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32.

GRIEF AND MOURNING


Stephen R. Shuchter, M.D., and Sidney Zisook, M.D
All psychiatrists encounter patients who have experienced the death of a loved one. Such losses often are quite traumatic and painful and can precipitate both psychological and medical sequelae which may require intervention. Appreciating the effects o f death on survivors can be a crucial element in assessing the putient.

1. What is grief?
Grief comprises the myriad psychological, physiologic, and behavioral responses which accompany the human awareness of an irrevocable loss, such as a pending or actual loss of a close friend or relative. It is an extraordinarily powerful emotion. Manifestations of Normal Grief Psychological Numbness or dissociation Sense of loss Anguish Yearning Anger Guilt Apathy Anxiety and fear Intrusive images Cognitive disorganization Distractibility Hallucinatory experiences Regression Physiologic Autonomic discharge: gastrointestinal, cardiovascular, respiratory, neuromuscular Insomnia Agitation Anorexia

2. What are the psychological aftereffects?


The psychological sequelae may include experiences of intense anguish and emotional pain accompanied by crying, feelings of loss, and yearning for the one who has died; feelings of anger or guilt; transient periods of numbness, shock, or disbelief, when the loss does not register emotionally; a sense of apathy or lack of direction; anxiety and fearfulness; intrusion of painful images and memories, especially if the nature or course of death was traumatic to the survivor; and cognitive disorganization. Behaviorally, survivors frequently search for evidence that their loved one is still alive. They may experience multiple sensory hallucinations of the deceased, most often in the form of sensing their presence but also including auditory, visual, haptic, and olfactory hallucinations. Many grieving persons attempt to isolate themselves from social contacts, which are too painful because of the memories they evoke. They may avoid discussing their loss or even confronting mundane experiences of life or possessions of the deceased which can trigger their anguish. The aggregation of these powerful emotional and cognitive forces often leads to a regression: an emotional state in which the grieving person feels overwhelmed, out of control, helpless, and child-like in heightened dependency.

3. What forms of physiologic responses are common? Physiologic responses occur frequently, often in reaction to reminders of the loss. They take the form of sudden autonomic discharge with acute symptoms reflecting the pangs of grief: chest pain
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(heartache), gastrointestinal distress (a knife in the belly), dyspnea, paresthesias, palpitations, dizziness, nausea, tremulousness, and others. Acutely grieving survivors may demonstrate hypercortisolism, sleep and appetite disturbances, and continuously heightened autonomic arousal.

4. Are all losses the same? No. Although the word grief generally is reserved for the feelings and behavior associated with death (e.g., bereavement), the same sort of reaction is seen after any loss considered important by the individual. Examples are stillbirth and miscamage, loss of a job, failing health, disability, amputation, loss of home, or divorce. Indeed, divorce, especially when dependent children are involved, can lead to some of the most tumultuous and persistent grief reactions. Sometimes a loss that seems trivial to the outside observer, such as the death of a pet or a favorite celebrity, or losing an object of sentimental value, is followed by a severe grief reaction because the loss has a disproportionate significance. The grief also can occur when the loss is intangible, such as after a stroke or cataract, when the loss is afunction of a part of the body. In each of these examples, the individual loses someone or something that is emotionally or physically part of themselves. The meaning of such losses, the intensity of the grief, and the way people ultimately cope with the changes in their lives vary from person to person.

5. What is mourning?
Mourning is an important aspect of the total grief reaction. It refers to a prescribed set of experiences-which may include a time-frame and a series of behaviors, rituals, and observances-that reflect a given cultures or religions views about the meanings of life and death and the role of the individual survivor within this context. Mourning customs may be strictly defined: the widow should wear black and avoid pleasantries for a year; the funeral and memorial services should contain certain elements; prayers for the dead are said on particular occasions. Some grief experiences, such as hallucinations, may be more acceptable or even desirable in certain cultures. In the United States, no standard traditions dictate the decisions and behavior of survivors. There are few tight-knit communities where widowed men and and women are scrutinized or monitored. Individuals religious beliefs may dictate some traditions, but for the most part, mourning has evolved toward a more individualized and relatively unstructured experience.

