diagnosing complicated grief: a closer look

Diagnosing Complicated Grief: A Closer Look�

Brian P. Enright and Samuel J. Marwit

University of Missouri—St. Louis

Over the past decade, a number of researchers have proposed a separateDSM category for complicated grief. Recently, there have been attemptsto determine empirically the number and nature of variables comprisingthe complicated-grief syndrome. The present research addresses one suchprocedure for defining these variables. Combining a past methodologythat demonstrated the relative utility of one classification of complicatedgrief (Worden, 1991) with dimensional concepts derived from other clas-sifications, the present research concludes that a relatively small numberof variables account for the concept. These findings are discussed notonly in terms of previous research on Worden’s categorization and morerecent classifications, but, more importantly, in terms of the more globaltheoretical and methodological issues surrounding the definition(s) of com-plicated grief. © 2002 Wiley Periodicals, Inc. J Clin Psychol 58: 747–757, 2002.

Keywords: complicated grief; DSM; Worden; posttraumatic stress syndrome

While grieving clients, in practice, receive a variety of DSM diagnoses, these may notdescribe adequately or consistently the difficulties experienced by clients after the loss ofa loved one. The thanatology literature proposes alternative classifications of compli-cated grief that some claim describe more adequately these reactions (Belitsky & Jacobs,1986; Bowlby, 1980; Horowitz et al., 1997; Marwit, 1996; Prigerson, et al., 1996; Rando,1993; Worden, 1991; Wortman & Silver, 1989).

Where the DSM has been used to diagnose complicated grief (CG), it has beendemonstrated that the most commonly assigned classifications are Posttraumatic StressDisorder (PTSD), Depressive Disorder, Adjustment Disorder, and Personality Disorder(Jacobs & Kim, 1990; Marwit, 1991; Middleton, Raphael, Martinek, & Misso, 1993;Raphael & Middleton, 1990). The utility of these labels, however, has been called intoquestion (Marwit, 1991, 1996).

While DSM diagnostic categories share some descriptive features with CG, they alsopresent fundamental differences. For example, with CG and PTSD, Prigerson and col-leagues (Prigerson, Shear, et al. 1999) acknowledged some “phenomenological overlap

Correspondence concerning this article should be sent to: Samuel J. Marwit, Department of Psychology, Uni-versity of Missouri at Saint Louis, 8001 Natural Bridge Road, St. Louis, MO 63121; e-mail: [email protected].

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(7), 747–757 (2002) © 2002 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.2002

between pathological grief and post-traumatic stress symptomatology” (p. 560), but rec-ognized that this overlap is incomplete. Their research (Prigerson, Jacobs, Rosenneck, &Maciejewski, 1999) identified traumatic-distress symptoms and separation-distress symp-toms as the core symptoms of traumatic grief (their term for complicated grief ). Theformer (e.g., numbness, disbelief ) bears resemblance to PTSD diagnostic criteria, but thelatter (e.g., yearning, searching, excessive loneliness resulting from the loss) are claimedto be uniquely different. Furthermore, according to Prigerson et al. (Prigerson, Jacobs,et al., 1999; Prigerson, Shear, et al. 1999), avoidance and hypervigilance criteria, whichare essential for diagnosing PTSD, are of low specificity when diagnosing traumaticgrief. In support, they reported research that demonstrated low rates of agreement betweenSCID-generated PTSD diagnoses and traumatic-grief diagnoses, at least in one studyinvolving suicide survivors. Marwit (1991, in press) similarly addressed overlap betweenPTSD and CG in terms of symptom characteristics and precipitating factors, and, likePrigerson, recognized differentiating qualities. Marwit’s focus is more on the impact onthe primary relationship network (universal in grief, but not always the case with trauma)and on the patient’s sense of safety in the world (often challenged in trauma, but notalways challenged with grief ). Concerning CG and depression, the same conceptualiza-tion acknowledging substantial, yet incomplete, phenomenological overlap exists and issupported by an even greater number of studies. Horowitz’s often-cited algorithm todescribe CG has been shown to differentiate patients with CG from patients with MajorDepressive Disorder (Horowitz et al., 1997). Prigerson et al. (1996) cited a number ofstudies that “demonstrate that the symptoms of traumatic grief (a) form a factor that isdistinct from factors of depression and anxiety, and (b) have distinct clinical correlatesfrom those associated with depression” (p. 67). Other research has shown that not allatypical grief meets the criteria for Major Depressive Disorder (Hartz, 1986; HorowitzBonanno, & Holen, 1993; Prigerson et al., 1995; Prigerson et al., 1996; Walker & Pomeroy,1996), and while some clients experiencing CG adequately may be described by a Depres-sive Disorder, others will not. Lastly, adjustment Disorder, the third most-commonlyassigned diagnosis, also is distinguishable from CG on a number of dimensions. Adjust-ment Disorder, by definition, generally begins within three months of the onset of astressor and lasts no longer than six months after the stressor or its consequences haveceased, although chronicity is a specifier. On the other hand, most theorists believe thatmourning lasts longer than six months, and may occur first in complicated form later thanthree months after the loss (Worden, 1991). The DSM-IV (American Psychiatric Asso-ciation, 1994) itself implies a distinction between CG and Adjustment Disorder by statingthat, “The diagnosis of Adjustment Disorder does not apply when the symptoms repre-sent Bereavement” (American Psychiatric Association, 1994) (p. 623).

