For older Americans, the loss of a loved one is a relatively common occurrence, yet it is often severely distressing and can have dire implications for mental and physical health. Over two million people die in the United States each year. Each of those deaths leaves behind a wake of grief that ripples through a web of surviving family members and friends. Older people are especially likely to experience such losses. Of the nearly one million people who are widowed each year, about 70 percent are over age sixty-five. For older people this highly prevalent occurrence is also one of the most painful. In a study of widowed people over age fifty, Dale Lund and colleagues found that 72 percent of participants reported that the death of their spouse was the most stressful event they ever experienced. Other studies of older adults have found that bereavement magnifies the risk of psychological disturbances, such as increased symptoms of anxiety, depressive symptoms, and major depressive episodes, as well as new or worsened physical illnesses, greater use of medication, and poorer self-rated health. These health complications, in turn, may result in more frequent use of health care services, such as visiting a doctor or receiving care in a hospital, thus making the issue of bereavement important in discussions of controlling health care costs. In addition, researchers have found that suicide and death in general are more likely to occur in the period following a significant loss.
This entry begins by addressing the concept of the "normal" grieving process and the various dimensions of which it may be composed. It then examines what are considered pathological reactions to loss, how these are related to and differentiated from the dimensions of normal grief, the rates at which they occur, and the extent to which these disorders overlap. Next is a discussion of the factors that have been found to influence whether a person will suffer a pathological bereavement response. Last is a review of the current pharmacological and psychotherapeutic treatments found to be effective in ameliorating bereavement-related distress.
Components of normal grief
What is a normal, or uncomplicated, response to losing a loved one? Due to the stressful nature of the event and the broad spectrum of grief manifestations that can result, there is no single, simple answer to this question. As outlined by Selby Jacobs, the array of common symptoms includes yearning for the lost person, preoccupation with the deceased, sighing, crying, dreams or illusions involving the deceased, searching for the lost loved one, anger, protesting the death, anxiety, sadness, despair, insomnia, fatigue, lethargy, loss of interest in previously enjoyable activities, loss of a sense of meaning, emotional numbness, nightmares, and being unable to accept the loss. Normal grief generally involves some subset of these features, with symptom intensities varying widely between individuals and over time.
In the form of a simple list, this collection of symptoms is somewhat bewildering. How are these emotional and behavioral responses related to one another? Are there sets of associated symptoms that tend to be exhibited as groups? Theorists have attempted to construct frameworks that draw connections between these manifestations in order to deepen understanding of the grieving process.
Stephen Shuchter and Sidney Zisook postulated that normal grief generally follows three stages. First, according to their model, there is a period of shock and disbelief, during which the bereaved person cannot accept that the loss has occurred. This gives way to an intermediate stage of acute mourning in which the individual is forced to confront the reality of the loss, resulting in increasing physical and emotional discomfort and social withdrawal. Ultimately, the person is able to assimilate the loss into the greater context of his or her life, and gradually returns to normal levels of functioning.
While this model is appealing for its simplicity, it is somewhat restrictive. By invoking uniform, sequential stages of grief progression, this framework cannot accurately describe a large percentage of the varied bereavement responses. Another approach, taken by Jacobs, is to look at the bereavement process as made up of multiple dimensions, or sets of symptoms, each of which can be present simultaneously, to varying degrees. As time passes, one dimension may replace another as the predominant grief manifestation, thus creating the appearance of stages but maintaining greater flexibility in the overall model.
Separation anxiety. Taking this approach, the question becomes What are the primary dimensions of grief? One of the most fundamental components seems to be a group of symptoms that have been labeled "separation distress" or "separation anxiety." This includes what Erich Lindemann has called the pang of grief— episodes of intense longing and yearning for the deceased, characterized by preoccupation with thoughts of the lost person, sighing, crying, and, in some cases, dreams, illusions, or even hallucinations involving the deceased. Behaviorally, this is manifested as searching for the lost person by seeking out places and things identified with that person, as if hoping to bring the deceased back to life. This searching behavior, often done unconsciously, ultimately meets with frustration, commonly resulting in another pang of grief.
The reason for such a reaction becomes more clear when we consider the concept of separation anxiety in the framework of attachment theory, which was initially developed by John Bowlby to explain how and why babies and children form bonds with their parents. Bowlby observed that young children exhibit pronounced "attachment behaviors," such as crying, touching, following, and calling, that serve to keep them in close contact with their parents or other protective individuals, known as "attachment objects." Bowlby hypothesized that these attachment behaviors came about, and were perpetuated in humans through evolution, because of the selective advantage such behaviors confer. Children who maintain relationships with parents and membership in social groups will be provided protection from predators, easier access to food, and improved ability to contend with competitors, all of which improve their chances of surviving to the age of reproduction. Thus, ingrained through evolutionary processes, attachment behavior is thought to be a "primary drive," hardwired into the neural circuits of the brain.
