the experience of grief in the head-injured adult

Pergamon Archives of Clinical Neuropsychology, Vol. 9, No. 4, pp. 323-336, 1994

Copyright 0 1994 National Academy of Neuropsychology Printed in the USA. All rights reserved

0887.6177194 $6.00 + .CO

The Experience of Grief in the

Head-Injured Adult

Sandra Dee Haynes, PhD

Psychology Department Colorado State University Fori Collins, CO

The current study attempted to assess the grief process in head-injured adults and to compare this with the grief process of individuals bereaved due to the death of a loved one. In aaiiition, because grief often produces difficulty with cognitive pmcess- es. it was hypothesized that bereaved individuals would demonstrate impaired per- formance on neumpsychological tests of memory, attention, and reasoning abiliry. Significant differences between head-injured and bereaved individuals were found on only one clinical scale of the Grief Experience Inventory largely supporting the idea that grief among these individuals is similar. While a trend suggestive of the second hypothesis was found on tests of cognition, the head-injured and bereaved subjects differed significantly on all such tests with the exception of the Wisconsin Card Sorting Test and specific subtests of the California Verbal Learning Test.

Much of the literature concerning loss and accompanying grief focuses on reactions to the death of a loved one. It has been suggested, if not thoroughly researched, however, that grief occurs in response to other losses as well. As Parkes (1988) stated almost any change can result in loss. At times, however, when a loss occurs, the ensuing response is not identified as grief (Parkes, 1988). Often this is because the response to change is not as intense or long in duration as a response to the death of a loved one could be. Basic patterns

Address correspondence to: Sandra D. Haynes, Department of Psychology, Colorado State University, Ft. Collins, CO 80523.

This paper is excerpted from a dissertation submitted to the Academic Faculty of Colorado State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy.

323

324 S. D. Haynes

and symptoms of grief, however, are present. As Bowlby (1980) stated, even when variations from the typical pattern of grief occur, the basic principles are still the same. Such reactions are simply “variations on a single theme”

(page 76). Several authors have suggested that grief is a common response to certain

losses. These losses include physical body losses [e.g., loss caused by illness (Speck, 1978; Sourkes, 1982) or loss, whether actual or functional, of a body part or internal organ (Bowen, 1981; Gyllenskold, 1984; Hendrick, 1981; Krieger, 1977; Lindemann, 1979; Parkes, 1975; Rodriquez, 1985)]; relationship losses [e.g., spousal divorce or legal separation (Crosby, Lybarger, & Mason, 1986; Hassall & Madar, 1980; Putney, 1981)); situational losses (e.g., loss of employment (Finley & Lee, 1981; Archer & Rhodes, 1987), relocation (Arredondo-Dowd, 1981; Fried, 1976; Lindemann, 1979) or victimization (Horowitz, 1985; Whiston, 1981); and developmental changes (e.g., loss that accompanies aging (Raphael, 1983)].

Head injury presents individuals with the potential for a variety of such losses, the most obvious being the chance for physical loss of function, paraly- sis or paresis (Long & Webb, 1983; O’Shanick, 1986). Commonly suffered by the head injured and perhaps most personally devastating, are personality changes resulting from cognitive impairments. Such changes may include cognitive changes, such as memory and attention deficits and decreased speed of information processing (Long & Webb, 1983) and emotional changes, be they psychogenic or physiological in origin, such as fatigue, confusion irri- tability, depression, and decreased libido (Kumer & Finley, 1986; Long & Webb, 1983). Secondary to physical losses and personality changes, is the potential for loss of occupation (Fraser, Dikmen, McLean, & Miller, 1988; Uzzell, Langfitt, & Dolinskas, 1986; Wrightson & Gronwall, 1981) and relationships (Edna & Cappelen, 1987; Kinsella, Ford, & Moran, 1989). Head- injured individuals, in effect, stand to lose life as it was known to them. When head-injured individuals experience loss, it would be expected that they would also experience grief.

Few authors, however, have noted the possibility of grief following head injury and none have empirically investigated the hypothesis. Some authors have mentioned that grief can follow head injury but do not base their asser- tion on solid empirical evidence (Alexy, 1983; Bennett, 1989; Bornstein, Miller, & Van Schoor, 1989; Dann, 1984; Lezak, 1978; O’Shanick, 1986; Sachs, 1984; Tadir & Stem, 1985).