The thanatology literature presents alternatives to the DSM-IV for classifying com-plicated grief and offers descriptive labels distinct from those appearing in the DSM.However, here, too, there are problems of inconsistency. Some grief theorists proposethat CG can be expressed in two distinct ways. For example, Belitsky and Jacobs (1986)posited the two-fold classification of delayed grief and distorted grief; Bowlby (1980)suggested prolonged grief and chronic grief. Others, such as Parkes (1965), presented athree-fold classification (chronic, inhibited, and delayed), whereas Worden (1991) pro-posed four complicated grief categories (chronic, delayed, masked, and exaggerated).More recently, Rando (1992) added distorted grief, conflicted grief, and unanticipatedgrief in proposing a classification of CG comprised of seven distinct forms. Prigersonet al. (1996) list 10 variables that cluster together to form a complicated grief factor andHorowitz et al. (1997), following DSM’s system of providing polythetic criteria sets, listsseven symptoms, any three of which are sufficient to define complicated grief.

748 Journal of Clinical Psychology, July 2002

Another problem with the growing literature concerning diagnosing complications inbereavement, especially in relation to DSM criteria, is that only a small portion has beenderived empirically. Three notable examples that empirically investigated CG are Horo-witz et al. (1997), Marwit (1996), and Prigerson et al. (1996). Any one of these wouldhave served as an appropriate vehicle for the current research. Marwit’s (1996) designwas chosen because it previously had been used to demonstrate that an existingthanatological system (Worden’s, 1991) was more reliable than was the DSM in diagnos-ing complicated grief, and because the authors believed that the current methodologywould provide a refinement of Marwit’s (1996) earlier conclusions.

In Marwit’s (1996) study, all cases were first diagnosed using DSM-III-R (AmericanPsychiatric Association, 1987) labels and then diagnosed using Worden’s (1991)complicated-grief labels (along with a fifth option of uncomplicated bereavement, whichalmost was never chosen). Results indicated that interrater agreement was low usingDSM categories despite a high dependence on those relatively few categories that tradi-tionally have been employed (i.e., PTSD, Depressive Disorder, Adjustment Disorder, andPersonality Disorder. In contrast, interrater agreement using Worden’s (1991) complicated-grief categories consistently was high.

However, Marwit’s study also has its limitations. The specific grief labels in Mar-wit’s (1996) study were derived from Worden’s (1991) thanatological categories, whichwere created from clinical experience rather than from an experimental base. Althoughthe chosen labels (chronic, delayed, exaggerated, and masked) and their accompanyingoperational definitions appear to have explanatory value and reasonably unique features,the existence of some, such as masked grief, are controversial (Wortman & Silver, 1989).Furthermore, it remains unclear what aspects of these labels were used by clinicians inMarwit’s (1996) study to differentiate grief cases.

