16 - Bereavement Reactions and Grief
Editors: Shader, Richard I.
Title: Manual of Psychiatric Therapeutics, 3rd Edition
Copyright 2003 Lippincott Williams & Wilkins
> Table of Contents > 16 - Bereavement Reactions and Grief
16
Bereavement Reactions and Grief
Richard I. Shader
Wayne A. Ury
Death is inevitable, and losses are a part of life; so, too, are grief and bereavement. Family members and others touched by a loss may need to go through these processes to move on with their lives. Bereavement and grief are central to letting go. In providing bereavement care, a key clinical issue is distinguishing what is normal and painful from that which is dysfunctional or illness, yet realizing that both require care, social support, and someone who will listen. Physicians, nurses, social workers, and other health care providers regularly encounter bereavement and grief; it is an integral part of caring for patients and their families. They encounter sorrow in the survivors of their patients; in their patients who are survivors; and in themselves when they lose people important to their lives, including patients. Death and grief are issues with which they need to be familiar and that they should be able to address in the clinical setting. To help others, clinicians need to be aware of their own reactions to people who are in grief and of their own concerns about death and dying.
The terms bereavement and grief are generally used interchangeably. Technically, bereavement refers to the experience of a loss through death, whereas grief refers to the feelings (e.g., the emotional suffering) and the behaviors (e.g., crying) associated with loss. Based on the attachments people normally form throughout life, grief and bereavement are the expected consequences of the death of a significant person, whether that individual is loved or not. Also included, however, are significant losses, such as those of a pet, of physical function, or of a part of the body (e.g., stroke, mastectomy); a new diagnosis that results in the loss of the ability to perform certain tasks or that makes giving up work or other activities that are an important part of a person's identity necessary; important relationships (e.g., divorce) or even jobs; a familiar home; or one's community. Therefore, grieving may occur not only with the death of another person but also with a loss of function or one's sense of self. Because more is known about grief as it relates to death, the sections below are focused accordingly.
Given the number of people who die each year and the average size of an American family, a reasonable estimate is that 7 to 9 million Americans experience the death of a family member in any year. Some estimates suggest that, across all demographic groups, at least 5% of all children lose one or both parents by the age of 15. Grief and bereavement are normal aspects of life and the life cycle, but, in certain instances, abnormalities in behavior and social or occupational function can occur. Clinicians need to recognize and to distinguish the sometimes subtle differences between normal grief, abnormal grief, and depression, a distinction that may not always be straightforward.
In normal grief and bereavement (see section I), the bereft person is significantly distressed, but he or she is still able to function. Over time, the distress and sadness gradually resolve. Grief and bereavement become abnormal (see section III) when the mourner suffers from clinical depression or some other form of psychopathologic response. In some instances of abnormal grief, significant occupational, family, or social dysfunction results from the bereavement process. In normal grief, social and, in some circumstances, psychologic support help the bereaved to return gradually to a place where he or she can move on with life. In abnormal grief, an appropriate intervention with psychologic or psychiatric care, social support, or spiritual resources is necessary.
Table 16.1 contrasts some of the features that may differentiate an episode of normal bereavement from an episode of major depressive disorder (MDD) (see Chapter 18). In addition to these features, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, points out that any hallucinatory experiences occurring during normal grief must be confined to thinking that one hears the voice of or transiently sees the image of the deceased. Any guilt should be limited to feelings about actions taken or not taken by the survivor at the time of death. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, classifies bereavement as an additional condition
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that may be the focus of clinical attention. A coding category of bereavement can be added to other diagnoses.
TABLE 16.1. BEREAVEMENT VERSUS MAJOR DEPRESSIVE DISORDER | ||||||||||||||||||
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I. Normal Grief
Commonly, acute grief can be expected to last days to weeks, perhaps with recurrence on anniversaries of important losses. When grief is uncomplicated, it typically proceeds in the following three phases: initial numbness and shock; waves of sadness and weeping along with altered sleep, appetite, and ability to concentrate; and resolution or acceptance an awareness that life will go on. During the second phase, transient feelings of guilt or self-blame (e.g., I should have done more ); blaming of others; or anger at fate, one's God or other deities, the person who died, or those who tried to help, including the treating physician, may be present. Some observations of bereaved persons suggest that one's first experience with loss is often the most difficult to endure and that how it progresses and resolves may set the tone for how future losses are handled.