With this perspective, it becomes understandable why isolation from an attachment figure is a threatening situation that results in feelings of alarm, anxiety, anger, loneliness, and insecurity. This separation distress, which is defined as the reaction to the danger of losing an attachment object, is readily observable in infants and young children upon separation from a parent. While adults do not usually exhibit this behavior as frequently and explicitly as children do, the loss of a close relationship does result in the separation distress that makes up a component of normal grief, and in excessive reactions, or dysfunctional grief (described later).
Traumatic distress. Mardi Horowitz outlined two components of a traumatic stress response. The first involves intrusive symptoms aroused by a fear that the event will recur: frightening perceptions (such as illusions, nightmares), hypervigilance (always being "on the lookout"), startle reactions, feelings of helplessness, and insecurity. The second component, partly in reaction to the intrusive symptoms, consists of strategies for psychologically avoiding thoughts of the traumatic event: denial that the death occurred, dissociation (becoming detached from one's environment), emotional numbing, and avoidance of any place or thing that would result in painful memories of the event. Often, bereavement occurs in conjunction with an objectively traumatic event (e.g., natural disaster, war, accident). In such cases, the bereaved person may be traumatized by the event as well as by the impact of losing a loved one(s).
Depressive symptoms. It is generally acknowledged that some depressive symptoms are common in normal grief (e.g., sadness, despair, loss of interest in activities, significant weight loss or gain without dieting, insomnia, and fatigue). Full depressive episodes also occur secondary to a major interpersonal loss.
It is clear from the above discussion that the manifestations of grief are manifold. Yet, if all of these variations can be seen as normal reactions to the loss of an intimate, then how is the pathological differentiated from the normal? First, this is done on the basis of the severity of the symptoms (their intensity and/or frequency). Second, duration is a factor. In normal grief there is a gradual reduction in symptoms, acceptance of the death, and reinvestment in new activities and relationships; when this process is prolonged, there is reason for concern. Third, to be considered a disorder, the symptoms must cause a clinically significant disruption in the bereaved individual's social, occupational, or other important domains of functioning. Finally, some symptoms are more rare and are found predominantly in pathologic forms of grief. The most common bereavement-related psychiatric disorders are considered below.
Major depression. When persistent and intense, the depressive symptoms present in normal grief can lead to a diagnosis of major depressive disorder. In addition to these symptoms, Jacobs and Paula Clayton have found that those suffering from major depressive disorder following a loss may experience hopelessness, worthlessness, low self-esteem, guilt, a slowing of movement, and thoughts of suicide. Since these symptoms are uncommon in bereaved people who are not clinically depressed, they seem to be key markers of depression following a significant loss. Studies have found that between 12 and 32 percent of widowed people are depressed in the first six months following the loss. A study by Carolyn Turvey and others found the rate of syndromal depression in the recently widowed to be nine times higher than that in married individuals. Furthermore, two years after the loss, the bereaved subjects were still more likely to be depressed than those who were married. Other studies have found that between 5 and 10 percent of widowed people are continuously or "chronically" depressed for at least two years following the loss.
Post-traumatic stress disorder, anxiety disorders. A death that is perceived as particularly violent or unexpected may result in clinically significant levels of what has been described as "traumatic distress." Those experiencing these symptoms (e.g., reexperiencing the traumatic event with intrusive thoughts; avoidance and numbness in reaction to the trauma; hypervigilance or hyperarousal at cues related to the exposure) at high intensities and frequencies generally meet diagnostic criteria for posttraumatic stress disorder (PTSD) and/or other anxiety disorders. More research is needed to determine whether the likelihood of developing PTSD following loss depends on the nature of the death (e.g., whether it occurred in a violent or unexpected manner) because available evidence on this is mixed. PTSD is less common than depression in the context of bereavement.
In addition to PTSD, other anxiety disorders are related to some symptoms of traumatic distress. Studies have found that up to one in four recently bereaved people may meet criteria for some anxiety disorder within two months of the loss. However, Paul Surtees found that these anxiety disorders rarely appear without concurrent depression, and resolve more quickly over time.
Traumatic grief. Until recently, there had been no diagnostic classification for people suffering from bereavement-specific symptoms, such as those associated with extreme separation anxiety (e.g., yearning and searching for the lost person). Motivated by the apparent need for such a diagnosis, a group of experts in the areas of bereavement and trauma convened in 1997 to examine this issue. The workshop reviewed a series of studies of independent samples of bereaved people and found that elements of separation distress and traumatic distress form a single cluster, and that this cluster is distinct from depressive and anxiety symptom clusters. This means that people who experience severe symptoms of separation distress also tend to suffer from certain symptoms of traumatic distress. In addition, this single cluster of traumatic and separation distress symptoms was found to persist for months or years in a significant minority of bereaved subjects.
