W13: Death & Dying

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Questions and Answers

Which approach to coping emphasizes the importance of being flexible and oscillating between different strategies?

A combined approach to coping (correct)

Restoration-oriented coping only

Loss-oriented coping only

Single-focused coping strategy

What is one way that meaning is reconstructed in the process of coping with grief?

Total avoidance of reminders

Identity loss

Assimilation of new understandings (correct)

Evasion of emotions

What attachment style is characterized by high emotionality and an inability to cope constructively with grief?

Preoccupied attachment (correct)

Disorganized attachment

Secure attachment

Dismissive attachment

Which term describes the concept that suggests bonds with the deceased can transform from concrete to symbolic attachments?

Continuing Bonds Theory Signup and view all the answers

In the context of coping with grief, what does 'Growing Around Grief' imply?

Individuals expand their lives alongside their grief Signup and view all the answers

Which of the following best defines bereavement?

The state of having lost someone Signup and view all the answers

What age group accounts for approximately 65% of deaths in Australia?

Older adults over 75 Signup and view all the answers

At what age do children generally begin to understand that death is irreversible?

5 years Signup and view all the answers

Which cause of death ranks highest for men in Australia?

Coronary heart disease Signup and view all the answers

What typically describes the physiological process as death approaches?

Digestive and respiratory functions begin to shut down Signup and view all the answers

What type of fear regarding death is most prevalent during adolescence?

Fear of death as a singular event Signup and view all the answers

What is the main characteristic of brain death?

Complete irreversible loss of all brain function Signup and view all the answers

Which of the following factors influences mourning behaviors?

Cultural and public norms Signup and view all the answers

What is a common proximal defense mechanism against death anxiety?

Denying current personal vulnerabilities Signup and view all the answers

What is the primary goal of death anxiety treatment?

To achieve neutral death acceptance Signup and view all the answers

Which statement accurately reflects the critiques of the Kubler-Ross stages?

Pushing individuals to reach acceptance may not be helpful. Signup and view all the answers

What are distal defenses concerning death anxiety primarily focused on?

Affirming self-esteem and worldview defense Signup and view all the answers

Which coping style is NOT associated with coping at the end of life?

Increased tendency to ruminate Signup and view all the answers

What recent addition to the DSM-5 reflects changes in understanding grief?

Prolonged Grief Disorder Signup and view all the answers

Which of the following is a risk factor for prolonged grief?

Previous experience of childhood adversity Signup and view all the answers

Which element is associated with effective coping in terminal illness?

Warm relationship with the therapist Signup and view all the answers

What does the Dual Processing Model of bereavement emphasize?

Secondary life consequences due to loss Signup and view all the answers

Which of the following describes a common reaction during the grieving process?

Prolonged periods of emotional numbness and conflict Signup and view all the answers

Which practice is recommended to help manage death anxiety?

Engaging in CBT for associated mental health issues Signup and view all the answers

Which of the following is NOT a characteristic of grief as described?

Complete detachment from social networks Signup and view all the answers

Which behavior is commonly not considered adaptive coping in response to death anxiety?

Engaging in denial about health risks Signup and view all the answers

Study Notes

Terminology

Bereavement: The state of having lost someone.
Grief: A wide range of responses to loss.
Mourning: The behavioral expression of grief, influenced by cultural and public norms.

Age Distribution of Death

In 1907, 26% of deaths were children under the age of 4.
In 2020, only 0.7% of deaths were children under the age of 7.
Factors contributing to this shift include:
- Improved neonatal care
- Increased medical support for children
- Greater community awareness of risks
- Advancements in sanitation and hygiene
- Infant vaccinations

Age at Death in Australia

In 2022, most deaths (~65%) occurred among people over the age of 75.
The median age of death for men was ~80, while for women it was ~85.

