Note: This was written for a class in complicated grief at Marian University.
I am not a professional therapist, counselor, or hospice worker. I would not be likely to encounter Sarah in a professional role. However, I do volunteer with the underprivileged and could encounter someone with similar symptoms in that role or possibly in my personal life. If I encountered someone with these symptoms through my volunteer work, I would escalate as appropriate. If I encountered someone with these symptoms in my personal life, I would gently suggest they seek help.
Observations
There are a number of things that stand out to me in this vignette:
· Although the vignette does not suggest that Sarah was abused as a child, it does indicate that she suffered from rejection as a child as it said that she felt like an outsider and that her father was highly critical of her right up until the day he died. Although childhood rejection does not generally meet DSM-5 Criteria for Post Traumatic Stress Disorder as rejection alone does not necessarily mean a person is afraid for their life, which is part of the DSM-5 criteria for PTSD (American Psychiatric Association, n.d.). However, Sarah may meet the criteria for Complex PTSD (CPSTD), which while not recognized by the DSM-5 is recognized by the World Health Organization’s International Classification of Diseases 11th Revision (ISM-11) (Leonard, 2022). CPTSD can be triggered by childhood rejection and one of its symptoms is not feeling good enough (Davis, 2022), which could manifest as self-loathing.
· It appears that she is suffering emotional pain in some form as she is irritable and angry and experiencing self-loathing. This pain represents psychache and could lead her to suicidal thoughts (Buqo, Ward-Ciesielski, & Krychiw, 2020, p. 255)
· In addition to the possibility of CPTSD, there is also the possibility that Sarah was suffering from PTSD as she was present at her father’s death. Although, people typically think of PTSD in terms of witnessing a violent death, witnessing the death of your father, even if not violent, could be considered to meeting the standard of witnessing a traumatic event as even a peaceful death could be considered traumatic if someone was not prepared for it.
· Sarah was coping until six months after her father’s death. It is possible that there was a triggering event, such as a birthday or anniversary (Mayo Clinic Staff, 2014), at that point that triggered her symptoms.
· Sarah has previously been diagnosed with Major Depressive Disorder (MDD) and is on medication for MDD. Although her medications were working up until three months ago, it is possible that her drugs stopped working because of the added stressor of her father’s death. Although pscyhatric medicines that work, typically continue to work, they do stop working in up to 33% of patients and a trigger can be new stressors (Paul Nestadt, n.d.).
· Sarah is 45 which could mean she is entering perimenopause or even menopause as 45 to 55 is when most people enter menopause (NIH: National Institute on Aging, 2021). Menopause can led to hormonal fluctuations which can lead to depression and sleep fluctuations (Payne, n.d.).
Information
Although I am not a professional, I believe the below information would help me to better understand Sarah and would help a professional better respond to this person:
· What happened at the six month point? As noted above, anniversaries can trigger grief and if there is an underlying disorder, such as complicated grief, MDD, or PTSD, it would make sense that an anniversary could trigger serious symptoms.
· Is Sarah in perimenopause or menopause? Knowing this information would help to determine whether or not her depressive symptoms could be related to hormonal fluctuations.
· When was the last time she had her MDD medications reviewed / adjusted? The vignette does not indicate if her medications were reviewed or adjusted recently. Knowing this information would help to develop a course of action.
· What specifically did her father say to her? There is a possibility that she has been ruminating on the last conversation with her father for the past six months. Knowing what he said to her would help a therapist/counselor be able to counter any negative messages.
· Is she feeling guilty for not living up to his expectations? Bereaved people who feel guilty for not doing enough for the deceased or who have unfinished business with the deceased often experience guilt (Li, Tendeiro, & Stroebe, 2019, p. 455). Grief is closely related to complicated grief and depression (Li, Tendeiro, & Stroebe, 2019).
· What else is going on in her life? Although the assumption is that her depression is related to her father’s death, there is the possibility that other things are going on in her life that has brought on these symptoms. Specifically, the viginette said that she “was happily married,” but there is no indication that she is still happily married. It is possible that other life events are singly or in combination with her father’s death responsible for her symptoms.