Furthermore, these symptoms, unlike depressive symptoms, did not respond to interpersonal psychotherapy, either alone or in combination with the tricyclic antidepressant nortriptyline. Finally, these symptoms predicted substantial morbidity (e.g., suicidal thoughts, hypertension, increased smoking) over and above the level predicted by depressive symptoms. The evidence reviewed indicated that aspects of separation distress and traumatic distress seem to constitute a single, distinct disorder that merits its own set of diagnostic criteria. The panel participants discussed the symptoms that should be included in a diagnosis and, ultimately, proposed a consensus set of criteria for the disorder, which they called traumatic grief (see Table 1).
A diagnosis of traumatic grief requires meeting both criterion A (separation distress) and criterion B (bereavement-specific traumatization occurring as a result of the loss). Preliminary studies indicate that people experiencing a majority of criterion B symptoms to a marked and persistent degree can be said to meet this criterion. A 1999 study in the British Journal of Psychiatry found that four out of the eight criterion B symptoms tested were required for a highly specific (excluding those without the disorder) and sensitive (including those with the disorder) diagnosis of traumatic grief. Criterion C, specifying a minimum duration of two months, and criterion D, requiring clinically significant impairment, may serve to further differentiate the disorder from a normal, or uncomplicated, grief response. However, additional research is necessary to determine the optimal mix of symptoms, duration, and impairment required for a diagnosis. Studies have found that between 10 and 20 percent of widowed people who have lost their spouse within six months meet criteria for traumatic grief.
Comorbidity. Psychiatric comorbidity (i.e., the presence of multiple disorders) is common following bereavement. In a study by Gabriel Silverman and colleagues (2000), traumatic grief, PTSD, and major depressive episode were found to overlap with each other to similar degrees. Of those with traumatic grief, 47 percent also received a diagnosis of major depressive episode, 33 percent met criteria for PTSD, and 40 percent had traumatic grief alone (these percentages sum to over 100 because 20 percent of those with traumatic grief received all three diagnoses).
Traumatic grief has also been found to predict lower energy levels; lower levels of social functioning; higher rates of hospitalization and physical health events, such as heart attack, cancer, and stroke; lower self-esteem; changes in sleeping and eating habits; and heightened levels of thoughts of suicide.
Risk factors for pathological grief
To some extent, the severity of the grief experienced by an individual can be predicted, given the presence or absence of identified risk factors for maladjustment to the loss. Current knowledge about such risk factors is reviewed below.
Demographic characteristics. Younger people have often been found to experience higher levels of grief. This may be understandable, in part, because they are more likely to be mourning a death that is considered untimely. However, Catherine Sanders found that though this was true initially for younger widows, two years following the death they had made significant improvements in their mental health, while older widows, who initially had lower levels of grief, now had more anxiety, loneliness, and feelings of helplessness, and also had declined in physical health. This difference over the long term may be explained, at least partially, by younger widowed people's greater resilience and tendency to feel less vulnerable following the loss of their spouse.
Though women tend to report more symptoms than men, Colin Murray Parkes and R. J. Brown found that between two and four years after the loss, widows were no more depressed than married women the same age, whereas widowers were still more depressed than married men. It is hypothesized that the reason for this is that during marriage, men may be more likely to depend on a spouse for emotional support and social contacts. When this resource is no longer available, these men, not in the habit of meeting new people, often isolate themselves or throw themselves into their work. Women, on the contrary, are more likely to cope with the loss by seeking out social support that might facilitate the bereavement process.
Low socioeconomic status has also been found to contribute to poor bereavement adjustment, worse health, reduced social participation, and greater loneliness. Unemployment is also a risk factor for depression following bereavement.
Nature of the death. If the death is particularly sudden, unexpected, or violent, the bereaved person may be predisposed to a pathological reaction, particularly to elements of traumatic distress and PTSD. Similarly, experiencing multiple losses near each other in time, known as "bereavement overload," has been found to increase risk of psychopathology.
Nature of the relationship. If the bereaved person was highly dependent (emotionally, physically, or otherwise) on the deceased person, or if their lives were largely intertwined with shared activities (an "enmeshed" relationship), the loss will result in major disruption in the survivor's daily life. Feelings of purposelessness, loss of meaning, and a shattered worldview are likely to be prominent and contribute to a diagnosis of traumatic grief. One study (The Gerontologist, 2000) by Holly Prigerson and colleagues found that, following the loss of their spouse, people who had harmonious marriages used a significantly greater number of health services than those whose marriages were discordant.