Any feelings of guilt and anger should be short-lived, but they may return. Typically, grief then gradually fades over a period of several months, coming back only with reminders of past shared experiences or when the individual encounters events or things that were special to, or shared with, the deceased. Grief can also be anticipatory, as with a loved one or friend who has an inoperable or untreatable illness, such as human immunodeficiency virus infection or cancer.
II. The Mourning Period
Customarily, acute grief is followed by a mourning period lasting 6 to 12 months or even up to 3 or more years. During this time, the bereaved person comes to terms with the painful feelings of loss and the changes in life that occur as a result of the loss. The process of working through a loss typically involves a number of steps that are listed in Table 16.2. These steps can be remembered by the mnemonic AFTER. Although these steps are commonly seen, tremendous variability in the time frame, experience, and process of mourning is observed. Therefore, the clinician needs to consider and address the needs of each person.
Mourning is also a social process. Most societies and cultures have rituals to aid mourners. Considering the potential social and psychologic benefits that religion or ritual can provide to certain individuals is important. A significant loss can trigger a questioning of religious beliefs that may even cause a worsening of depressive symptoms. For some, their congregation or a religious leader can provide social support during the period of grief and mourning. One's religious community may even be able to provide individuals who will visit those in mourning, as well as meals or aid with transportation.
TABLE 16.2. TYPICAL STEPS IN THE MOURNING PROCESS | ||
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Although normal mourning can last up to 3 or more years, many bereaved persons believe that something must be wrong when their loss-related distress lasts so long. Sometimes well-meaning family, friends, and physicians push them to get beyond the mourning period sooner than may be natural. Observers may react with impatience rather than tolerance, or they may mistake prolonged normal mourning for pathologic grief. Family and close friends, as identified by the mourner, need to be educated by the health care provider or the mourner about how long mourning can last. They need to know that a normal mourning process can include feeling sad on anniversaries or birthdays, occasional periods of crying, and occasional displays of mourning and sadness that occur after the mourning period appears to have passed, as long as the mourner is functioning adequately in daily life and the pattern of symptoms seen in abnormal grief is not present.
Normal grieving is also not accompanied by drug or alcohol abuse; a prolonged period of social isolation after the death; loss of interest in hobbies, work, or intellectual pursuits; or problems with occupational functioning that do not remit. A prolonged pattern of any of the above signs requires further professional evaluation. If a practitioner is unable to evaluate or to address these concerns, a consultation or referral should be initiated. Possible sources of referral include psychologists, psychiatrists, social work therapists, bereavement counselors, or other persons trained to do bereavement counseling.
Recent data suggest that the mourning period may be associated with increased vulnerability to and morbidity from a variety of illnesses. This has been hypothesized to be the result of the stress of loss and readjustment or to secondary alterations in immunologic function. The first year after a significant loss may be a particularly vulnerable time for elderly widowers. They may suffer social isolation and despair, and they are at high risk for alcoholism, depressive disorders, and suicide. A recent study suggests that depression and weight loss are more likely to occur among those spouses who did not actively participate as caregivers before a death. For those spouses strained by the caregiver role, the death itself did not appear to increase their overall distress. Instead, the surviving spouses reduced their health risk behaviors (e.g., skipping their own medical checkups, getting insufficient rest). Those who live alone or who do not eventually remarry are at especially high risk. However, in general, remarriage shortly after a loss may compromise the resolution of grief, and those counseling the bereaved may wish to convey this perspective.
III. Abnormal Grief
Grief can become prolonged or pathologic. It may also merge into or trigger a major depressive episode. Some degree of sadness, despair, or unhappiness is to be expected in all normal grieving, but these feelings should gradually resolve. Depression per se should be suspected when the symptoms and signs persist or intensify (e.g., transiently disrupted sleep becomes a persistent pattern of early morning awakening). In normal grief, a bereaved person may transiently fear losing his or her mind, or he or she may have brief (i.e., minutes to a few days after the funeral) thoughts of or impulses toward self-harm or suicide. In depression, such thoughts or impulses are likely to persist or intensify, and they interfere with social, occupational, or physical functioning.
