Bereavement

BEREAVEMENT

Bereavement is defined as the objective state of having experienced the loss of a loved one. Grief, in contrast, is the psychological and emotional reaction to bereavement. Grief is a healthy, normal, and appropriate response to loss. It is a process of adaptation, with a number of signs or manifestations that are part of the experience. Grief may also precede a loss, in which case it is termed "anticipatory" grief. In this case, grief is the process of slowly coming to terms with the potential loss of a significant person, such as may be seen in a caregiver of a person with a progressive illness.

The duration and expression of "normal" bereavement vary considerably among both individuals and cultural groups. For some individuals, bereavement becomes overwhelming, and grief leads to pathological or complicated mourning, with negative implications for functioning or physical health. Complicated grief entails a failure to return to pre-loss levels of performance or states of emotional well-being within eighteen months after a death, and is manifested by poorer global functioning, depressed mood, poorer sleep quality, and lower self-esteem.

Bereavement is a stressful process that affects morbidity and mortality. The recently bereaved report increased depression, deteriorating physical health, and increased consumption of tobacco, alcohol, and tranquilizers. Studies have found a 40 percent increase in mortality rates among widowers in the first six months after the loss of their spouse. Severe psychological stress secondary to bereavement has been associated with abnormalities in immune function. Between 20 and 25 percent of bereaved persons remain depressed one year after a death, and up to 26 percent of bereaved persons exhibit depressive symptoms after two years.

The experience of grief is described as occurring in phases, with one phase gradually following the next. The process of uncomplicated grief can be thought of as an interwoven pattern of changing emotional states, somatic symptoms, and motivational stages. These phases overlap, as do each of the components within the phases.

The first phase is one of shock. This phase begins immediately after a loss and it generally lasts two weeks or less. During this period the survivor is often in a state of numbed disbelief. Somatic symptoms include crying, dysphagia, chest tightness, nausea, and a sensation of abdominal emptiness. Individuals may feel lost, dazed, stunned, helpless, and disorganized. The shock phase is often more pronounced if the death is sudden or unexpected. Similar experiences may occur after an individual learns of a grave diagnosis, even if death is not imminent.

Phase two consists of preoccupation with the deceased. This phase is marked by a sense of unreality and decrease in the feeling of disbelief. Emotional numbness gives way to fully experiencing the painful sadness of the loss. Crying spells persist. Symptoms include insomnia, fatigue, and loss of appetite. Most characteristic of this period is an intense, almost obsessive, preoccupation with the memory of the deceased, and past grievances, anger, guilt, and other unresolved conflicts are reexamined. Dreams of the dead may be intensely vivid. Transient hallucinatory episodes may occur in which the deceased's voice is heard or strangers may be mistakenly identified as the deceased. A period of social withdrawal and introversion is also typical. This phase is usually well developed by three months and may persist for six months or longer. Recurrences of these symptoms may occur on birthdays, anniversaries, or other special dates that remind the survivor of the deceased.

Phase three is a period of resolution, heralded by the bereaved's being able to recall events with sentimental pleasure and regaining an interest in activities. New social contacts are gradually made and life is reorganized around new activities and interests. Crying spells, feelings of emptiness, and longing for the dead still occur, but begin to diminish in intensity and duration. Somatic symptoms and preoccupation with memories begin to wane. Getting over a death does not mean that sad and empty feelings are never evoked by the memory of the loved one, but rather that the survivor does not remain preoccupied with the deceased and is not restricted socially and psychologically as a result of the death. Bereaved individuals should not expect to, nor be expected to, recover within a specified period of time.

Bereaved individuals may benefit from support services, including bereavement counselors, psychologists, and support groups. Most hospices provide bereavement services, informational materials, and support groups, even if the deceased did not receive hospice services. Local funeral homes are a good source for informational materials about grief and bereavement. AARP offers a number of resources through its web site. Compassionate Friends is a national nonprofit, self-help support group for families who are grieving the death of a child. The National Funeral Directors Association and the National Hospice and Palliative Care Organization offer a variety of resources on bereavement issues.

Jean S. Kutner

(see also: AARP; Crisis Counseling; Family Health; Widowhood )

Bibliography

Brown, J. T., and Stoudemire, G. A. (1983). "Normal and Pathological Grief." Journal of the American Medical Association 250:378–382.

Lattanzi-Licht, M.; Kirschling, J. M.; and Fleming, S., eds. (1989). Bereavement Care: A New Look at Hospice and Community Based Services. New York: Haworth Press.

Parkes, C. M. "Bereavement." In The Oxford Textbook of Palliative Medicine, 2nd edition, eds. D. Doyle, G. W. Hanks, and N. MacDonald. New York: Oxford University Press.

Prigerson, H. G.; Frank, E.; and Kasl, S. V. (1995). "Complicated Grief and Bereavement-related Depression as Distinct Disorders: Preliminary Empirical Validation in Elderly Bereaved Spouses." American Journal of Psychiatry 152:22–30.

Wass, H., and Neimeyer, R. A., eds. (1995). Dying: Facing the Facts. Washington, DC: Taylor & Francis.