The nature of the relationship is partly dependent upon the personality and "attachment style" of the bereaved person. Attachment disturbances, such as excessive dependency or insecure or anxious attachment, are likely to result in severe separation distress following the loss. Such disturbances are often established during childhood, when the ability to form secure attachments is learned. A study by Gabriel Silverman and others (2000) found that adversities experienced during childhood (physical or sexual abuse, death of a parent) were significantly associated with traumatic grief, while adversities occurring in adulthood (nonbereavement traumatic events and death of a child) were associated with PTSD. This suggests that there is a vulnerability to traumatic grief explicitly rooted in childhood experiences.
Social support. Lack of social support (i.e., friends or family who are available to provide emotional and practical help) has been widely cited as a risk factor for poor bereavement adjustment. However, Lund notes that simply having available family members is not enough, because such "support" can be negative (e.g., judgmental, inconsiderate, pushy, demanding, unreliable). Rather, only empathetic support, stable over time, appears to result in lower rates of depression and more positive ratings of coping, health, and life satisfaction.
While there have been no randomized, controlled, clinical trials of treatment for traumatic grief, inferences can be made from studies done treating PTSD, separation anxiety disorder, and depression.
Pharmacotherapy. Considering a review of this literature done by Jacobs, it seems that selective serotonin reuptake inhibitors might be more effective for the broad range of traumatic grief symptoms than tricyclic antidepressants. The latter tend to affect intrusive, anxious, and depressive symptoms alone, while the former reduce these symptoms as well as manifestations of avoidance, particularly avoidance stemming from distress over reminders of the loss.
Psychotherapy. Though findings have been mixed, both psychodynamically oriented treatments and behavioral/cognitive treatments have, in some studies, demonstrated effectiveness in treating pathological grief. When addressing bereavement-related distress, it is important for the therapist to review the relationship to the deceased person and the circumstances of the death. In addition, the therapist should advise the patient on what to expect from the grieving process. Though as yet there is no treatment designed to specifically address the symptoms of traumatic grief, M. Katherine Shear and Ellen Frank are developing and testing one such therapy based on Edna Foa's treatment for PTSD. Continued strides in this direction are cause for optimism in the search for efficacious treatments for traumatic grief and other bereavementrelated disorders.
Gabriel K. Silverman Holly G. Prigerson
See also Antidepressants; Anxiety; Cognitive-Behavioral Theory; Depression; Widowhood.
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Bereavement refers to the period of mourning and grief following the death of a beloved person or animal. The English word bereavement comes from an ancient Germanic root word meaning "to rob" or "to seize by violence." Mourning is the word that is used to describe the public rituals or symbols of bereavement, such as holding funeral services, wearing black clothing, closing a place of business temporarily, or lowering a flag to half mast. Grief refers to one's personal experience of loss; it includes physical symptoms as well as emotional and spiritual reactions to the loss. While public expressions of mourning are usually time-limited, grief is a process that takes most people several months or years to work through.
Bereavement is a highly individual as well as a complex experience. It is increasingly recognized that no two people respond the same way to the losses associated with the death of a loved one. People's reactions to a death are influenced by such factors as ethnic or religious traditions; personal beliefs about life after death; the type of relationship ended by death (relative, friend, colleague, etc.); the cause of death; the person's age at death; whether the death was sudden or expected; and many others. In addition, the death of a loved one inevitably confronts adults (and older adolescents) with the fact that they too will die. As a result of this variety and emotional complexity, most doctors and other counselors advise people to trust their own feelings about bereavement, 0 and grieve in the way that seems most helpful to them.
It is also increasingly understood in the early 2000s that people can experience bereavement with regard to other losses. Some examples of these so-called "silent losses" include miscarriages in early pregnancy, the death of a child in the womb shortly before birth, or the news that a loved one has Alzheimer's disease or another illness that slowly destroys their personality. In addition, many counselors recognize that bereavement has two dimensions, the actual loss and the symbolic losses. For example, a person whose teenage son or daughter is killed in an accident suffers a series of symbolic losses—knowing that their child will never graduate from high school, get married, or have children—as well as the actual loss of the adolescent to death.
Causes and symptoms
The immediate cause of bereavement is usually the death of a loved friend or relative. There are a number of situations, however, which can affect or prolong the grief process:
- The relationship with the dead person was a source of pain rather than love and support. Examples would include an abusive parent or spouse.
- The person died in military service or in a natural, transportation, or workplace disaster. Bereavement in these cases is often made more difficult by intrusive news reporters as well as anxiety over the loved one's possible physical or mental suffering prior to death.
- The person was murdered. Survivors of homicide victims often find the criminal justice system as well as the media frustrating and upsetting.
- The person is missing and presumed dead but their death has not been verified. As a result, friends and relatives may alternate between grief and hope that the person is still alive.
