Grief and bereavement
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Grief and bereavement Author Susan D Block, MD
Section Editors Peter P Roy-Byrne, MD Kenneth E Schmader, MD
Deputy Editor David Solomon, MD
Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Nov 19, 2012. INTRODUCTION — Over 2,500,000 deaths occur annually in the United States and between 5 and 9 percent of the population sustains the loss of a close family member each year [1,2]. Loss of a close relationship often causes profound suffering and can have important effects on health status. The vast majority of bereaved individuals (80 to 90 percent) cope with their losses without requiring professional intervention [3]. However, bereavement can have serious and long-term adverse health effects, and patients often consult clinicians for help in managing distress associated with bereavement. By understanding both normal and dysfunctional grieving processes the clinician can appropriately reassure individuals with normal grief responses and intervene to help those experiencing dysfunctional reactions to loss. NORMAL BEREAVEMENT — Death is the most powerful stressor in everyday life, causing both somatic and emotional distress in virtually everyone closely tied with the person who has died [4]. The effects may be intense and long lasting. Our culture uses three discrete terms to talk about the loss of a close relationship: Bereavement is the reaction to the loss of a close relationship. Grief is the emotional response caused by a loss including pain, distress, and physical and emotional suffering. Mourning refers to the psychological process through which the bereaved person undoes his or her bonds to the deceased. Anticipatory grief — Grieving is thought to begin when an individual is forewarned of an impending death. Anticipatory grieving may take the form of sadness, anxiety, attempts to reconcile unresolved relationship issues, and efforts to reconstitute or strengthen family bonds. Caretaking behavior may be a form of anticipatory grieving, as the caretaker expresses affection, respect, and attachment through the physical acts of providing care. Anticipation and an opportunity to prepare psychologically for death is thought to ease the adaptation of the grieving individual after death. Normal grief reaction — Immediately following death, whether or not it has been anticipated, survivors often experience feelings of numbness, shock, and disbelief. They "go through the motions," taking care of funeral arrangements, greeting relatives and friends, and tending to financial matters. However, the reality of the death has not been fully comprehended. Shock and numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness commonly arise in the weeks after the death. "Searching behaviors," including visual and auditory hallucinations of the deceased person, are common and may lead the bereaved person to fear that he or she is "going crazy." Despair and sadness are common as it becomes clear that the deceased will not return. Sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic complaints (especially those similar to the symptoms of the deceased) are common [5].
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Grief and bereavement
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The survivor often replays and remembers the relationship with the deceased, particularly the events of the terminal illness and death, and commonly ruminates over regrets and missed opportunities. Anger at the person for dying, at God, and at professional caregivers may occur. The individual may withdraw from family and friends. Being with others and being alone are both difficult. Grief comes in waves that are often precipitated by reminders of the deceased; the bereaved may feel fine one moment, and be overcome with sadness and grief the next moment. Feelings of pleasure are often experienced as a betrayal of the relationship with the person who has died. Normal grief resolution — Distressing feelings gradually diminish in intensity for most bereaved persons, usually over months; the grieving individual slowly comes to accept the reality of the loss, reestablishing mental and physical balance. Similar to stages of grief in dying described by Kubler Ross [6], resolution of grief, to some degree, occurs in stages [7]. In the early phases after a loss, the intensity and symptomatology of grief can overlap with signs and symptoms of complicated grief (see 'Complicated or prolonged grief' below). These signs and symptoms, and their intensity, subside slowly over time for patients experiencing normal grief. Usually, these impairments are beginning to resolve by six months [3,7]. As the loss becomes more fully accepted the bereaved begins reorganizing his or her life and reinvesting in living. The bereaved person slowly becomes able to remember the deceased without being overwhelmed by grief, can work productively, can sustain a sense of self-esteem and purpose, and can carry on with pleasure and enjoyment. Anniversaries and important events continue to precipitate waves of sadness; the amplitude of these waves diminishes over time, although the grief may never go away entirely. There is considerable range in the duration and intensity of the bereavement process. Some variables that may have an impact are: Age of deceased — The death of an elderly person after a full life will have a different impact than the death of a child or a young adult. Pregnancy and newborns — Miscarriage or death of a newborn are often not recognized as major losses but can precipitate prolonged grief. Suicide — Bereavement due to suicide or other socially disapproved deaths may lead to more isolation and to increased vulnerability to suicide among some survivors [8]. ABNORMAL BEREAVEMENT — The primary care clinician is in an excellent position to prevent both physical and psychological morbidity associated with bereavement, and to help the bereaved individual adapt to his or her loss. Despite experiencing worse health, persons with abnormal bereavement are less likely to use health services. Thus, outreach efforts are particularly important in identifying individuals at risk and preventing the adverse effects of abnormal bereavement. Risk factors for poor bereavement outcomes — A number of risk factors for the development of poor bereavement outcomes have been identified, including the following: Poor social supports Past history of psychiatric problems, especially depression Past history of childhood separation anxiety High initial distress Unanticipated death, lack of preparation for death Other major concurrent stresses and losses History of abuse or neglect in childhood Lifestyle rigidity (aversiveness to lifestyle change) Highly dependent relationship with the deceased Death of a child Psychological sequelae of abnormal bereavement — Depression, suicide, anxiety, and complicated grief are the most common adverse psychological sequelae of loss. Rates of depression during the first year after the loss of a spouse, 15 to 35 percent, are four to nine times higher than the rate in the general population [9]. Suicide
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rates after loss of a spouse are elevated, particularly in older men and in the first year [2,10]. Complicated or prolonged grief — Complicated/prolonged grief is a syndrome with characteristic symptoms and risk factors, a predictable course, and outcomes. Complicated/prolonged grief represents a disturbance of attachment associated with an unstable sense of self and insecurity [11,12]. Complicated/prolonged grief is defined as the persistence, for at least six months, of a constellation of disruptive emotional reactions including yearning and four of the following eight symptoms: Difficulty moving on Numbness/detachment Bitterness Feelings that life is empty without the deceased Trouble accepting the death A sense that the future holds no meaning without the deceased Being on edge or agitated Difficulty trusting others since the loss Other indicators of complicated grief include social withdrawal and difficulty reengaging with life. Symptoms of complicated/prolonged grief at six months post-loss are highly predictive of impairment and complications at 13 and 24 months post-loss [13,14]. Bereavement related depression — While many patients with complicated/prolonged grief also meet diagnostic criteria for major depression and/or generalized anxiety disorder [15], only a small minority (