The design of the present study specifically addresses the variables underlying CGand their relationship to clinicians’ diagnoses. To do so, the current study employs stimuliused in Marwit’s (1996) research, but the design differs in two important ways. First, itallows clinicians to identify and rate those variables considered relevant in the represen-tative cases. Identifying the variables that clinicians consider important in coming to acomplicated-grief diagnosis will provide preliminary information about the criterion-related validity of Worden’s (1991) complicated-grief taxonomy and will reveal informa-tion regarding how the complicated-grief categories are used to distinguish between cases.

The second important design alteration is the inclusion of a measure that allows cliniciansto record the relative weight of their various complicated-grief diagnoses. Unlike Marwit’s(1996) study, which required a forced-choice primary diagnosis for each case vignette, thepresent method provides a continuous measure of each case’s conformity to the CG labels.This procedure was chosen to show the relative weight of each complicated-grief diagnosisand to help determine if some labels were relied upon more confidently than were others.

In addition to evaluating, and possibly refining, Worden’s (1991) CG taxonomy, itmore importantly is hoped that this study will provide a model for evaluating othercomplicated-grief taxonomies that exist in the literature and, as such, will help move thefield toward a more consensual understanding of the construct. Since this research isexploratory in nature, no specific hypotheses are offered.

Method

Participants

Forty-one packets of research materials were sent to licensed mental-health professionalswho agreed to participate in the study; 30 (73%) were returned. The final sample con-

Complicated Grief 749

sisted of 21 doctoral-level licensed clinical psychologists and 9 master’s-level licensedmental-health professionals (clinical social workers and professional counselors). Nodistinctions between disciplines were made for the purposes of data analysis. Participantswere recruited from private practices and social-service agencies in the St. Louis metro-politan area, and from psychology graduate-school alumni lists involving a geographi-cally and professionally diverse membership. For the final sample, the average numberof hours per week spent in direct clinical service was 15.89 (SD � 10.39) and the averagenumber of years in clinical practice was 12.97 (SD � 9.20). Regarding primary theoret-ical orientation, 12 identified themselves as cognitive behavioral, 10 interpersonal sys-tems, 4 humanistic, and 4 psychodynamic.

Materials

Participants were presented with Marwit’s (1996) case vignettes, which served as theprimary stimuli. The vignettes are detailed, one-page case studies originally provided byclinical psychologists whose primary service was grief therapy. They were developedfrom actual patient accounts and presented so that grief was a common feature in each,yet grief was embedded within a broader psychological framework (personality, familyhistory, complicating factors, etc.) to allow for DSM diagnoses. Cases were selected sothat each of the four categories of complicated grief outlined by Worden (1991) wasrepresented. The chosen case vignettes had been rated objectively by expert grief thera-pists to ensure their consistency with Worden’s (1991) complicated-grief categories (Mar-wit, 1996). At that time, three cases yielded unanimous agreement, while one case resultedin three out of four agreements. Therefore, it was concluded that the chosen vignettesrepresented clear examples of specific cases of chronic, exaggerated, delayed, and maskedCG, “at least to clinicians knowledgeable in the field” (Marwit, 1996) (p. 3).

In addition to the four case vignettes, participants were presented with two measures.

Measure 1. The first measure was intended to assess if participants used the CGvariables intended by Worden (1991) to arrive at diagnoses according to his taxonomy. Toaccomplish this, the operational definitions for his categories were divided into theircomponent parts, and a list of items was generated. A total of nine items were identified:

1. abnormally short grief reaction,

2. excessive and intense grief reaction,

3. previous unresolved loss,

4. insufficient grief reaction,

5. absence of satisfactory conclusion,

6. excessive duration of grief reaction,

7. maladaptive behavior,

8. somatic or psychiatric symptoms, and

9. prolonged time before to grief onset.