- The person committed suicide. Survivors may feel guilt over their inability to foresee or prevent the suicide, shame that the death was self-inflicted, or anger at the person who committed suicide.
- The relationship with the dead person cannot be openly acknowledged. This situation often leads to what is called disenfranchised grief. The most common instances are homosexual or extramarital sexual relationships that have been kept secret for the sake of spouses or other family members.
- The loved one was an animal rather than a human being. Western societies are only beginning to accept that adults as well as children can grieve for a dead animal; many adults still feel that there is "something wrong" about grieving for their pet. The question of euthanasia may be an additional source of sorrow; even when the pet is terminally ill, many people are very uneasy about making the decision to end its life.
Bereavement typically affects a person's physical well-being as well as emotions. Common symptoms of grief include changes in appetite and weight, fatigue, insomnia and other sleep disturbances, loss of interest in sex, low energy levels, nausea and vomiting, chest or throat pain, and headache. People who have lost a loved one in traumatic circumstances may have such symptoms of post-traumatic stress disorder as an exaggerated startle response, visual or auditory hallucinations, or high levels of muscular tension.
Doctors and other counselors have identified four stages or phases in uncomplicated bereavement:
- Shock, disbelief, feelings of numbness. This initial phase lasts about two weeks, during which the bereaved person finally accepts the reality of the loved one's death.
- Suffering the pain of grief. This phase typically lasts for several months. Some people undergo a mild temporary depression about six months after the loved one's death.
- Adjusting to life without the loved one. In this phase of bereavement, survivors may find themselves taking on the loved one's roles and responsibilities as well as redefining their own identities.
- Moving forward with life, forming new relation-ships, and having positive expectations of the future. Most people reach this stage within one to two years after the loved one's death.
BEREAVEMENT IN CHILDREN. Children do not experience bereavement in the same way as adolescents and adults. Preschool children usually do not understand death as final and irreversible, and may talk or act as if the dead pet or family member will wake up or come back. Children between the ages of five and nine are better able to understand the finality of death, but they tend to assume it will not affect them or their family. They are likely to be shocked and severely upset by a death in their immediate family. In addition to the physical disturbances that bereaved adults often experience, children sometimes begin to act like infants again (wanting bottle feeding, using baby talk, etc.) This pattern of returning to behaviors characteristic of an earlier life stage is called regression.
TRAUMATIC AND COMPLICATED GRIEF. Since the early 1990s, thanatologists (doctors and other counselors who specialize in issues related to death and dying) have identified two types of grief that do not resolve normally with the passage of time. Traumatic grief is defined as grief resulting from a sudden traumatic event that involves violent suffering, mutilation, and/or multiple deaths; appears to be random or preventable; and often involves the survivor's own brush with death. The symptoms of traumatic grief are similar to those of post-traumatic stress disorder (PTSD). Such events as the terrorist attacks of September 11, 2001, the East Asian tsunami of December 2004, and airplane crashes or other transportation disasters may produce traumatic grief in survivors.
Bibliotherapy— The use of books (usually self-help or problem-solving works) to improve one's understanding of personal problems and/or to heal painful feelings.
Biofield healing— A general term for a group of alternative therapies based on the belief that the human body is surrounded by an energy field (or aura) that reflects the condition of the person's body and spirit. Rebalancing or repairing the energy field is thought to bring about healing in mind and body. Reiki, therapeutic touch, polarity balancing, Shen therapy, and certain forms of color therapy are considered forms of biofield healing.
Complicated grief— An abnormal response to bereavement that includes unrelieved yearning for the dead person, the complete loss of previous positive beliefs or worldviews, and a general inability to function.
Disenfranchised grief— Grief that cannot be openly expressed because the death or other loss cannot be publicly acknowledged.
Euthanasia— The act of putting a person or animal to death painlessly or allowing them to die by with-holding medical services, usually because of a painful and incurable disease.
Mourning— The public expression of bereavement; it may include funerals and other rituals, special clothing, and symbolic gestures.
Regression— A return to earlier, particularly infantile, patterns of thought and behavior.
Thanatology— The medical, psychological, or legal study of death and dying.
Traumatic grief— Grief resulting from the loss of a loved one in a traumatic situation (natural or transportation disaster, act of terrorism or mass murder, etc.)
In contrast to traumatic grief, complicated grief does not necessarily result from a specific type of event but rather refers to an abnormally intense and prolonged response to bereavement. While most people are able to move through a period of bereavement and recover a sense of purpose and meaning in life, people with complicated grief feel as if their entire worldview has been shattered. They cannot stop thinking of the dead person, long to be with him or her, and may feel that part of them died along with the loved one. They sometimes start acting like the deceased person, mimicking the symptoms of his or her illness, behaving in reckless ways, talking about "joining" the loved one, or refusing to accept the reality of the death. In general they are unable to function normally. Complicated grief should not be regarded as simply a subtype of clinical depression; the two conditions may coexist or overlap in some patients but are nonetheless distinct entities.