Identification and empirical examination of grief in head-injured persons has important implications. First, clarification of the origin of the emotional effects of head injury may result from such study thus leading to the inclusion of grief therapy with the head-injured individual. Also, since a common subjective manifestation of grief is a disturbance in attention, memory, and problem-solving abrlities, identification of grief in head-injured individuals could help to explain, in part, the cognitive impairment seen in these persons.

Grief & Head Injury 32.5

Helping head-injured patients work through grief may then serve the dual function of working through grief and correcting some cognitive problems.

The purpose of the current study was, therefore, threefold. The study was designed to determine if the experience of grief can be empirically measured in persons with head injury. How this process is similar to the grief process experienced by persons bereaved due to death and how grief affects recovery from head injury specifically in the area of cognitive functioning was also addressed. It was hypothesized that, given the potential for a variety of losses with head injury, persons with head injuries undergo a grief process and that this experience would be empirically measurable. It was further hypothesized that there would be no significant differences between the grief responses of those bereaved due to death and head-injured individuals as measured by the Grief Experience Inventory. In addition, it was hypothesized that the grief process would have an affect on cognition, specifically decreasing attention, memory, and reasoning ability. It was proposed that cognitive deficits would be greater for the head-injured group than the bereaved and control groups but that such deficits would be greater for the bereaved group than for the control group.

METHOD

Subjects

Subjects were selected to serve in one of three groups, a head-injured group, a bereaved group, and a control group. Each group contained 26 subjects. The head-injured group consisted of individuals who had suffered a mild to moderate closed head injury within the past year. Severity ratings were based on report from their primary care physician. Time since injury ranged from 1 month to 1 year with a mean of 6 months. The majority of subjects (20) had sustained their head injury as a result of a motor vehicle accident (MVA). Four subjects were injured in falls from heights and two were assault victims. Severity ratings were evenly divided among subjects with 13 classi- fled as mild injuries and 13 classified as moderate injuries. No participants suffered from anosagnosia (organic denial of symptoms) nor from physical impairments that could have interfered with their ability to complete the required psychometric tests. In addition, no subjects within this group had a history of substance abuse nor were they under the influence of drugs or alco- hol at tbe time of injury. Five subjects in this group, however, were currently taking analgesics or antiseizure medications on a regular basis. No subjects had sustained previous head injuries or had a history of prior neurological impairments. None had experienced the loss of a loved one within the past 3 years. No subjects were involved in litigation.

The second experimental group consisted of individuals who had experienced the death of a loved one within the past year. The amount of time since

326 S. D. Haynes

the occurrence of the death ranged from 1 to 11 months with a mean of 5 months. Cause of death was highly varied. Three deaths resulted from MVAs, six from heart attacks, four each from suicide, cancer, and diseases other than cancer, and one each from accidental overdose, stroke, complications from Alzheimer’s disease, sports-related accident, and natural causes. Relationship to the deceased was also varied. Three subjects experienced the death of a child, seven the death of a parent, three the death of a sibling, two the death of their spouse, six the death of a close friend, three the death of a grandparent, and one each the death of an aunt and a niece.

The third group of subjects were selected to serve as a control group for the other two groups and consisted of volunteers who had not suffered the loss of a loved one within the past 3 years had no history of injuries, disorders, or diseases that may affect neurological functioning. No subjects within this group had a history of substance abuse.

Materials

A variety of psychometric tests were selected to measure grief, attention and memory processes, and reasoning ability. In this regard, all subjects were administered the following tests:

1. The Grief Experience Inventory (GEI) (Sanders, Mauger, & Strong, 1985). The test consists of three validity scales and nine clinical scales. Three forms of the test were utilized. Persons serving as subjects in the bereaved group received the initial form of the test designed to assess grief in persons bereaved because of the death of a loved one. The control group received Form B of the test, a version designed to assess grief in persons experiencing losses other than death. Because all references to a specific death were removed from Form B, the test is abbreviated, containing 104 rather than 135 questions and 9 rather than 12 scales. Form B contains all three of the validity scales but only six of the clinical scales. The three missing scales were designed to assess guilt, rumination, and depersonalization. It was believed, however, that these states would be important dimensions in the grief of head-injured individuals. Thus, in an attempt to measure these states in persons with head injury, the 31 questions missing from Form B were revised with permission from the tests’ distributor to relate to head injury rather than death and reinserted into a third form of the test. A similar revision reinstating the guilt scale was made by Zinner, Ball, Stutts, and Mikulka (1991) in their study on the grief response of mothers of head-injured adolescents and young adults. These authors entitled their revision Form I to reflect the modifications geared toward injury. The revision used in the current study will be referred to as Form Ib and was used to measure grief in head-injured subjects.