Causes of Death in Australia

Men:
1. Coronary heart disease
2. Dementia
Women:
1. Dementia
2. Coronary heart disease

Causes of Death by Age

First year of life: Congenital issues, premature birth
Children: Accidents
Adolescents and young adults: Suicide

The Experience of Dying

Brain death or circulatory death: Signals "death."
Physiological processes:
- Digestive and respiratory functions begin to shut down.
- Circulation slows, leading to a significant drop in blood pressure.
- Breathing becomes shallow and sporadic; rattling sounds may occur.
- Agonal breathing (gasping, labored breathing caused by abnormal brainstem reflex) may occur.
- The dying individual may sleep more and talk less, but can still hear.
Brain death:
- Different from a vegetative state or coma (where the brainstem remains active).
- Can remain on life support to preserve organs.
- The active stage typically lasts ~3 days but can be shorter or longer.

Understanding Death

Infants and toddlers: Limited understanding of death.
Pre-schoolers: May believe death is temporary or reversible.
Around age 5: Begin to understand that death is irreversible.
7-9 years old: Understand that death only happens to living things, that all living things will die, and that all bodily functions will stop.
By 10 years old: Understand internal and external factors that can cause death.

Fear of Death

Can appear as young as age 3.
Increases between ages 5-10 as understanding of death develops.
By age 7 and through adolescence, fear of death is the most common fear.
Fear of death is lowest among older adults.
Cultural influence:
- Many cultures try to ignore and avoid mortality.
- It is not clear whether death anxiety is cultural or universal, as there is variability across cultures.
- Some cultures are more death-affirming (e.g., Day of the Dead in Mexico)
Terror Management Theory:
- Motivation to live + Inevitability of death = Existential terror
- Fear of death is managed by:
  - Belief in cultural worldviews
  - Gaining symbolic immortality
  - Subscribing to things that will outlive you (e.g., political views, historical impact)
  - Religious beliefs that promise a form of immortality
  - Self-esteem boosting practices
  - Close interpersonal relationships
Mortality Salience:
- Proximal Defenses:
  - Trying to push death out of mind
  - Denying vulnerability to death
  - Denying current risk of personal death
  - Distracting from death thoughts
  - Intention to engage in future healthy behaviors
- Distal Defenses (unconscious thoughts about death):
  - Worldview defense
  - Self-esteem bolstering
  - Affirming close relationships

Coping with Death Fears

Death fears can motivate:
- Materialism
- Health behaviors
- Self-esteem bolstering
- Adaptive coping (e.g., increased photography, art, legacy, family names)
Fear of death can be a transdiagnostic construct for a range of mental health problems (e.g., panic, OCD, separation anxiety, phobias, depression).
Correlations exist between death anxiety and the severity of mental disorders.
Death anxiety can be reduced with treatment, especially CBT.
Goal of treatment is neutral death acceptance.

Kubler-Ross Stages of Psychological Reaction to Dying

Introduced in 1969.
Cultural shift in the dialogue about death - more public.
Stages:
- Denial and isolation
- Anger
- Bargaining
- Depression
- Acceptance
Critique:
- Stages were never intended to be linear or universally applicable.
- Not everyone reaches acceptance.
- It is problematic to push someone through these stages.

End-of-Life Issues

70% of people desire to die at home, but only 14% do.
Psychological issues during end of life:
- Issues related to consent, advanced care planning, and palliative care.
- Developmental issues:
  - Meaning and impact of illness
  - Coping styles
  - Impact on sense of self and dependence on care
  - Relationship changes (those who need to become caregivers)
- Stressors:
  - Spiritual resources
  - Anger when young children are dying (sense of unfairness)
  - Regret in older age
  - Economic circumstances (ability to afford treatment)
- Physician-patient relationship:
Factors that assist with coping at end of life:
- Hospice/palliative care associated with better quality of life, less depression and anxiety compared to aggressive life-prolonging treatment.
- Factors associated with effective coping:
  - Good communication and trust between the patient, family, and clinical team.
  - Pain management.
  - Ability to share fears and concerns.
- Most terminally ill patients benefit from an approach that combines:
  - Emotional support
  - Flexibility
  - Appreciation of the patient's strengths
  - A warm and genuine relationship with the therapist
  - Elements of life-review and exploration of fears and concerns
- Little evidence supports the claim that psychological therapy is superior to other therapies at end of life.