· Is she feeling suidal? Risk factors for suicide include life stressors such as a death in the family and a diagnosis of depression. Additionally, she is indicating key behavior changes that are indicators of suicidal ideation including withdrawal, sleeping too much, anger, irritability, and feeling as if they are a burden to others (American Foundation for Suicide Prevention, n.d.).
Signs and Symptoms
Sarah is exhibiting a number of symptoms that could be signs of uncomplicated grief, complicated grief, depression, and or trauma. The chart below shows which symptoms could be related to which. As you can see, since there is significant overlap, it is difficult to diagnose based solely on the information included in the viginette.
| Sadness | Hypersomnia | Irritability | Angry | Self-Loathing | Inability to function | |
| Grief1 | X | X | ||||
| CG2 | X | X | X | X | X | |
| Depression3 | X | X | X | X | X | X |
| PTSD4 | X | X | X | X | X | X |
| CPTSD 5 | X | X | X | X |
1. (John Hopkins Medicine, n.d.)
2. (Mayo Clinic, n.d.)
3. (Psychiatry.org, n.d.)
4. (American Psychiatric Association, n.d.)
5. (Leonard, 2022).
Concerns
I am concerned that Sarah may be suicidal as she meets two of the risk factors, a death in the family and a depression diagnosis. Additionally, she is exhibiting behaviors that are indicators of suicidality including withdrawal and sleeping too much. She is also experiencing emotional indicators of suicidality including anger, irritability, and self loathing.
References
American Foundation for Suicide Prevention. (n.d.). Risk factors, protective factors, and warning signs. Retrieved from American Foundation for Suicide Prevention: https://afsp.org/risk-factors-protective-factors-and-warning-signs
American Psychiatric Association. (n.d.). Post Traumatic Stress Disorder. Retrieved from American Psychiatric Association: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-PTSD.pdf
Buqo, T., Ward-Ciesielski, E. F., & Krychiw, J. K. (2020). Do Coping Strategies Differently Mediate the Relationship Between Emotional Closeness and Complicated Grief and Depression? Omega: Journal of Death and Dying, 1-13.
Davis, S. (2022, February 7). Rejection Trauma. Retrieved from CPTSD Foundation: https://cptsdfoundation.org/2022/02/07/rejection-trauma/
John Hopkins Medicine. (n.d.). Grief and Loss. Retrieved from John Hopkins Medicine: https://www.hopkinsmedicine.org/health/caregiving/grief-and-loss
Leonard, J. (2022, February 2). What is complex PTSD: Symptoms, treatment, and resources to help you cope. Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/322886
Li, J., Tendeiro, J. N., & Stroebe, M. (2019). Guilt in bereavement: Its relationship with complicated grief and depression. International Journal of Psychology, 454-461.
Mayo Clinic. (n.d.). Complicated Grief. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/complicated-grief/symptoms-causes/syc-20360374
Mayo Clinic Staff. (2014, November 14). Grief: Coping with reminders after a loss. Retrieved from Mayo Clinic: https://www.mayoclinic.org/healthy-lifestyle/end-of-life/in-depth/grief/art-20045340
NIH: National Institute on Aging. (2021, September 13). What Is Menopause? Retrieved from NIH: National Institute on Aging: https://www.nia.nih.gov/health/what-menopause#:~:text=Menopause%20is%20a%20point%20in,between%20ages%2045%20and%2055.
Paul Nestadt, M. (n.d.). Why Aren’t My Antidepressants Working? Retrieved from John Hopkins Medical: https://www.hopkinsmedicine.org/health/wellness-and-prevention/why-arent-my-antidepressants-working
Payne, J. (n.d.). Can Menopause Cause Depression? Retrieved from John Hopkins Medicine: https://www.hopkinsmedicine.org/health/wellness-and-prevention/can-menopause-cause-depression
Psychiatry.org. (n.d.). What is Depression. Retrieved from