Grief & Head Injury 327

2. Tests of attention a. Seashore Rhythm Test (from the Halstead-Reitan Neuropsychological

Test Battery). b. Speech Sounds Perception Test (from the Halstead-Reitan

Neuropsychological Test Battery). c. Digit Vigilance Test.

3. Tests of memory a. California Verbal Learning Test (CVLT). b. Rivet-mead Behavioral Memory Test (RBMT).

4. Tests of reasoning, logical analysis, and problem solving a. Trail making Test, Parts A and B (from the Halstead-Reitan

Neuropsychological Test Battery). b. Wisconsin Card Sorting Test (WCST).

Procedure

Subjects in the head-injury group were asked to provide relevant information about their head injury including cause of injury, results of neurological tests and/or neuropsychological tests, and time since injury. The head-injured and bereaved subjects were asked about their subjective impression of changes that had occurred since the injury or death. In an attempt to quantify subjects’ perceptions of changes experienced with regard to cognitive functioning, all subjects were asked to rate their current level of attention, memory, and reasoning ability on a likert-type scale. The five anchors on the scale were as follows: No problem, mild problem, moderate problem, severe problem, and very severe problem. All subjects were asked to provide information per- taining to their gender, age, education, marital status, histories of substance abuse or neurological disorders, and major changes in their lives over the past year. Given that stress is a correlate of grief, it was of particular interest to note changes shown to cause significant stress. Thus, subjects were asked if they had experienced any of the top 12 events leading to stress as assessed by the Social Readjustment Rating Scale (Holmes & Rahe, 1967) within certain time frames. Subjects in the head-injured and control groups were disqualified from participation if they had experienced the death of a close family member or friend within the past 3 years. All subjects were asked if they had experienced a change in marital status (marriage, divorce, separation, or reconciliation), jail term, severe personal illness or injury (other than the head-injury qualifying them to participate in the current study), major change in occupation (retirement or firing), major change in the health of a close family member, or pregnancy within the last year. No subjects reported experiencing divorce, marital separation, or marital reconciliation. Likewise, no subjects had served a jail term, sustained a severe personal injury or illness nor experienced a major change in the health of a family member. None had been fired

328 S. D. Haynes

from a job or retired. Three subjects, two control subjects and one bereaved subject, had been married in the past year. Two subjects, one control and one head-injured subject, had been pregnant within the past year. Both pregnancies were carried to term and were relatively uneventful.

RESULTS

Between group differences on scores of each test and the subjects ratings of their cognitive difficulties were analyzed via analysis of variance (ANOVA). Fishers’ test of least significant difference (LSD) was utilized in conjunction with ANOVA to make pairwise comparisons of groups. As noted, the GE1 and GE1 Form Ib are divided into 12 subscales. Graphic representation of group mean raw scores are presented in Figure 1 on a GE1 profile sheet.

Between group differences were assessed via a series of ANOVAs for each scale except for comparisons between the head-injured and bereaved groups on the guilt, rumination, and depersonalization scales. Because these comparisons were made between only two groups, t-test’s were utilized. Results are summarized in Table 1.

Examination of Table 1 reveals that significant differences were found among groups on each scale of the various forms of the GE1 with the exception of Guilt and Rumination. These two scales are found only on the original form of the GE1 and Form Ib. On the third scale, depersonalization, found only on the original GE1 and Form Ib, a significant difference was noted between groups with mean scores in the bereaved group higher than the head-injured group.

