The Denial of Death: A Three-decade Long Case of Absent Grief.

Bereavement reactions are associated with numerous physical and mental complications. Atypical bereavement reactions have been described but their place in the classificatory system has not been established. We present the case of an eighty-year-old woman who came with the belief that her deceased son was alive. We discuss the diagnostic dilemma she posed and conclude that it may be difficult to differentiate atypical bereavement from other psychiatric illnesses.

INTRODUCTION

“Bereavement” refers to the psychological reactions of those who survive significant loss and grief is the subjective feeling precipitated by the death of a loved one.[1] Numerous mental and physical complications are associated with bereavement.[23] Bereavement responses can be atypical and have been called “abnormal” and “complicated.” They are not recognized as a distinct mental disorder. Lichtenthal et al. proposed the term “complicated grief” and demonstrated its distinction from other psychiatric disorders.[4] Recently, Prigerson et al., have proposed the diagnosis of prolonged grief disorder[5] and established its psychometric validity for inclusion in DSM V and ICD-11.[6] We present the case of an elderly woman who did not manifest any signs of grief for over three decades and the diagnostic dilemma posed.

CASE REPORT

Mrs. SM, an 80-year-old woman admitted to the surgical unit for a gluteal abscess, was referred for psychiatric evaluation. The referring physician said that the patient believed that her deceased son was still alive. She had two sons and a daughter, who provided the psychiatric history. The deceased son was her favorite, but her relationship with other family members was depleted. When he was in his twenties, he was accused of fraud at his workplace, following which he developed depressive symptoms. At 10 days later he committed suicide by consuming poison, leaving separate notes for his mother and sister. When taken to the morgue, the patient claimed that he was not dead. The suicide note was not shown to her.

Over the next few months, the patient displayed behaviors indicating that she believed her son was alive. She maintained his room and belongings exactly as before. She often rushed up to the terrace at the sound of airplanes and would say that her son was returning home. The above behaviors persisted for the next 35 years. Her self-care, sleep and appetite were unchanged. Her daughter reported that during the current admission the patient had been looking for her son among the medical interns.

Patient was an emotionally restrained person who was not demonstrative about her affection for her children. There was a family history of suicide in her paternal uncle, sister and her son as described above and depression in her grandson.

On mental status examination, her higher mental functions were intact. When asked about her son she said she could not talk about him, but requested us to arrange for his return.

Diagnosis and management

Based on the history and examination, we considered differential diagnoses of delusional disorder and atypical bereavement. The family refused any psychiatric intervention for her. She passed away 2 months later. Her daughter subsequently presented to us with depression.

DISCUSSION

Patient posed a diagnostic difficulty because she did not clearly fit in any of the existing diagnostic categories. Her symptoms could be viewed as an atypical bereavement response, as delusional disorder or an overlap between the two. We first examine her diagnosis in the light of terminology used to describe atypical bereavement.

Atypical bereavement responses are described as “abnormal”[7] “complicated”[8] and “maladaptive.”[9] Jacobs used the term “pathological” grief and described five variants that included absent, delayed, prolonged, inhibited and distorted grief.[10] Lichtenthal, Lichtenthal et al. built a case for inclusion of “complicated grief” as a distinct diagnostic category.[4] Several studies showed that complicated grief was distinct from depression and anxiety.[111213] It was shown that complicated grief had risk factors including caregiver burden (not a predictive factor for Major Depressive Disorder),[14] a close and insecure attachment style (not a predictive factor for MDD)[15] and a lack of preparedness for death (not a predictive factor for Major Depressive Disorder or PTSD).[16] Pasternak et al. and Prigerson et al. also showed that complicated grief did not respond to treatment with nortriptyline or interpersonal therapy as opposed to MDD.[111718] Our patient does not fall in these categories, but has two risk factors for abnormal grief, namely, lack of preparedness for the death and death by suicide.

Recent studies concluded that PGD met the DSM criteria for a distinct mental disorder as it was a clinically significant form of psychological distress associated with disability.[6] The study proposed nine symptoms that included confusion about one's role in life, difficulty accepting the loss, avoidance of reminders of the loss, inability to trust others, bitterness or anger related to the loss, difficulty moving on with life, numbness, feeling that life is meaningless and feeling stunned or shocked by the loss. Our patient had difficulty accepting the death, avoidance of reminders of loss and emotional numbing.

Delusional disorder can be diagnosed if a patient has persistent non-bizarre delusions for a period of 1 month. This is a diagnostic possibility in our patient as she firmly believed that her son was alive.

Our patient illustrates that bereavement itself can be atypical or it can act as a stressor to precipitate another psychiatric disorder and that it is was not easy to differentiate the two.