The nine items then were affixed to the appropriate CG labels according to theirdirect presence in Worden’s (1991) definition or according to the experimenters’ deter-mination that it was an assumed feature in the operational definition. Chronic grief wasdescribed directly by Worden (1991) as including (5) absence of satisfactory conclusionand (6) excessive duration of grief reaction, and to this was added (2) excessive andintense grief reaction because it appeared to be an assumed feature in this category.


Delayed grief was described directly by Worden (1991) as including (2) excessive andintense grief reaction, (3) previous unresolved loss, (4) insufficient grief reaction, (9)prolonged time before grief onset, and the experimenters theorized that items (1) abnor-mally short grief reaction and (5) absence of satisfactory conclusion were assumed fea-tures in the definition. Worden (1991) directly described exaggerated grief as including(2) excessive and intense grief reaction and (7) maladaptive behavior, and no assumedfeatures were identified. Worden (1991) directly described masked grief as including (4)insufficient grief reaction and (8) somatic or psychiatric symptoms, and to this the exper-imenters added (1) abnormally short grief reaction.

For each vignette, participants were asked to make a rating for all nine items on a7-point scale ranging from “not at all” to “very strong” to indicate how strongly eachcontributed to the belief that the case represented CG. Instructions indicated that partici-pants were to rate each variable independently of ratings for all other variables, thereason being that Worden’s (1991) operational definitions contain duplicate and contra-dictory variables. For example, a delayed-grief reaction is explained as a response thatappears insufficient to the loss initially, but is manifest excessively over a subsequent loss(Worden, 1991).

Measure 2. The second measure was designed to assess the degree to which partici-pants believed the case vignettes conformed to each of Worden’s (1991) CG categories.Participants were asked to make a rating on a 7-point scale ranging from “not at all” to“very highly” to indicate how strongly each case vignette conformed to the four opera-tional definitions included in the CG taxonomy.

Procedure

The study was administered in two parts. Part 1 instructed clinicians to read carefullyeach case vignette and rate the contribution, using a 7-point scale, that each of the nineitems made to the case. After the participants rated all nine items for each case, they wereasked to place their rating forms in a return envelope and to proceed to the second part ofthe study. Part 2 instructed participants to read each case again and to make ratings, usinga 7-point scale, based on how well each case vignette conformed to Worden’s (1991)operational definitions of chronic, delayed, exaggerated, and masked grief. Uncompli-cated bereavement was not included both because previous research (Marwit, 1996) haddemonstrated that clinicians chose not to apply this label to these vignettes, and because,in the present study, clinicians were free to rate any and all cases as low as “not at all”regarding the degree of conformance to Worden’s definitions, which in essence would beequivalent to uncomplicated bereavement.

Results

To determine which variables were used to arrive at diagnosis ratings, a separate corre-lation matrix was created for each case vignette that included the item ratings on one axisand diagnosis ratings on the other axis. Results of this analysis appear in Table 1.

When the significant correlations are compared to the expected item–diagnosis rela-tionships drawn from Worden’s (1991) operational definitions, chronic grief proved toconform most strongly to the predetermined expectations. Chronic grief was predicted tobe represented by the absence of a satisfactory conclusion, excessive and intense griefreaction, and excessive duration of grief reaction. For Case II, which was developed to


represent chronic grief, correlations were high for all three of these items, and they wereshown to account for 31, 30, and 13% of the total variance, respectively.

The anticipated relationships for the other three grief labels did not hold up nearly aswell. Excessive-and-intense-grief reaction was the only item significantly correlated withdelayed-grief ratings (accounting for 27% of the total variance). However, it should benoted that this correlation was unexpectedly negative. Somatic or psychiatric symptomswere the only items significantly correlated with exaggerated grief (accounting for 18%of the total variance), but this relationship was unexpected because it was not included inWorden’s (1991) operational definition of this type of grief. Finally, somatic or psychi-atric symptoms were the only items correlated with masked-grief ratings (accounting for26% of the total variance). Although previous research (Marwit, 1996) demonstratedrelatively high reliability when using Worden’s (1991) complicated-grief taxonomy fordiagnosing cases, results from this analysis revealed that clinicians did not use the full setof originally intended variables inherent in or implied by Worden’s operational defini-tions, thus calling into question the criterion-related validity of the taxonomy.