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When suicidal ideation, slowed speech or motor movements, or agitation persist for more than a few days after a death, an abnormal reaction to grief, including the possibility of MDD, should be considered; immediate evaluation is then necessary. When neurovegetative symptoms (e.g., sleep or appetite disturbances) persist or social and occupational functions do not begin to return to normal after approximately 2 months, the possibility of a major depressive episode should be considered, and an evaluation by an experienced psychiatrist or psychologist should be conducted or obtained. In 15% to 20% of those who grieve after a loss, clinically significant depression may be present 1 year later.
Grief can also be intensified or unresolved in other ways. The grieving person (a) may deny the loss or feel despairing helplessness; (b) may pine for the deceased or lost person, a preoccupation that blocks engagement with others and getting on with life; (c) may avoid experiences, people, and things linked to the deceased; (d) may identify with the deceased (e.g., taking on some characteristics or even symptoms); (e) may overidealize the deceased; or (f) may suffer nightmares and social withdrawal suggestive of a posttraumatic stress reaction.
Grief may be especially painful when parents lose children, including adult children; spouses or life partners die; or children lose parents. Table 16.3 lists categories of people in whom complicated or dysfunctional grief may be more likely to occur. Patients with a history of mental illness often have difficulty with grief and mourning. Clinicians may wish to consider all these aspects when they are trying to identify risk factors in their patients.
IV. Treatment Considerations
A. Social Support
People who are experiencing grief should be urged to have a friend or relative move in with them for at least the first few days after a death. When this is not possible, sleeping at the house of a relative or friend may be a wise alternative. This is not a good time to be isolated, but it is also not a good time to rush into other relationships or to make other major changes or moves. Relatives or friends can often be helpful by assisting with funeral and burial arrangements. Through its sense of community, religious rituals that aid in coping with grief, organized programs, and networks of volunteers, the mourner's place of worship can also be an invaluable resource. Some funeral homes now provide grief counseling or have arrangements for referrals.
B. Clinician Support and Counseling
Physicians and other appropriately licensed clinicians should encourage and support an open discussion of the feelings of loss and sadness, as well as of the individual's positive and negative feelings about the deceased person. When involvement in bereavement rituals seems appropriate, they should also encourage this, especially with those that are consistent with, and supported by, one's religious (e.g., wake, sitting shiva ) community or
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cultural background. People sometimes feel helped if they are encouraged to find their own rituals. Physicians and other clinicians also need to remind the bereaved that grief is often recurrent or cyclical and that it is not simply a linear process that goes from sorrow to recovery. Many clinicians fail to consider that helping a patient with his or her grief may be difficult if the patient has not previously experienced concern and a caring attitude from the clinician.
TABLE 16.3. PERSONS AT RISK FOR DYSFUNCTIONAL GRIEF | |
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C. Sedative-Hypnotic Medications
Transient and judicious use of a sedative-hypnotic medication may be considered, but requests for prolonged use should lead to the consideration of some form of unresolved grief or the emergence of depression. When making the clinical judgment of whether to use a sleep-promoting agent, the treating physician also has to consider and balance a number of different and sometimes conflicting issues.
Short-acting rapid-onset benzodiazepines (e.g., triazolam) or other agents that bind to these same receptors (e.g., zolpidem, zaleplon) are good choices when a short-term pharmacologic treatment of insomnia (see Chapter 15) is indicated. Because diphenhydramine or sedating antidepressants (e.g., trazodone, amitriptyline) that are sometimes used to help with insomnia have a high rate of unwanted effects (e.g., anticholinergic side effects, daytime sedation, difficulties with concentration), their use can be problematic and it should be avoided.
The sedative-hypnotic agent chosen should be used for a brief period (typically up to a maximum of 2 weeks). Requests for prolonged use or the presence of a sleep problem that does not improve with medication should lead to the consideration of some form of pathologic grieving or MDD.