Bereavement is considered a normal response to a death or other loss. A doctor who suspects that a patient is suffering from traumatic or complicated grief, however, may use various psychological inventories or questionnaires to see whether the patient meets the criteria for PTSD, major depression, or acute stress disorder. In addition, there are several specific questionnaires to help diagnose complicated grief.
Most people do not require formal treatment for bereavement. In the early 2000s, however, many people choose to participate in support groups for recently bereaved people or hospice follow-up programs for relatives of patients who died in that hospice. Bereavement support groups are particularly helpful in guiding members through such common but painful problems as disposing of the dead person's possessions, celebrating holidays without the loved one, coping with anniversaries, etc.
Traumatic grief is usually treated in the same way as post-traumatic stress, with temporary use of medications to control sleep disturbances and anxiety symptoms along with long-term psychotherapy. Those suffering from traumatic grief may also be referred to support groups of people dealing with the same type of sudden and violent loss. Some of these organizations are listed below. Complicated grief is usually managed with a combination of group and individual psychotherapy.
Alternative therapies that have been reported to help with the sleep disturbances and other physical symptoms of bereavement include prayer and meditation; such movement therapies as yoga and tai chi; therapeutic touch, Reiki, and other forms of biofield healing; bibliotherapy and journaling; music therapy, art therapy, hydrotherapy, and massage therapy.
Most people move through the stages of the normal grief process within several months to two years, depending on the length and closeness of the relationship. Traumatic grief and complicated grief, however, may take three years or longer to resolve, even with appropriate treatment.
Bereavement is considered a normal response to death and loss, which are universal human experiences. It should ordinarily be allowed to run its course; most counselors maintain that trying to stifle or cut short the grief process is more likely to cause emotional problems later on than to prevent them.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.
Dossey, Larry, MD. Healing Beyond the Body: Medicine and the Infinite Reach of the Mind. Boston and London: Shambhala, 2001. The chapters on "The Return of Prayer" and "Immortality" are particularly relevant to bereavement.
"Mood Disorders." Section 15, Chapter 189 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2005.
Bowles, Stephen B., Larry C. James, Diane S. Solursh, et al. "Acute and Post-Traumatic Stress Disorder after Spontaneous Abortion." American Family Physician 61 (March 15, 2000): 1689–1696.
Kersting, Karen. "A New Approach to Complicated Grief." Monitor on Psychology 35 (November 2004): 51.
Lubit, Roy, MD. "Acute Treatment of Disaster Survivors." eMedicine, 17 June 2004. 〈http://www.emedicine.com/med/topic3540.htm〉.
Ogrodniczuk, John S., William E. Piper, Anthony S. Joyce, et al. "Differentiating Symptoms of Complicated Grief and Depression among Psychiatric Outpatients." Canadian Journal of Psychiatry/Revue canadienne de psychiatrie 48 (March 2003): 87-93.
Alzheimer's Association. 225 North Michigan Avenue, 17th Floor, Chicago, IL 60601-7633. (312) 335-8700. 24-hour hotline: (800) 272-3900. 〈http://www.alz.org〉. This website is an excellent resource for anyone with a loved one suffering from Alzheimer's or another dementing illness.
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. 〈http://www.aacap.org.〉.
American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173-4360. 〈http://www.avma.org〉. The AVMA website includes links to resources about pet loss.
Dougy Center for Grieving Children and Families. 3909 SE 52nd Avenue, Portland, OR 97206. (866) 775-5683 or (503) 775-5683. Fax: (503) 777-3097. 〈http://www.grievingchild.org〉. Provides age-appropriate support groups, information, and referral services for bereaved children and adolescents.
National Air Disaster Alliance/Foundation (NADA). 2020 Pennsylvania Avenue #315, Washington, DC 20006-1846. (888) 444-NADA. Fax: (336) 643-1394. 〈http://www.planesafe.org〉. NADA was founded in 1995 following the loss of USAir Flight 427 to meet the needs of people who have lost loved ones in air disasters as well as work for better transportation safety standards.
National Hospice and Palliative Care Organization (NHPCO). 1700 Diagonal Road, Suite 625, Alexandria, VA 22314. (703) 837-1500. Fax: (703) 837-1233. 〈http://www.nho.org〉. This website is a good source of information about hospice-based bereavement services and support groups.