Given the above findings, we decided to evaluate the diagnostic sensitivity of eachcase. First, separate means for diagnosis ratings were calculated for each case study (seeTable 2). Then comparisons were made between the four means obtained for each case(horizontal comparisons) to determine if the diagnosis the case was intended to representproduced a significantly higher mean rating than that of the other three possible diagno-ses. Although one-way ANOVA tests also were performed for each of these groups ofcomparisons because we desired to perform all of the possible comparisons within each

Table 1Significant Correlations between Variable Ratings and Diagnosis Ratingsfor Each Complicated Grief Label and Its Representative Case Study

Variable ratings significantly correlated with chronic-grief-diagnosis ratings for Case II.55** Excessive and intensive grief reaction.56** Absence of satisfactory conclusion.36 Excessive duration of grief reaction

Variable ratings significantly correlated with delayed-grief-diagnosis ratings for Case IV�.52** Excessive and intense grief reaction

Variable ratings significantly correlated with exaggerated-grief-diagnosis ratings for Case III.42* Somatic or psychiatric symptoms

Variable ratings significantly correlated with masked-grief-diagnosis ratings for Case I.51** Somatic or psychiatric symptoms

*p � .05; **p � .01.

Table 2Means of Diagnosis Ratings for Each Case

Masked Chronic Exaggerated Delayed

Case I (masked) 5.40 3.73 4.33 5.20Case II (chronic) 2.13 5.67 3.80 1.63Case III (exaggerated) 2.47 2.90 4.33 1.87Case IV (delayed) 4.07 2.73 2.07 6.00

Note. The label within ( ) represents the grief label that each case was developed to represent.


group of means, we elected to present paired t-tests. It should be noted that for each groupof means, the overall analysis of variance was significant, and when held to an equallystringent �, significant mean differences from the post-hoc comparisons were identical tothose found using t-tests. For all of the following means comparisons, an overall � levelof .05 was selected and a Bonferroni procedure was used to determine the appropriate �level for each individual comparison.

For Case II (chronic), paired samples two-tailed t-tests revealed that the mean forchronic grief (M � 5.67, SD � 1.35) was significantly higher than that for delayed grief[M � 1.63, SD � 1.22), t(29) � 11.61, p � .0001], exaggerated grief [M � 3.80, SD �1.81), t(29) � 5.36, p � .0001], and masked grief [M � 2.13, SD � 1.74), t(29) � 9.96,p � .0001], suggesting that chronic-grief ratings were made primarily for this case. ForCase IV (delayed), the mean for delayed grief (M � 6.00, SD � 1.55) was significantlyhigher than that of chronic grief [M � 2.73, SD � 2.23), t(29) � 5.62, p � .0001],exaggerated grief, [M � 2.07, SD � 1.33), t(29) � 7.92, p � .0001], and masked grief[M � 4.07, SD � 2.16), t(29) � 4.48, p � .0001], suggesting that delayed-grief ratingswere made primarily for this case. For Case III (exaggerated), the mean for exaggeratedgrief (M � 4.33, SD � 1.83) was significantly higher than that of delayed grief [M � 1.87,SD � 1.43), t(29) � 6.16, p � .0001] and masked grief [M � 2.47, SD � 1.55), t(29) �4.80, p � .0001], but not chronic grief, suggesting that exaggerated-grief ratings were notcompletely consistent for this case. Finally, for Case I (masked), the mean for maskedgrief (M � 5.40, SD � 2.04) was not significantly higher than that of any other CG diag-noses, suggesting that masked-grief ratings were not consistent with defining this case.