An important caveat is to ensure that one does not block or delay the grieving process by prescribing medications that may interfere with it. Similarly, because many sedative-hypnotics can impair memory for new learning to some degree at or near doses that are close to those that are effective for the desired target (e.g., the induction of restorative sleep) or because they may have next-day carryover effects on motor performance, the benefit from sedative-hypnotics also may carry some potential of side effects. Physicians should be concerned that, in some high-risk patients (e.g., an older male with a drinking history who will now be alone), the availability of sedative-hypnotics could contribute to the lethality of a suicide attempt by overdose. On the other hand, grief is an acute stress, and the stress per se along with its sequelae (e.g., insomnia, daytime fatigue, irritability) may take its toll in the form of medical illness, somatization, depression, and significant anxiety. One could also argue that persistent insomnia is a physiologic response resulting from the loss and suffering and thus medical treatment (medication) is indicated.
Two additional considerations are also present. First, some bereaved respond to the act of giving them something for relief, so over-the-counter products, such as acetaminophen, combined with a low dose of an antihistamine, may be sufficient. Second, the use of alcohol to promote sleep should be discouraged because its use may lead to fragmentation of sleep and increased daytime difficulties.
D. Antidepressants
Antidepressants probably have only a limited role to play in managing acute grief. Their preventative use early in the grieving process is most likely to benefit patients with a history of MDD or other affective disorders. For this latter group, intervention with an antidepressant may reduce the likelihood of a transition from grief to depression and may thereby facilitate the resolution of the grief and may lessen the morbidity associated with depression (e.g., excessive emotional pain and impaired quality of life). Making the decision to initiate antidepressant therapy is not always straightforward because having and tolerating some degree of emotional pain is part of the normal grieving process and its resolution. When a clinician is uncertain
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about the use of antidepressants, a psychiatrist with pharmacologic and bereavement experience should be consulted.
When grief triggers an episode of MDD (see Chapter 18) or persisting depressive symptoms (sometimes called minor depression), antidepressants should be given serious consideration. Positive results have been reported in preliminary studies of paroxetine, nortriptyline, and sustained-release bupropion. Because many patients who require an antidepressant have taken one before, reinstituting one they are familiar with and that they have benefitted from is the best starting point. When pharmacologic treatment is chosen, the antidepressant doses used to treat a major depression should be instituted, and the patient should have frequent appointments (i.e., every 1 to 2 weeks) to identify and treat side effects, to provide support, and to assess the treatment response. Unfortunately, many people either who are at high risk for depression or who develop significant depressive or anxiety symptoms will decline the offered antidepressant treatment. In these instances, follow-up appointments should be scheduled, and the physician should again try to prescribe medication for the clinically depressed mourner or to work out a referral for grief work or targeted cognitive-behavior therapy.
E. Psychotherapy and Self-Help Groups
Counseling or psychotherapy is of benefit to the bereaved with symptoms serious enough to merit antidepressant treatment; it should therefore be offered as adjuvant therapy. Referral to a psychiatrist or another appropriately trained mental health specialist should be considered for those with prolonged or complicated grief. Patients who decline pharmacologic treatment should be strongly encouraged to engage in grief counseling or psychotherapy with a psychologist, psychiatrist, or licensed therapist. Counseling or psychotherapy may also benefit those in whom normal mourning and grief are prolonged or in which their daily activities are particularly impaired.
The therapist to whom the patient is referred should have familiarity and experience in dealing with grief and bereavement. Another option is a grief counselor who is trained in and who specializes in this type of counseling. Even if the patient agrees to psychotherapy or grief counseling, the primary health provider should also see him or her for frequent regular visits (every 1 to 2 weeks) because this provides short-term and long-term support.
Therapy for these patients addresses their feelings of helplessness and dependency; their numbness, avoidance, or persistent denial; or their feelings of being overwhelmed and traumatized. Some degree of transient emotional withdrawal may be necessary and may facilitate the mourner's ability to carry on. In addition to providing support and encouragement during the exploration of feelings about the deceased, including the negative feelings, the therapist also emphasizes regaining autonomy and achieving self-acceptance and a feeling of wholeness. Each person has to establish a new relationship with the lost one in his or her own way. Some characterize this process as internalizing the loss; perhaps, it may be more simply stated as finding a place in one's heart for him or her.