Pairwise comparisons indicated significant differences between groups in the following patterns. On the denial scale, there was a significant difference between the head-injured and the bereaved groups, with head-injured subjects demonstrating more denial than bereaved subjects. Significant differences were not found between either experimental group and the control group. On the atypical response and the loss of control scales, significant differences were noted between the two experimental groups, and between each experimental group and the control group. Again, head-injured subjects were more likely to select atypical responses than were bereaved subjects. Opposite results were found on the loss of control scale. Mean raw scores for subjects in both experimental groups were significantly higher than for control subjects on both of these scales. For the remaining scales, no significant differences were obtained between the two experimental groups yet significant differences were noted between the experimental groups and the control group.

The differences among groups concerning subjective ratings of severity of cognitive difficulties were examined. Results are reported in Table 2.

Significant differences were noted among groups on all four of the subjective severity ratings. Pairwise comparisons revealed significant differences between head-injured and bereaved subjects ratings of their problems with


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20_ : ; :

: : : : : j : : : : : : : : :

-.: : : : : : : : : j : : f : : j : : :

: : : : : :

Den AR SD Des AH Gu SI LC RU DR Som DA

Mean B 1.54 6.42 4.23 6.34 5.73 1.73 2.92 6.61 5.73 5.80 1.27 6.65

Raw HI 2.96 6.96 4.04 6.73 5.81 1.62 3.62 5.35 5.46 3.90 7.65 5.77

scores c 2.42 4.12 3.12 1.56 1.96 1.50 2.31 2.46 3.96

B

FIGURE 1. Comparison of mean scores among groups on the various forms of the GEI.

attention, disorganized thoughts, and memory with head-injured subjects rating these cognitive difficulties as more severe than bereaved subjects. In addition, significant differences were found between experimental groups and the control group. Significant differences were not found between the two experimental groups with regard to planning ability but were noted between the experimental groups and the control group.

ANOVA and LSD tests were applied to the tests of cognition as well. Impairment ratings were utilized for comparisons between groups on tests of attention, reasoning ability, and the RRMT. Selected raw scores were utilized for between-group comparisons on the CVLT. Results from tests of cognition are summarized in Table 3.

Significant differences were noted between groups on all measures of cognition with the exception of the following four measures from the CVLT: List

330 S. D. Haynes

TABLE 1 Observed F Values and Probabilities for the Individual

Scales on tbe Three Forms of the GE1

Scale F P

Denial (Den) 3.79 Atypical Responses (AR) 23.01 Social Desirability (SD) 4.74 Despair (Des) 37.53 Anger/Hostility (AH) 27.88 Guilt (Gu) .lO Social Isolation (SI) 9.13 Loss of Control (LC) 51.00 Rumination (Ru) .15 Depersonalization (DR) 11.67 Somatization (Sam) 22.97 Death Anxiety (DA) 10.13

*Indicates significance at the .05 level. **Indicates significance at the .Ol level.

.03*

.01**

.01**

.01**

.01**

.76

.01**

.01**

.70

.01**

.01**

.01**

A trial 1, List A trial 5, List B, and False Positives on the recognition test. Pairwise comparisons indicated that significant differences were obtained between the head-injured and both the bereaved and control groups on all measures of attention, Trails B, RBMT, and CVLT list A total trials, list A long delay cued recall, and recognition hits. Significant differences were not noted on these measures between the control and bereaved groups. On the Wisconsin Card Sorting Test, significant differences were obtained between the head-injured and control group and the bereaved and control group. On the CVLT, list A trial 1, list A trial 5, list A short delay free recall, list A short delay cued recall, and list A long delay free recall, significant differences were found between the head-injured and control group but not between any other groups.

The normative data for the adult version of the CVLT are based on a sample of individuals with a lower age limit of 17. Because one subject in the current sample was 16 years of age, a series of ANOVAs were performed on the CVLT data with her data and without her data to ascertain that this violation of norms

TABLE 2 Observed F Values and Probabilities for Subjects

Subjective Ratings of Cognitive Diffkulties

Symptom

Inattentive/Less Alert Disorganized Thoughts Memory Problems Poor Planning

F P

12.44 .01* 15.58 .01* 20.46 .01*

4.98 .01*

*Indicates significance at the .05 level.