While results from the mean comparisons suggest that two of the CG labels (chronicand delayed) appear convincingly useful, and one (exaggerated) shows moderate utility,a more-critical inspection of the highest diagnosis ratings for each case provides anotherperspective on this issue. Many participants rated the case vignettes as conforming equallyas high to two, and sometimes three, CG labels. With the exception of Case II (chronic),a high number of ties for diagnosis rating were observed. Case III (exaggerated), forexample, had 4 two-way ties and 2 three-way ties. This means that 20% of subjects failedto provide spontaneously a single-highest rating for that case. Case IV (delayed) resultedin 10 two-way ties and 0 three-way ties, indicating that 33% of subjects failed to providea single-highest rating for that case. Case I (masked) produced 11 two-way ties and 6three-way ties, indicating that 56% of subjects did not provide a single-highest rating forthat case. The only semi-pure case was Case II (chronic), which produced only 3 two-wayties. This again supports the relative strength and clarity of the chronic-grief category.

Since these dimensionally derived results display less diagnostic purity than Mar-wit’s (1996) categorically derived results, the continuous data obtained in this study wereconverted to categorical data for purposes of comparison. This was accomplished byusing the highest diagnosis rating for each case. Where any two ratings were equallyhigh, both were counted. Thus, for example, if a subject rating Case II assigned a ratingof “7” for both chronic grief and exaggerated grief, then each was counted once as thehighest diagnosis rating for that case. In those cases where a subject made equally highratings for three diagnoses (three-way ties), the data were considered insufficiently dis-criminating and no highest-diagnosis rating was entered for that subject and case. Table 3indicates that converting continuous data to categorical data produced results that looksimilar to those presented by Marwit (1996).

Referring again to Table 2, comparisons were made between the four means obtainedfor each diagnostic label (vertical comparison) to determine if the case it was intended torepresent produced a significantly higher mean rating than that of the other three cases.This analysis is intended to evaluate the distinctiveness of the CG labels, or each label’s


ability to discriminate between clinical cases of CG. Although one-way ANOVA testsalso were performed for these groups of means, we elected to present t-test results for thesame reason previously discussed. As with the earlier results, the overall ANOVA wassignificant for each group of means, and significant mean differences from the post-hoccomparisons from the one-way ANOVA tests were identical to those found using t-tests.

For the chronic-grief diagnosis, paired samples two-tailed t-tests revealed that themean for Case II, (M � 5.67, SD � 1.35) was significantly higher than that of Case I (M �3.73, SD � 2.30), t(29) � 3.88, p � .001, Case III, (M � 2.90, SD � 1.83), t(29) � 7.53,p � .0001, and Case IV, (M � 2.73, SD � 2.23), t(29) � 6.68, p � .0001, suggesting thatthe chronic-grief diagnosis was used adequately to distinguish between CG cases. For thedelayed-grief diagnosis, the mean for Case IV (M � 6.00, SD � 1.55) was significantlyhigher than that of Case II, (M � 1.63, SD � 1.22), t(29) � 12.01, p � .0001, and CaseIII, (M � 1.87, SD � 1.43), t(29) � 9.54, p � .0001, but not Case I, which was intendedto represent masked grief. The mean for Case I (M � 5.20, SD � 1.92) also was found tobe significantly higher than that of Case II, (M � 1.63, SD � 1.22), t(29) � 9.71, p �.0001, and Case III, (M � 1.87, SD � 1.43), t(29) � 8.60, p � .0001, suggesting thatthere may be some overlap between the delayed-grief and masked-grief diagnoses, andthat delayed grief alone was not used adequately to distinguish between CG cases. For theexaggerated-grief diagnosis, the mean for Case III (M � 4.31, SD � 1.85) was signifi-cantly higher than that of Case IV, (M � 2.07, SD � 1.33), t(29) � 4.82 p � .0001, but nothigher than the other two cases, suggesting that the exaggerated-grief diagnosis was notused adequately to distinguish between CG cases. For the masked-grief diagnosis, themean for Case I (M � 5.40, SD � 2.04) was significantly higher than that of Case II, (M �2.13, SD � 1.74), t(29) � 7.53, p � .0001, and Case III, (M � 2.46, SD � 1.55), t(29) �7.32, p � .0001, but not Case IV, which was intended to represent delayed grief. Themean for Case IV (M � 4.07, SD � 2.16) also was found to be significantly higher thanthat of Case II, (M � 2.13, SD � 1.74), t(29) � 4.14, p � .0001, and Case III, (M � 2.47,SD � 1.55), t(29) � 3.57, p � .001, suggesting that masked grief alone was not usedadequately to distinguish between CG cases. Furthermore, as the data for delayed griefsuggested, masked grief and delayed grief may share some conceptual overlap. As can beseen in Table 2, diagnosis ratings of masked grief were high for cases intended to repre-sent masked grief, as well as for cases intended to represent delayed grief. Moreover,diagnosis ratings of delayed grief were high for cases intended to represent delayed grief,as well as for cases intended to represent masked grief.