National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (886) 615-NIMH. 〈www.nimh.nih.gov.〉
Tragedy Assistance Program for Survivors, Inc. (TAPS). National Headquarters, 1621 Connecticut Avenue NW, Suite 300, Washington, DC 20009. (202) 588-TAPS. Hotline: (800) 959-TAPS. 〈http://www.taps.org〉. TAPS provides grief support for those who have lost a loved one serving in the Armed Forces.
Alzheimer's Association. Fact Sheet: About Grief, Mourning and Guilt. Chicago, IL: Alzheimer's Association, 2004.
American Academy of Child and Adolescent Psychiatry (AACAP). Children and Grief. AACAP Facts for Families #8. Washington, DC: AACAP, 2004.
American Academy of Child and Adolescent Psychiatry (AACAP). When a Pet Dies. AACAP Facts for Families #78. Washington, DC: AACAP, 2000.
Harper, Linda R., PhD. Healing after the Loss of Your Pet. 〈http://www.bestfriends.org/theanimals/pdfs/allpets/PetLossHarper.pdf〉.
National Institute of Mental Health (NIMH). Mental Health and Mass Violence: Evidence-Based Early Psychological Interventions for Victims/Survivors of Mass Violence. NIH Publication No. 02-5138. Washington, DC: U. S. Government Printing Office, 2002.
National Organization of Parents of Murdered Children (POMC). Information Bulletin: Survivors of Homicide Victims. 〈http://www.pomc.com/survivor.cfm〉.
Bereavement is the experience a person has when a loved one dies.
Bereavement usually refers to the experience of losing a loved one to death. Grief refers to the reaction people have to loss or bereavement. Most people can expect to be bereaved at some point in their lifetimes. Many people are bereaved each year. In 2003, for example, nearly 2.5 million U.S. citizens died, leaving behind many millions of bereaved individuals.
Bereavement is thus a common and normal part of life, and is not a psychiatric disorder. People who have normal, uncomplicated reactions to bereavement usually adjust to their loss over time and do not need clinical intervention. However, research indicates that bereavement is one of the most stressful experiences faced by people. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) lists bereavement as a condition that may be a focus of clinical attention, even though it is not considered a disorder. Bereavement is associated with a high risk of psychological distress, social isolation, physical illness, and death.
Many researchers agree that bereaved people go through different phases after the loss of a loved one. In the avoidance phase, people may have difficulty understanding and coming to grips with the reality of the situation. They may experience shock, numbness, disbelief, and denial. In the confrontation phase, people realize the reality of their loss, and they typically have intense negative feelings such as deep sadness, guilt, helplessness, panic, confusion, powerlessness, anger, rage, and despair. They may blame themselves or others for the loss, feel that life is unjust, and experience a sense of disillusionment and a loss of faith. In the accommodation phase, people gradually adjust to their loss. People do not necessarily go through these phases in an orderly fashion. Instead they may move back and forth between them over time.
Painful feelings typically continue for many months after bereavement, but they diminish in intensity over time, eventually becoming episodic. Such feelings may reemerge in more acute forms on memorable occasions such as anniversaries and holidays, and when especially poignant memories of the deceased are recalled. While negative feelings associated with bereavement typically do not completely disappear over time, they become less debilitating and overwhelming. Successful adjustment to the loss is marked by the ability to manage these feelings effectively as they wax and wane.
Not all feelings and experiences associated with bereavement are negative. Some bereaved people feel positive emotions such as relief that the deceased is no longer suffering, particularly after a lengthy illness. Over time, some people find that bereavement, though a difficult experience, is also a time of personal growth. They may develop a new appreciation for life and come to have an increased sense of self-esteem as they master new tasks and adjust to the experience of carrying on independently from the loved one they lost.
Adapting to loss involves recognizing and accepting the life changes that follow the loss. Finding ways to focus on the positive aspects of life and trying to find meaning in the loss are helpful coping strategies. Bereaved people often continue to have some form of relationship with the deceased person. Attachment to physical reminders of the deceased is common, especially in the initial period after bereavement. People often maintain a continuing bond with the deceased person through their religious or spiritual faith. Spiritual connections with the deceased may take the form of praying to the deceased or sensing the presence of the deceased in one’s life. Many cultures endorse preserving bonds with the dead through commemorative festivals and rituals. For example, the Day of the Dead celebration in Mexico allows the bereaved to celebrate the lives of the deceased.