TABLE 3 Observed F Values and Probabiities for tbe Tests of Cognition

Test F P

Attention measures: Speech Sounds Perception Test Seashore Rhythm Test Digit Vigilance Test

Reasoning measures: Trails B Wisconsin Card Sorting Test

Memory measures: Rivermead Behavioral Memory Test California Verbal Learning Test: List A total trials List A trial 1 List A trial 5 List B List A short delay free recall List A short delay cued recall List A long delay free recall List A long delay cued recall Recognition hits False positives

11.31 .01** 6.74 .01** 7.24 .01**

8.13 .01** 3.99 .05*

10.20 .01**

6.43 .01** 2.64 .08 2.65 .08 1.33 .27 4.33 .02* 5.17 .01** 4.33 .02* 5.23 .01** 5.98 .01** 2.18 .12

*Indicates significance at the .05 level. **Indicates significance at the .Ol level.

had not skewed the data. No appreciable differences were noted when compar- ing CVLT results with and without the data collected on the 16-year-old subject.

Two further analyses were conducted in an attempt to discover whether or not inclusion of individuals with a history of substance abuse and subjects who were currently taking medications had skewed the results of tests of cognition. As with data collected from the 16-year-old subject, comparisons of data analysis including and excluding subjects with a history of substance abuse and those currently taking medications revealed no appreciable differences.

DISCUSSION

Between Group Differences on Scales of the GEI

On each clinical scale common to all forms of the GEI, both bereaved and head-injured subjects scored significantly higher than the control subjects indicating a more severe grief response in the experimental groups. Differences in grief patterns were noted between the bereaved and head- injured group on only four scales of the GEI. Of these four scales, only two were clinical scales (loss of control and depersonalization). Thus, the

332 S. D. Haynes

hypothesis that grief could be measured with the GE1 in head-injured individuals and that there would be no differences between grief of bereaved and

grief of head-injured individuals was largely supported. Such results support clinical observations made by authors such as Alexy (1983), Bennett (1989), Lezak (1978) O’Shanick (1986) and Tadir and Stem (1985). Still some differences between the grief of head-injured individuals and persons bereaved due to death were noted.

One main difference between the grief of bereaved and that of head-injured individuals was noted on the loss of control and depersonalization scales. Scores on the loss of control scale indicates a person’s inability to control overt emotions, especially crying. Higher scores indicate greater loss of inhi- bition in this realm (Sanders et al., 1985). The result indicating that head- injured subjects scores were lower on average than the bereaved subjects is of interest in that head-injured individuals often exhibit such loss of emotional control and, thus, it was not expected that this difference would exist. Still, it must be kept in mind that the head-injured group scored significantly higher than the control group on this scale indicating that head-injured individuals are more prone to this type of behavior than would be expected in persons who were not grieving. In addition, given that crying is often seen as socially unde- sirable or as a sign of weakness, subjects in the head-injured group may have opted not to endorse items that revealed this behavior (Sanders et al, 1985). Perhaps higher scores in the bereaved group could be explained by looking at gender differences. There were many more females in the bereaved group than in the head-injured group. Given social norms, it would be expected that females would be more willing to endorse items indicative of displaying emotions. Further investigation on gender differences as related to the grief experience of head-injured persons may be useful in understanding this result.

Scores on the depersonalization scale indicate level of numbness, shock, and confusion. Endorsing items consistent with the theme of the scale indicates that one may be experiencing feelings similar to that of a dissociative state [e.g., “I have feelings that I am watching myself go through the motions of living” (true)]. Significantly higher mean scores were found in the bereaved group than in the head-injured group. Unfortunately, since this scale is not part of form B, a comparison could not be made between the experimental groups and the control group. Sanders et al. (1985) state that higher scores on this scale suggest a deeper more intense form of bereavement. The current result suggests that items on this scale represent behaviors or states that may be unique to individuals bereaved due to death. Exclusion of this scale by the original authors (Sanders et al., 1985) on form B supports this conclusion. Analysis of the grief response over varying time periods since the death or injury may also lend credence to this interpretation. With bereavement due to the death of a loved one, the most intense grief reactions are typically seen within the first 6 months following the death (Schneider, 1980). As mentioned, the mean time since death for subjects in the bereaved group was 5


months suggesting that these individuals could still be experiencing intense grief. In the head-injured group, mean time since injury was 6 months.