Table 3Frequencies [and Percentages—in ( )] of Highest Ratings for Grief Labels

Masked Chronic Exaggerated Delayed

Case I 13 (37) 6 (17) 6 (17) 10 (29)(Marwit, 1996) 28 (70) 0 (0) 1 (2.5) 10 (25)

Case II 2 (6) 26 (79) 4 (12) 1 (3)(Marwit, 1996) 0 (0) 32 (80) 6 (15) 0 (0)

Case III 3 (9) 6 (19) 21 (66) 2 (6)(Marwit, 1996) 0 (0) 4 (10) 31 (77.5) 0 (0)

Case IV 9 (23) 4 (10) 1 (2) 26 (65)(Marwit, 1996) 11 (27.5) 0 (0) 0 (0) 29 (72.5)

*Results from the present study and results from Marwit (1996).


In addition to investigating the relationship between item ratings and diagnosis rat-ings for each CG label’s representative case study, the relationship between items and CGdiagnoses in general (across all cases) also was analyzed. Since clinicians in this studydid not use the diagnoses completely for their intended cases, this analysis was includedto show generally which variables seemed predictive of which complicated grief diagno-ses. Delayed and masked grief again appear to have significant conceptual overlap, eachbeing correlated with the same four variables (previous unresolved loss, insufficient griefreaction, somatic or psychiatric symptoms, and prolonged time before grief onset). Exag-gerated grief ratings did not correlate significantly with any variables and chronic grief ispredicted by three variables (previous unresolved loss, absence of satisfactory conclu-sion, and excessive duration of grief reaction).

Discussion

This research was stimulated by recent attempts to develop diagnostic criteria for describ-ing complicated grief. It was stimulated further by previous findings that demonstratedgreater reliability of diagnosing complicated grief when using a thanatological taxonomyin comparison to the DSM classification system (Marwit, 1996). When the complicated-grief taxonomy proposed by Worden (1991) was shown to be relatively consistent formaking diagnoses, the question was raised whether the variables described in his opera-tional definitions were actually those variables which clinicians used in arriving at theirdecisions. While the present study was intended to provide a preliminary investigationinto the validity of Worden’s (1991) CG taxonomy, its more global aim was to increaseknowledge about the specific variables underlying the concept of CG.

The present results indicated that, with the exception of the chronic-grief label, therewas little evidence to suggest that clinicians used the full constellation of variables out-lined by Worden (1991). Chronic grief was observed to conform very strongly to pre-determined expectations, while exaggerated, delayed, and masked grief did not. Thechronic-grief construct, therefore, is the only one fully supported as a component of thebroader complicated-grief syndrome. Delayed, masked, and exaggerated grief did nothold up as well as independent constructs descriptive of complicated grief. Since clini-cians did not appear to use the full compliment of variables intended by Worden (1991) inmaking diagnostic decisions, the diagnostic validity of his system is questioned. With theexception of the vignette representing chronic grief, clinicians failed to rate consistentlya single complicated-grief diagnosis as the best category to describe each case. Both theitem ratings and the diagnosis ratings revealed that conceptual discrimination betweeneach of Worden’s (1991) complicated-grief categories was not supported. Masked anddelayed grief appeared to have significant conceptual overlap, a finding consistent withMarwit’s (1996) earlier conclusions, and exaggerated grief failed to hold up well as aspecific component of the complicated grief syndrome.

