Research reportThe relationships between complicated grief, depression, and alexithymia according to the seriousness of complicated grief in the Japanese general population
Introduction
Maciejewski et al. (2007) empirically found that natural psychological responses to grief, such as disbelief, yearning, anger, and depression, peek within 6 months following the death of significant others. Most people who experience bereavement overcome their natural emotional response to bereavement. However, integration of the loss does not occur and acute grief becomes more intensive and continuous in the form of complicated grief (Shear and Shair, 2005).
Individuals with complicated grief experience a constellation of symptoms that often include preoccupation with the lost person, anger about the death, and avoidance of reminders of the loss (Ogrodniczuk et al., 2005). Although it is widely recognized that symptoms of normal grief are similar to those of depression, there are distinctions between depression and complicated grief in phenomenology, psychophysiology, and responses to treatment (Lichtenthal et al., 2004). Previous research found that complicated grief does not respond well to proven efficacious treatments for depression (Reynolds et al., 1999, Zygmont et al., 1998). The prevalence rates of complicated grief reported by epidemiological studies on the non-clinical population were 4.2% (Middleton et al., 1996), 24.6% (Chiu et al., 2009), and 2.4% (Fujisawa et al., 2010).
To improve the treatment of complicated grief, it is necessary to investigate the characteristics that effectively buffer complicated grief. Alexithymia, a patient characteristic that influences psychological distress in depression, has been found to influence a patient's response to psychotherapy (McCallum et al., 2003, Taylor, 2000). Ogrodniczuk, et al. (2005) found that the negative influence of alexithymia on general symptoms, for example, anxiety, depression, and interpersonal distress, was buffered by psychotherapy. Taylor et al. (1997) found the following three core features of alexithymia: (1) difficulty in identifying feelings, (2) difficulty in communicating feelings, and (3) externally oriented thinking. This three-factor characterization of alexithymia has become the standard for describing the construct (Ogrodniczuk et al., 2005). Of note, alexithymia is not a psychiatric disorder, but rather a characterization of thinking, feeling, and relating processes among patients with a wide range of psychiatric diagnoses.
There has been a sizeable amount of theoretical and empirical work on the relationships between alexithymia and general depressive symptoms (Lipsanen et al., 2004, Ogrodniczuk et al., 2005). Statistically, Lipsanen et al. (2004) demonstrated that depression and alexithymia are highly correlated but distinct. Parker et al. (1991) have summarized the possible causes of overlap between alexithymia and depression as follows. First, the manifestation of alexithymic features might be a transitory reaction (secondary alexithymia) evoked by stressful situations and the accompanying depression and anxiety. Second, secondary alexithymia is a defensive response to the acute depression that typically accompanies stressful situations. Finally, it is a response to overall changes in the quality of life, and not depression per se, that is associated with the manifestation of secondary alexithymia. Furthermore, in some patients, secondary alexithymia may become permanent and indistinguishable from primary (i.e., trait) alexithymia (Parker et al., 1991).
However, few researches have been conducted on the relationship between complicated grief and alexithymia, and none have been conducted in Japan. For example, Ogrodniczuk et al. (2005) found that alexithymia (except for externally oriented thinking) did not correlate with complicated grief, for example, intrusion, pathological grief, and avoidance. A question related to the difference between complicated grief and general depression symptom is as follows: how different is the relationship between the extent of complicated grief and alexithymia from the relationship between depressive symptoms and alexithymia according to the seriousness of complicated grief? The investigation of complicated grief's relationship with alexithymia, which is related to feeling and expressing emotion, will be helpful in understanding and treating complicated grief. In addition, as there are both distinctions and similarities between complicated grief and depressive symptom, it may be necessary to simultaneously and separately explore how extent complicated grief relates to general depressive symptoms.
The aim of the current study was to investigate whether the relationship between alexithymia and complicated grief differs from the relationship between alexithymia and general depressive symptom according to the seriousness of complicated grief. The hypothesis model of the relationships between alexithymia, depression symptom, and complicated grief is shown in Fig. 1.
Section snippets
Procedures
A cross-sectional anonymous questionnaire was administered to a sample of the general Japanese population. Four target areas (Tokyo, Miyagi, Shizuoka and Hiroshima prefectures) were identified to obtain a wide geographic distribution for the nationwide sample. The four areas included an urban prefecture (Tokyo) and mixed urban–rural areas (Miyagi, Shizuoka and Hiroshima).
Initially, 5000 subjects aged 40–79 years were identified by a stratified two-stage random sampling method of residents of the
Results
According to previous research, the participants were divided to three groups: high risk of complicated grief (n = 25), probable complicated grief (n = 218), and low risk of complicated grief (n = 705). It might be appropriate to compare three groups; however, the high risk group of complicated grief with the group of probable complicated grief were combined and regarded as the high risk group (a score of 5–10) because the number of participants in the high risk group of complicated grief was
Discussion
The results of the current study have advanced our understanding of the relationship between alexithymia, complicated grief, and general depressive symptom in the Japanese general population. The findings showed that the relationship between alexithymia and complicated grief differed according to the seriousness of complicated grief. In other words, alexithymia scarcely contributed to complicated grief, especially in the high risk of complicated grief group, and the contribution ratio in the
Role of funding source
This study was fully supported by the Grant-in-Aid for Cancer Research endowed to Mitsunori Miyashita from the Ministry of Health, Labor and Welfare, Japan (MHLW); the MHLW had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The authors express gratitude to Koken Ozaki, Ph. D., for advising on the analysis.
Conflicts of interest
All authors declare that they have no conflicts of interest.
References (28)
- et al.
The twenty-item Tronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure
Journal of Psychosomatic Research
(1994) - et al.
Negative cognitions and avoidance in emotional problems after bereavement: a prospective study
Behaviour Research and Therapy
(2006) - et al.
Prevalence and determinants of complicated grief in general population
Journal of Affective Disorders
(2010) - et al.
The effects of temperament, character, and defense mechanisms on grief severity among the elderly
Journal of Affective Disorders
(2011) - et al.
A case for establishing complicated grief as a distinct mental disorder in DSM-V
Clinical Psychology Review
(2004) - et al.
The negative effect of alexithymia on the outcome of group therapy for complicated grief: what role might the therapist play?
Comprehensive Psychiatry
(2005) - et al.
Alexithymia and depression: distinct or overlapping constructs?
Comprehensive Psychiatry
(1991) - et al.
Health outcomes of bereavement
Lancet
(2007) - Arbuckle, J.L., 1983–2009. Amos...
- et al.
Gender differences in traumatic grief symptom severity after the loss of a spouse
Omega: Journal of Death and Dying
(2003)