The experience of grief in the head-injured adult

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<ul><li><p>Pergamon Archives of Clinical Neuropsychology, Vol. 9, No. 4, pp. 323-336, 1994 </p><p>Copyright 0 1994 National Academy of Neuropsychology Printed in the USA. All rights reserved </p><p>0887.6177194 $6.00 + .CO </p><p>The Experience of Grief in the </p><p>Head-Injured Adult </p><p>Sandra Dee Haynes, PhD </p><p>Psychology Department Colorado State University Fori Collins, CO </p><p>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. </p><p>Much of the literature concerning loss and accompanying grief focuses on reac- tions 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 </p><p>Address correspondence to: Sandra D. Haynes, Department of Psychology, Colorado State University, Ft. Collins, CO 80523. </p><p>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. </p><p>323 </p></li><li><p>324 S. D. Haynes </p><p>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 </p><p>(page 76). Several authors have suggested that grief is a common response to certain </p><p>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)]; relation- ship losses [e.g., spousal divorce or legal separation (Crosby, Lybarger, &amp; Mason, 1986; Hassall &amp; Madar, 1980; Putney, 1981)); situational losses (e.g., loss of employment (Finley &amp; Lee, 1981; Archer &amp; 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)]. </p><p>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 &amp; Webb, 1983; OShanick, 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 &amp; Webb, 1983) and emotional changes, be they psychogenic or physiological in origin, such as fatigue, confusion irri- tability, depression, and decreased libido (Kumer &amp; Finley, 1986; Long &amp; Webb, 1983). Secondary to physical losses and personality changes, is the potential for loss of occupation (Fraser, Dikmen, McLean, &amp; Miller, 1988; Uzzell, Langfitt, &amp; Dolinskas, 1986; Wrightson &amp; Gronwall, 1981) and rela- tionships (Edna &amp; Cappelen, 1987; Kinsella, Ford, &amp; 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. </p><p>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, &amp; Van Schoor, 1989; Dann, 1984; Lezak, 1978; OShanick, 1986; Sachs, 1984; Tadir &amp; Stem, 1985). </p><p>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 sub- jective manifestation of grief is a disturbance in attention, memory, and prob- lem-solving abrlities, identification of grief in head-injured individuals could help to explain, in part, the cognitive impairment seen in these persons. </p></li><li><p>Grief &amp; Head Injury 32.5 </p><p>Helping head-injured patients work through grief may then serve the dual function of working through grief and correcting some cognitive problems. </p><p>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 expe- rienced 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 experi- ence 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. </p><p>METHOD </p><p>Subjects </p><p>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 sub- jects. 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. </p><p>The second experimental group consisted of individuals who had experi- enced the death of a loved one within the past year. The amount of time since </p></li><li><p>326 S. D. Haynes </p><p>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 Alzheimers 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. </p><p>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 dis- eases that may affect neurological functioning. No subjects within this group had a history of substance abuse. </p><p>Materials </p><p>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: </p><p>1. The Grief Experience Inventory (GEI) (Sanders, Mauger, &amp; 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. </p></li><li><p>Grief &amp; Head Injury 327 </p><p>2. Tests of attention a. Seashore Rhythm Test (from the Halstead-Reitan Neuropsychological </p><p>Test Battery). b. Speech Sounds Perception Test (from the Halstead-Reitan </p><p>Neuropsychological Test Battery). c. Digit Vigilance Test. </p><p>3. Tests of memory a. California Verbal Learning Test (CVLT). b. Rivet-mead Behavioral Memory Test (RBMT). </p><p>4. Tests of reasoning, logical analysis, and problem solving a. Trail making Test, Parts A and B (from the Halstead-Reitan </p><p>Neuropsychological Test Battery). b. Wisconsin Card Sorting Test (WCST). </p><p>Procedure </p><p>Subjects in the head-injury group were asked to provide relevant informa- tion 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 func- tioning, 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 &amp; 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 experi- enced a change in marital status (marriage, divorce, separation, or reconcilia- tion), 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 experi- enced a major change in the health of a family member. None had been fired </p></li><li><p>328 S. D. Haynes </p><p>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. </p><p>RESULTS </p><p>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. </p><p>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 compar- isons were made between only two groups, t-tests were utilized. Results are summarized in Table 1. </p><p>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...</p></li></ul>

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