Interview by Erika Kao, Ph.D. 

I had the pleasure of interviewing Sidney Zisook, MD at his office at University of California, San Diego (UCSD). Filled with natural light and cozily decorated, his office is an inspiring environment for research on therapeutic mental health interventions.

Dr. Zisook is an accomplished researcher and Professor of Psychiatry at UCSD, and a kind, interesting, and warm person. His interest in Grief and its manifestations have roots in both his personal and professional life; he first began thinking about Grief as a teenager, when he encountered it first-hand after losing a close friend. His professional interest in Grief began when his mentors at Massachusetts General Hospital, where he was a resident, and at Harvard Medical School, where he was a fellow were studying Grief as a model for resilience or psychopathology. Today, Dr. Zisook is considered to be a leading authority in the field of Grief research.

What is “Complicated Grief” (also known as prolonged grief, or, in the DSM-5 as “persistent complex bereavement disorder”) and how does it matter to you as a clinician?

“There is no formula for how to grieve or a definition for ‘normal’ or ordinary grief. Everyone grieves in their own way: Grief may be different for different losses, and shifts over time. Yet, there are some commonalities, including intense emotionality (e.g., pangs of yearning, longing, sorrow, anxiety, guilt, anger and shame Interspersed with positive emotions),  cognitions  (e.g., a sense of disbelief, frequent insistent thoughts and memories of  the person who died, difficulty concentrating on other things) and behaviors (e.g., proximity seeking and/or avoiding reminders of the loss). Many of these features overlap with symptoms of depression and, especially after a very violent, sudden, unanticipated or traumatic loss, such as after suicide, accidents or homicide, features that overlap with posttraumatic stress are common. Nevertheless, for most bereaved individuals, intense emotionality subsides, thoughts and memories recede into the background, the sense of disbelief lessens, and wellbeing is restored. Although the loss will never be erased, healing occurs over time and the individual is able to get on with this or her life. However, sometimes this progression gets derailed and intense grief persists, often accompanied by strong negative feelings such as unrelenting guilt, blame, and loneliness, avoidance of, or preoccupation with, reminders of the deceased, feeling disconnected to the past, present and future, and a sense of meaningless and despair. This condition, the failure to adapt to the loss, is what we call ‘Complicated Grief.’

Those suffering from Complicated Grief may have self destructive tendencies; they appear unable to move forward, and are at higher risk for suicide. In the DSM-5 complicated grief is identified as Persistent Complex Bereavement Disorder (PCMD), a condition for further study. It appears in the section of Trauma-and Stressor-Related Disorders.  Complicated Grief (or PCBD)   differs from Posttraumatic Stress Disorder (PTSD) in that the trigger is loss rather than threat. Correspondingly, primary emotions are yearning and sadness rather than anxiety and fear. Intrusive thoughts and images are focused on the person rather than the event, and these thoughts and memories are not frightening. At times, they may even be pleasurable.

In the absence of treatment, Complicated Grief may persist indefinitely and is associated with substantial ongoing emotional pain and psychological and medical morbidity. The good news is that there are several emerging, evidence-based therapies for Complicated Grief. The form of therapy with the most evidence, simply called Complicated Grief Psychotherapy (CGT) has now been found effective in three large, randomized trials. CGT is a form of cognitive behavioral therapy that also draws upon exposure therapies, interpersonal therapy, motivational interviewing and gestalt therapy. Each of the 16 manualized sessions focuses on both loss and restoration.”

A recently completed NIMH-funded randomized controlled study of CGT lead by Dr. M. Katherine Shear (Columbia University) with Drs. Charles Reynolds (University of Pittsburg), Naomi Simon (Harvard), and Sidney Zisook (UCSD) also explored the role of antidepressant medications for symptoms of Complicated Grief.  That study did not find medications particularly effective, either alone or in combination with CGT, but it did confirm the robust effectiveness of CGT. At the initiation of treatment, participants had been profoundly impaired, often for several years. Comorbid depression and PTSD were common and 43% of the bereaved participants expressed suicidal thoughts at the start of treatment. Despite the severity and chronicity of symptoms, an impressive 83% of the treatment group responded to CGT. There were corresponding improvements in function, depressive and anxious features, and suicidality. Indeed, none of the participants who received CGT were suicidal at the end of treatment. In addition, the subset of participants who had suffered from losses that were particularly violent and traumatic, such as after suicide, accidents and homicide, did equally well with CGT as those whose loved ones died from  nonviolent, natural causes of death. Few clinicians are familiar with this innovative and highly effective treatment, and thus may not well equipped to optimally help their clients with Complicated Grief.

Dr. Zisook also shared important work he has done in suicide prevention. He is involved in a project to reduce suicide amongst physicians and other healthcare providers. Healthcare providers, including physicians, nurses, and pharmacists are at elevated risk for suicide (there is anecdotal data that psychologists, too are risk for suicide, but there are no studies yet). Female physicians are at especially at high risk. In light of these sobering occupational risks, Dr. Zisook and his team at UCSD have launched a proactive educational, support and outreach program aimed at destigmatizing mental health treatment, and preventing burnout and suicide.

Dr. Zisook,  Alana Iglewicz, M.D., and Danielle Glorioso, L.C.S.W. of the UCSD Complicated Grief Study Team will talk about this ground breaking treatment for Complicated Grief at the SDPA Fall Conference taking place on October 28th, 2017.

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Dr. Kao has been a licensed psychologist since 2001. She practices in the Del Mar- Carmel Valley area. She has two sons, and a small but fearsome dog. Attachment theory in relationships, career development, anxiety, trauma, grief, loss, and medical/legal assessment are her areas of practice.