Grief

Affective experience: Sadness, yearning, loneliness, anger, guilt, relief, anxiety, numbness.
Cognitive experience: Decline in short-term memory, decision-making, concentration. Increased rumination and confusion.
Physical symptoms: Sleep disturbances, appetite changes, fatigue, increased risk of illness, increased risk of mortality, impaired immune function, crying.
Spiritual: Renewal or loss of faith, loss of meaning.
Social: Detachment or conflict.
Death anxiety can exacerbate grief.
Most people recover from grief after a brief period of disruption (acute grief), returning to an emotional baseline (integrated grief) typically within 6-12 months post-loss.
Often considered the price we pay for love.
Not about saying goodbye; rather, it’s a change in the relationship (from physical presence to memory).
Problems during grief: Can arise from other people's reactions.

Patterns of Grief

Stable low grief symptoms: 26-45%
High (20%) or moderate (30%) grief immediately post-loss
Low initial grief that increases post-loss: 10%
Stable high levels of grief: 7-10%

Bereavement as a Disorder

In March 2022, the DSM-5-TR added Prolonged Grief Disorder (PGD).
Symptoms of PGD:
- Intense yearning or longing for the deceased, and/or preoccupation with thoughts or memories of the deceased present most days.
- Bereavement lasting over a year (for children, 6 months).
- Clinically significant distress or impairment in functioning.
- 3 or more symptoms:
  - Identity disruption
  - Marked sense of disbelief
  - Avoidance of reminders
  - Intense emotional pain
  - Difficulty with reintegration
  - Emotional numbness
  - Feeling that life is meaningless
  - Intense loneliness

Risk Factors for PGD

Older age
Female
Lower SES
History of depression, bipolar disorder, or childhood adversity
Early depression symptoms post-loss
Caregivers
Sudden or traumatic death circumstances
Maladaptive thoughts
Avoidance behaviors
Inability to manage painful emotions
Lack of social support

Treatment for PGD

No evidence that early intervention is preventative.
Treatment is not focused on saying goodbye to the deceased.
Incorporates elements from attachment theory.
CBT:
- Focus on loss-focused and restoration-oriented coping
- CBT for associated problems, including:
  - Sleep problems
  - Major depressive disorder (MDD)
  - PTSD
  - Anxiety
Bereavement groups: May help in acute stages, but there’s no evidence that they will help prolonged grief.
Pharmacotherapy: Unlikely to be effective.

Theories of Bereavement

Old: Kubler-Ross Stages
Current models:
- Dual Processing Model:
  - Proposes that when a loved one dies, it has many secondary consequences on life.
  - People will oscillate between loss-oriented coping and restoration-oriented coping.
  - The need for flexibility in coping, not focusing on only one aspect.
- Reconstruction of Meaning:
  - Death can disrupt life narratives and core beliefs about the world.
  - Coping with grief involves creating new meaning through:
    - Sense-making
    - Benefit-finding
    - Identity reconstruction
  - Meaning is reconstructed via:
    - Assimilation: Finding a new way to think about the loss that doesn’t challenge core beliefs
    - Accommodation: Thinking differently about the world
Attachment Theory (Bowlby)
- Secure: Might react emotionally to loss but not overwhelmed by grief.
- Dismissive: Less emotional reaction; suppress/avoid memories.
- Preoccupied: Chronic grief, high emotionality and expressiveness of grief, inability to talk or cope constructively.
- Disorganized: Difficulty talking coherently, poor adaptation.
Continuing Bonds (Klass, Silverman, and Nickelman)
- Challenges the belief that to successfully cope, you need to let go of the person.
- Moves bonds from a concrete attachment to a symbolic attachment.
- Mixed research outcomes on whether continuing bonds help adjustment.
- More recent recognition of individual differences in continuing vs. relinquishing bonds.
- For some people, continuing will be beneficial depending on:
  - Relationship quality
  - Attachment
  - Functioning during bereavement
Mental Representation Theory: - Ongoing internal connection to a deceased loved one. - Stored in explicit memory and can be retrieved for comfort or discomfort. - Explicit and implicit representations affect the extent and kind of bond to the deceased. - Adaptive coping involves both connection and disengagement. - Adaptation involves:
- Primary control: Environment-oriented coping
- Secondary control: Emotion-focused coping

- Individual differences in disposition.

Growing Around Grief (Tonkin)
- Grief doesn't always get smaller, but we get bigger around it.
- We become able to live alongside the grief.

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