6. What is pathologic grief? Pathologic grief is a commonly used term with an elusive definition. It originally referred to those patients whose grief was absent or excessively intense or prolonged. It also referred to situations where grieving patients developed medical or psychiatric illnesses. Although clinicians will likely continue to encounter references to pathologic grief, it is not a useful concept. First, the spectrum of normative responses to loss is enormous. Some peoples grief is brief and limited in terms of their emotional responses and sequelae; others grieve profoundly for a long time. Furthermore, particularly following the death of a spouse or a child, survivors are likely to continue to manifest elements of grief intermittently throughout their lives. Responses at both ends of this continuum are normal and not pathologic. Second, some individuals are vulnerable to the development of medical and psychiatric illnesses in the context of grief. These illnesses also do not constitute pathologic grief, but idiosyncratic vulnerability (genetic and developmental), as expressed at a point of an enormous stressor.
7. How long does grief last? There is great variability in the course of grief. The most important determinant of the length and intensity of grief is the closeness of the relationship between the deceased and survivor: how central that person was to the survivors emotional life. In the closest of relationships, an acute period of grief may last from a few weeks to several months, and protracted grief may last for years. If you encounter such extended grief, or a persistent, intense grief a year or more after the death, consider the possibility of major depression.
8. Does grief end? The most common and clinically normal forms of protracted grief occur on an intermittent basis for several years, or forever. A person who has lost a child may experience elements of acute grief

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every time he or she hears the name of the child, on special occasions (birthdays, holidays, anniversaries), or when seeing the childs picture. Such grief, often referred to as anniversary reactions, usually is short-lived and dissipates in minutes. Similarly, when a clinician makes an inquiry into the emotions of any patients loss, it should be recognized that in such a regressively oriented exploration, elements of grief are likely to appear and are normal. It is a mistake to think that grief resolves in the sense that it disappears or goes away. In most people, grief is circumscribed and suppressed, only to re-emerge in response to familiar triggers.

9. What is the relationship between grief and depression?


Acute grief represents one of the most powerful paradigms for the stress-diathesis model of medical illness, including psychiatric illness (see figure). The death of a loved one is likely to be the most profound and intense stressor that most people will encounter. Studies repeatedly have demonstrated the association between grief and the development of numerous stress-related medical disorders, including heart disease, cancer, and the common cold. The bereaved are vulnerable, as well, to psychiatric syndromes, especially depression.

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Vulnerable Individual (genetic predisposition, past history, poor health, and inadequate social

Atherosclerotic cardiovascular disease

Depression, panic, post-traumatic stress disorder

n
Duodenal ulcer, ulcerative colitis Cancer

Marrow
Stress-diathesis model of medical illness

Historically, bereaved individuals, their families, and physicians have taken the position that grief is depressing and that mourning and melancholia are inseparable phenomena. No one is surprised when a survivor is depressed; it seems normal and natural. Consequently, the physician exhibits less zeal in treating a disorder that otherwise would be the object of aggressive therapy. At some time during the first year after the death of a spouse, 30-50% of widows and widowers meet the criteria for a major depressive episode. Recognizing the ubiquity of depressive symptoms in grief, the DSM-111 and DSM-111-R introduced the term Uncomplicated Bereavement to demarcate depressive syndromes occurring shortly after the death of a close friend or relative from a major depressive disorder. Because uncomplicated bereavement is not considered an illness, the ciinical ruleof-thumb has been benign neglect rather than active treatment. Such depressions often are persistent, however, and may be associated with substantial morbidity. Therefore, the DSM-IV changed the term uncomplicated bereavement to Bereuvemenf, suggesting that only mild depressive syndromes beginning and ending within 2 months of the death should be considered normal.

10. Can grief and depression be distinguished?


Although manifestations of acute grief frequently mimic or overlap those of depression, they can be differentiated by the intermittent and trigger-related quality of grief symptoms and the

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autonomous quality of depressive symptoms. Once depression has a life of its own, the intermittent periods of good functioning and relatively normal affects that punctuate the lives of the nondepressed grieving individual are less likely. Other differential points are: several symptoms of depression occur simultaneously most of the time, for at least 2 weeks; and relentless anhedonia is common in depression but less frequent in grief uncomplicated by major depression. The DSM-IV lists several additional factors that should alert the clinician that a major depression may be present. These include: (1) guilt unassociated with the death; (2) preoccupation with death independent of the specific death of the loved one; (3) morbid preoccupation with worthlessness; (4) marked psychomotor retardation; ( 5 ) prolonged and marked functional impairment; and (6) hallucinations not involving the deceased.
Differentiation of Mourning and Melancholy
NORMAL DEPRESSION OF BEREAVEMENT (DSM-IV) MAJOR DEPRESSIVE EPISODE (MDE)

Onset Duration Course

Within 2 months of death Less than 2 months Circumscribed episode: symptoms associated with triggers, then resolve Rarely include severe guilt, suicidal ideation, morbid worthlessness, psychomotor retardation, or psychosis Brief and mild to moderate Normal

Any time after death (or before death in response to prolonged dying) Weeks to years; typically at least 6-9 months History of chronic, intermittent, or recurrent symptoms; current symptoms autonomous (i.e., independent of trigger) All symptoms of MDE, often including atypical, melancholic, or psychotic features May be prolonged and marked Disordered