An unpredicted finding for the delayed-grief category revealed an issue that maycontribute to the conceptual breakdown of the delayed-grief and masked-grief categories.High delayed-grief ratings correlated with low ratings on the excessive-and-intense-griefreaction variable. Although this finding was diametrical to one of the predeterminedexpectations drawn from Worden’s (1991) definitions, it was not surprising because delayedgrief was described as involving an insufficient grief reaction initially and an excessivegrief reaction later, following a subsequent loss (Worden, 1991). The use of contradictoryvariables to represent different times in a single grief syndrome may be more confusingto diagnosticians than helpful. When presented with the opportunity to describe a singlecase as involving both periods of insufficient grief and periods of excessive grief, clini-


cians appear to have chosen to focus on the insufficient-grief component, not on theexcessive-grief component. Clarifying similar contradictions may be an important con-sideration in arriving at empirically validated complicated-grief categories.

The current data suggest, as did Marwit’s (1996) data, that the complicated-griefsyndrome may not require four distinct diagnoses to describe the phenomenon adequately.Symptoms ultimately may factor in to as few as two primary dimensions.When Marwit (1996)proposed this, he characterized these dimensions as (a) intensity and (b) duration of a griefreaction. He arrived at this conclusion because there seemed to be evidence in his data foroverlap between chronic and exaggerated grief, as well as between delayed and masked grief.This trend also was observed in the present study. Referring to Table 3, if delayed and maskedgrief had been combined into a single category, they would have accounted for 66% of thehighest ratings for Case I and 88% of the highest ratings for Case IV. The relationship be-tween these grief labels also was observed when the means for diagnosis ratings were com-pared (see Table 2). Finally, when variables were collapsed across cases, the same four itemswere predictive of both masked-grief and delayed-grief diagnoses, suggesting significantoverlap in what constitutes these two constructs. Similarly, although the overlap betweenchronic and exaggerated grief was not observed to be as dramatic as that for masked anddelayed grief, there was some evidence for a relationship. Referring again to Table 3, ifchronic- and exaggerated-grief ratings had been combined into a single category, they wouldhave accounted for 91% of the highest ratings for Case II and 85% of the highest ratings forCase III. Of these two categories, chronic grief proved to be the more useful construct.Clinicians were reluctant to give strong ratings for the diagnosis of exaggerated grief, andexaggerated grief was not correlated with any of its expected variables. These results aresuggestive of a conceptual lack of clarity for the construct of exaggerated grief, which maybe described more accurately as representing more-diffuse aspects of the general complicated-grief syndrome.

It needs to be noted that the current study is limited in a number of ways. First, theuse of vignettes, while allowing for experimental rigor, is never the equivalent of behav-ioral observations over time. Second, employing only one vignette to represent eachdiagnostic entity follows the design of the Marwit (1996) study, which was essential forthis study, but may provide an overly restrictive stimulus sample. Third, there may becircularity in reasoning when rating vignettes specifically developed to depict the diag-noses being rated. Marwit (1996) was aware of this in his original 1996 work and arguesa case for this methodology. Future research also would benefit from a larger clinical-participant sample and might benefit further from greater attention being paid to clients’subjective experiences rather than relying exclusively on behavioral markers of grief.Finally, if the Worden taxonomy is ever used again, it might be interesting to add moredefinition to time frames, etc.; for example, stating that chronic grief is grief that hasgone beyond some time frame (maybe beyond 2 years or so) or that exaggerated grief isonly exaggerated within some definable cultural context. This was not done in the currentstudy in order to remain faithful to Worden’s writings.

It may be that CG is described more accurately by symptom clusters as those proposedby Prigerson, Jacobs, et al. (1999); Prigerson, Shear, et al. (1999); and Horowitz et al. (1997)rather than by categories of excess or absence of reaction as proposed by Worden (1991), orit may be that CG is described most accurately by some combination of behavioral symp-toms along with better operationally defined notions of intensity and duration as sug-gested by Marwit (1996) and the present authors. Regardless, the movement away fromthe earlier descriptive taxonomies based upon clinical intuition and toward more empir-ically verifiable schemas is laudatory and should bring us closer to understanding the truenature and number of dimensions comprising the concept of complicated grief.


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diagnosing complicated grief: a closer look

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