Many neonatal intensive care units provide grief work for parents, and they can help with referrals to groups for parents who have lost newborns or older children. Other self-help groups include those for widows or widowers, parents of deceased children, or women who have undergone a mastectomy. They can provide support, an opportunity to share the grief experience, information about other resources in the community, and perspective. Self-help groups are not a form of medical treatment because they are not monitored by a health provider; therefore, they should not be considered as an alternative to psychotherapy or grief counseling.
V. Special Considerations for Children and Young Teens
Some children can be too young to understand death and its consequences, and some older adolescents may be unwilling to share with or expose their grief to adults.
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Grief work can only be done by a child who is developmentally ready and who is given the time and support to do so. Children less than 2 years of age have no frame of reference for death, so they experience only abandonment; children from about 2 years of age to about 6 or 7 may think of death as similar to a prolonged sleep (i.e., death is impermanent). Young children may temporarily lose developmental gains and may blame themselves for the death. They may also use play as a way of expressing their feelings. Older children (7 to 11 years of age) gradually become aware of the finality of death, but they may believe that some people are immortal. An understanding of children's developmental capacities, temperament, and coping styles will help any adult who has to inform a child about a death, and it may help to guide any decisions about participation in organized bereavement rituals. For example, for a 7 year old who is accompanied by a trusted person to leave a special picture or some other personal memento for the lost loved one at the grave site or some other meaningful place may be appropriate. Similarly, for some grieving adolescents, having a few close friends sit with them during a service may be even more beneficial than sitting with the family would be. Children may also reexperience their losses as time goes by, as their development progresses, and as important life events are encountered that bring up the absence of the deceased. As with adults, distinguishing between normal grief and abnormal grief or childhood depression may not be easy. For the latter two outcomes, a referral for counseling to a child or adolescent mental heath clinician is generally indicated. Table 16.4 outlines some of the features that might be of aid in deciding when a referral is in order. Those wishing for more understanding of childhood and adolescent depression should consult Chapter 21.
VI. Additional Issues
Several trends that have occurred in recent years may affect the mourning process. Among these are the increasingly frequent choice of cremation, a movement away from open caskets, and the specification in living wills of preferred approaches to the way one's death should be managed (e.g., end of life care, organ or body donation, burial procedures, rituals). Life-prolonging treatments may also permit some grieving to take place well before death occurs. How these changes and experiences alter the mourning experience for a given individual may vary from comfort and relief that is found in following the wishes of those who have died to distress, guilt, and even conflict among survivors who may prefer not to follow these wishes. Concerned clinicians need to be aware of these differing perspectives and outcomes and to find ways to be supportive.
TABLE 16.4. FEATURES THAT MAY DISTINGUISH NORMAL FROM ABNORMAL GRIEF IN CHILDREN | ||||||||||||||||||
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ACKNOWLEDGMENT
We thank Jessica R. Oesterheld, M.D., for her help with our understanding of children and death, and Sandra L. Bertman, PH.D., for her perspective that death does not diminish the importance of special relationships.
ADDITIONAL READING
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Clayton PJ, Herjanic M, Murphy GE, et al. Mourning and depression: their similarities and differences. Can Psychiatr Assoc J 1974;19:309 312.
Jacobs SC, Kasl SV, Ostfeld AM, et al. The measurement of grief: bereaved vs non-bereaved. Hospice J 1986;2:21 35.
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McHorney CA, Mor V. Predictors of bereavement depression and its health services consequences. Med Care 1988;26:882 893.
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Zisook S, Shuchter SR, Pedrelli P, et al. Bupropion sustained release for bereavement: results of an open trial. J Clin Psychiatry 2001;64:227 230.
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Helpful Books for Grieving Parents or Children
Buscaglia L. The fall of Freddie the leaf. Thorofare, NJ: Slack, 1982.
Fitzgerald H. The grieving child a parent's guide. New York: Simon & Shuster, 1992.
Maning D. Don't take my grief away from me. Oklahoma City, OK: In-Sight Books, 1979.
Mellonie B, Ingpen R. Lifetimes the beautiful way to explain death to children. Toronto: Bantam Books, 1983.
Schaefer D, Lyons C. How do we tell the children? New York: Newmarket Press, 1993.
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