In the initial months of bereavement, people often have symptoms that are characteristic of clinical depression, such as sadness, insomnia, loss of appetite, and weight loss. However, because these kinds of symptoms are normal and expected reactions to loss, a diagnosis of major depressive disorder, or clinical depression, is not generally given unless these symptoms are present to a significant degree two months after the loss of the loved one. Although grief may produce permanent changes in bereaved people, most people are able to accept their loss over time, see that there is still potential for having satisfying relationships with people, be productive, enjoy activities, have a sense of self-esteem, and find meaning and purpose in their lives. A small minority of bereaved people, however, experience pathological grief reactions that may need clinical intervention. Pathological reactions are more common among people who suffer traumatic losses, such as the violent death of a loved one, and among people who are excessively dependent on the deceased. Some may experience major depressive disorder or post-traumatic stress disorder (PTSD). Major depressive disorder is generally diagnosed only after two months have passed since the loss, and only if the bereaved person experiences persistent feelings of guilt that are not limited to guilt about the death of the loved one, thoughts of death that are unrelated to the death of the loved one, feelings of unworthiness, feeling slowed down, and being unable to perform normal activities. Post-traumatic stress disorder may be diagnosed if the bereaved person experienced the violent or traumatic death of a loved one, has recollections of the death that are recurrent and disturbing, avoids situations that are reminiscent of the death, and has marked irritability and difficulty sleeping and concentrating. In one study, researchers found that 9% of bereaved people met the criteria for major depressive disorder four months after their loss, and 5.7% met the criteria for post-traumatic stress disorder. Some scientists have proposed that the term “complicated grief disorder” be applied to describe additional cases in which people experience pathological reactions after bereavement. In one study, 10% of bereaved people studied met the criteria for complicated grief disorder. Complicated grief disorder is not listed in the DSM-IV, but scientists have proposed that it be included in the next edition. Complicated grief disorder has also been referred to as atypical grief, abnormal grief, pathologic grief, and pathologic mourning. Unlike people who experience normal bereavement, people who experience complicated grief disorder remain in a chronic state of mourning. They are unable to accept their loss and to make the adjustments needed to live effectively and productively without the loved one. They feel an intense yearning for the person they lost, experience persistent distressing thoughts about the deceased, and feel bitter and agitated about their loss. Although these kinds of reactions are common and normal in people in the initial months following the loss of a loved one, persistence of such symptoms beyond six months may be indicative of a pathological condition that may not resolve naturally. People who have difficulties with attachment to others, feel unprepared for the death of the loved one, and feel unsupported after the loss are at particularly high risk for complicated grief disorder. Psychotherapy, medications, and participation in support groups may be helpful in reducing the chronic, dysfunctional levels of grief that such people experience.
It is important to note that the reactions to bereavement can vary a great deal. Reactions are influenced by the personalities of the bereaved, their relationship to the deceased, the manner of death, and the cultural background of the bereaved. There are considerable differences between cultural groups in the ways that bereavement is expressed and in the duration of normal bereavement. Variations in bereavement reactions should be taken into account when trying to determine whether the particular response of a bereaved person is normal or pathological.
Many community organizations offer support to the bereaved. These include hospitals, social service agencies, funeral homes, hospices, YMCAs, and religious organizations such as churches, synagogues, and mosques.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.
Lendrum, Susan and Gabrielle Syme. Gift of Tears: A Practical Approach to Loss and Bereavement in Counselling and Psychotherapy. 2d ed. New York: BrunnerRoutledge, 2004.
Dutton, Yulia Chentsova, and Sidney Zisook. “Adaptation to Bereavement.” Death Studies 29 (2005): 877-903.
“JAMA Patient Page: Grief.” The Journal of the American Medical Association 23.21 (June 2005). <http://jama.ama-assn.org/cgi/content/full/293/21/2686>.
Zhang, Baohui, Areej El-Jawahri, and Holly G. Prigerson. “Update on Bereavement Research: Evidence-Based Guidelines for the Diagnosis and Treatment of Complicated Bereavement.” Journal of Palliative Medicine 9.5 (2006): 1188–1203.
American Hospice Foundation. 2120 L Street NW, Suite 200, Washington, D.C. 20037. Telephone: (202) 223–0204. <http://www.americanhospice.org>.
American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209–3901. Telephone: (703) 907–7300. <http://www.psych.org>.
Dougy Center for Grieving Children. P.O. Box 86552, Portland, OR 97286. Telephone: (503) 775–5683. <http://www.dougy.org>.
Mental Health America. 2000 N. Beauregard Street, 6th Floor Alexandria, VA 22311. Telephone: (703) 684–7722, (800) 969–6MHA (6642). <http://www.nmha.org>.
National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892–9663. (866) 615–6464. <http://www.nimh.nih.gov>.
TAPS (Tragedy Assistance Program for Survivors), Inc. 2001 S Street NW, Suite 300, Washington, D.C. 20009. Telephone: (800) 959–TAPS. <http://www.taps.org>.
The Compassionate Friends, Inc. P. O. Box 3696, Oak Brook, IL 60522–3696. Telephone: (877) 969–0010, (630) 990–0010. <http://www.compassionatefriends.org>.
Ruvanee Pietersz Vilhauer, PhD
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 )
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