Unfortunately, the affects of time since injury on grief in head-injured individuals has not been previously assessed. In their study concerning the grief of mothers of head-injured adolescents and young adults, Zinner et al. (1991) however, found no significant differences in intensity of grieving as related to time since injury. This suggests, that as with grief associated with a child with birth defects, grief is a continuous process. Again, differences in intensity of grief as related to time since death or injury may be a key difference between head-injured individuals and individuals bereaved due to the death of a loved one. For example, head-injured individuals may not experience grief until weeks or months after the injury when they become aware of their losses. This is unlike persons bereaved due to death who experience acute grief immedi- ately after the death.

Measures of Cognition

When asked to subjectively rate problems with attention, memory, and dis- organization of thoughts, head-injured subjects tended to rate their difficulties as more severe than bereaved individuals did. Bereaved individuals, however, did note difficulties in these areas, and their ratings were significantly higher than those of control subjects. No differences were found between subjective ratings of planning ability in the head-injured and bereaved groups. Mean ratings from both of these groups, however, were significantly different than those of controls. These results were in line with the hypothesis that head- injured individuals would demonstrate more cognitive impairment than bereaved and control subjects, and that bereaved individuals would demonstrate more cognitive impairment than control subjects. These results were not, however, supported by results obtained on the objective tests of cognition.

On all tests of attention, no differences were found between bereaved and control subjects. Likewise, no differences were found between these two groups on Trails B, the RBMT, and the CVLT list A total trials, list A long delay cued recall, recognition hits, and false positives. Significant differences were obtained, however, between the head-injured group and the bereaved and control groups indicating that head-injured individuals showed greater degrees of impairment on these measures than either of the two other groups.

Initial analysis on the remaining measures of the CVLT revealed significant differences between only the head-injured and control groups. Means from the bereaved group on all these measures were between the head- injured and control groups.

Thus, while not significant, a trend suggestive of the hypothesis that a hierar- chical pattern, with head-injured individuals showing more cognitive impairment than bereaved individuals who would show more cognitive impairment than controls, at least with regard to verbal memory, was observed. Such a trend

334 S. D. Haynes

is supported with the results of several studies demonstrating that impairments on neuropsychological tests, particularly in verbal memory, can be caused by emotional states, especially depression (Richards & Ruff, 1989; Roy-Byrne, Weingartner, Bierer, Thompson, & Post, 1986; Sweet, 1992; Sweet, Newman, & Bell, 1992; Wolfe, Granholm, Butters, Saunders, & Janowsky, 1987).

Given the lack of statistical significance found in the current study, it is impossible to ascertain whether or not grief truly affects verbal memory. A suggested course of study would be to correlate degree of impairment in bereaved individuals with time since death or injury. Since grief intensity lessens over time, it would be suspected that, if verbal memory impairments are related to grief, these deficits would also decrease. This suggestion is in line with the work of Sweet (1992) who found that cognitive impairments in depressed patients improved as their depression lifted.

On the WCST significant differences were obtained between the two experimental groups and the control group but not between the bereaved and head-injured groups. This result is the most suggestive of the hypothesis that bereaved individuals experience difficulty with cognition. Although designed as a test of flexibility of thought, the WCST requires a great deal of attention and concentration, the use of short-term memory, and hypothesis testing or problem solving. This finding is again supported with the results of studies designed to measure cognitive impairment in depressed individuals (Abrams & Taylor, 1987; Cassens, Wolfe, & Zola, 1990; Fisher, Sweet, & Pfaelzer- Smith, 1986).

Limitations of the Current Study

Limitations of the current study are not unlike several studies concerning grief. One such limitation lies in the fact that subjects from different ethnic groups were not utilized. All subjects in the current study were Caucasian. Thus, results can not be generalized to persons of other ethnic backgrounds.

In addition, all subjects were volunteers. As noted by Stroebe, Stroebe, and Domittner (1988), individuals who choose to participate in grief studies may differ from those who choose not to participate. Again, this would minimize the ability to generalize the findings of this study to the general population. Although attempts were made to equate groups and balance demogragphic differences by utilizing a control group, there were differences between the three groups that may have impacted ratings on the GE1 (e.g., age and gender). In addition, within the bereaved group, the relationship to the deceased as well as the cause of death was highly varied. This may have contributed to within group differences that impact on responses to the GEI. These limitations must be kept in mind when interpreting the results of this study.

Acknowled~men? - The author thanks Thomas L. Bennett for his assistance in obtaining sub-

jects for this project and for his guidance.


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