Symptoms

Impairment Self-DerceDtion

11. Are grief and depression intrinsically connected? Yes. Another complicating element in the relationship between grief and depression is that depression recruits grief that is, depressive states have a tendency to exacerbate prior experiences of grief. Patients with a major depression whose focus is on some relationship that ended, or on the death of someone important in their lives, are not uncommon. Such losses may have occurred years before. This presentation often leads a clinician to believe that the depressive episode is a manifestation of unresolved grief and to begin to focus treatment on the grief. Remembering that grief does not resolve but only subsides, the correct assessment will reveal that the grief is a manifestation of depression; it will subside once the depression is treated. In this scenario, depression begets grief, rather than the converse. 12. Should grieving patients be treated with psychopharmacologic agents? It depends. Grief itself is a normal response to loss. At times, people feel overwhelmed by the power of their emotions. They often try to dose themselves, by allowing exposure to stimuli that evokes anguish and then avoiding it when it becomes too much. People learn what is painful and what is not, which activities they can do safely and which are dangerous as triggers for their grief. For those who are experiencing this type of distress, there is no indication to medicate despite what may be a perceived need by the patient for relief. However, there are exceptions. 13. When should grieving patients be treated with psychopharmacologic agents? When grief-related symptoms of anxiety are expressed so continuously that they interfere with cognitive and other functions of living in a substantial way, consider the use of a benzodiazepine. This medication also is an option in patients who have a higher risk of development or exacerbation

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of a major depression or anxiety disorder. Usually, benzodiazepines are used as needed for relatively brief periods. When substantial sleep disorders develop, short-term intervention with pharmacology can be both humane and helpful. Agents include: ( 1 ) hypnotics, (2) short-acting anxiolytics, or ( 3 ) low doses of sedating antidepressants (e.g., trazodone, 50 mg). A persistent and continuous sleep disorder with features of early, middle, or late insomnia may indicate the onset of major depression, requiring closer monitoring and possible use of antidepressants in standard doses. Depression is under-diagnosed and often under-treated even when diagnosed. Historically, physicians have been reluctant to treat the depression of bereavement aggressively, feeling that treating such depression interferes with normal grief and natures restorative properties. However, depression is depression, regardless of the context in which it appears or the existential reasonableness of its presentation. Depression carries with it substantial morbidity, both medical and psychological. Treat major depression aggressively, even if it appears in the context of bereavement!

14. How can I counsel the bereaved to get past their loss or to put it behind them? You cannot, and you ought not try. The death of ones spouse or child or sibling is forever, and elements of the survivors grief also will last forever. Healthy people find many ways to cope with their losses and grief. One of the most human ways to deal with such loss is to mitigate against it by keeping the loved one alive. It is normal and healthy for survivors to maintain a relationship with the deceased. Survivors frequently have a sense that their loved one is with them, watching over them, protecting them. It is not uncommon for a widow to carry on conversations with her dead husband or to ask for his advice. These and similar phenomena occur in healthy people with intact reality-testing whose sensory perceptions are highly directed toward keeping their loved ones alive. As time goes by, the actual sense of their loved ones presence evolves into an emotional feeling of the persons place in their heart. Qualities of the deceased may become incorporated into the identity of the survivor. Cherished possessions and memories keep the deceased alive for those who have physically lost them. lmportant emotional ties do not disappear when our loved ones die, and clinicians must learn to appreciate these connections, respect them, and even foster communication about them. For survivors, life will go on, and more comfortably once they have established an emotionally viable way of sustaining their relationship with the deceased. Therefore, it is not helpful to convince a bereaved individual to let go or get on with life in a way that disregards the loved one. Instead, let such patients know you care. Listen when they feel like talking. Offer the perspective of someone who identifies with the painful and often protracted course of grief. Be ready to step in when, and if, a major depression or other medical or psychiatric complications develop.
15. What are the other common problems of the bereaved? Frequently, problems develop because of the reactions of others to grief. Friends and family may be unable to tolerate grief and may avoid the bereaved or, when with them, discourage them from expressing what they feel. Grieving persons may feel isolated, at times because of their reluctance to inflict their own suffering on others. In time, they will find closeness and comfort with others who have felt such pain and with whom they feel a common bond. For this reason, involvement in a bereavement support group usually is helpful. Of particular concern is the difficulty physicians and therapists can have in dealing with the bereaved, particularly those in the most acute throes of grief. Empathetic clinicians may find themselves experiencing much anguish and helplessness in the face of their patients suffering. At times this may feel intolerable, and clinicians may become inclined to push their patients away or to divert them from their grief. Other therapists may fear being swallowed up by the intense need of the grieving person. The intense regression of grief is, however, a time-limited phenomenon, and the clinicians emotional availability is central to his or her ability to help the bereaved. The healthy clinician emerges from the suffering, often stronger for the experience.

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BIBLIOGRAPHY
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