skilled intervention of mental health professionals. Primary care providers can aid in facilitating the transition through normal grief, providing they can differentiate between grief, complicated grief and depression. However, further promotion of education to enhance awareness of common symptomology and subtleties in these areas would aid clinical excellence. It is also important to remember that although differentiation can be used to improve patient-centred care, it is also a preventive measure for the profession. Everyone, at some point in their life, will experience grief; as a profession, to aid patients, colleagues and ourselves, we should understand the complications that can arise and the pathophysiology involved.