Additionally, a myriad of stressors emerge as a consequence of requirements to attend to a range of things not usually on the agenda. Coping with these is necessary for restoration of ongoing life. A deceased loved one thus bequeaths an array of emotional and practical problems that a bereaved person must solve. Given the scope and magnitude of the impact of losing a loved one, it is notable that relatively few negative long-term consequences usually occur.
Most people meet the coping demands, with the help of supportive companions, and find a pathway that leads to restoration of a potentially satisfying and meaningful life.
Instead, they become entangled in grief, caught up in a futile struggle of silent protest, trying to avoid reminders, and being carried helplessly on endless waves of acutely painful emotion. These people are suffering from complicated grief CG , a syndrome in which healing is impeded and acute grief is intense and prolonged. Clinicians need to recognize symptoms of CG and differentiate this condition from usual acute grief, as well as depression and anxiety disorders.
It is useful to have a framework for conceptualizing CG in order to better accomplish the differential diagnosis and to recognize risk factors and understand principles used to treat CG. Using the terms bereavement, grief, and mourning interchangeably is a problem.
To do so is not wrong, but it is more useful to allow the terms to denote specific components of the experience of loss. Therefore, in this paper, the term bereavement refers to the experience of having lost someone close. Grief is the psychobiological response to bereavement whose hallmark is a blend of yearning and sadness, along with thoughts, memories, and images of the deceased person. Insofar as we never stop feeling sad that loved ones are gone, or stop missing them, grief is permanent.
However, the acute, all-consuming intensity usually moderates over time, as grief becomes deeper, less intrusive, and integrated into our lives. Mourning is the array of psychological processes that are set in motion by bereavement in order to moderate and integrate grief by coming to terms with the loss and reorienting to a world without our loved one in it.
When we look, we can discern a general framework for grief, but its day-to-day manifestations are variable and wide-ranging, influenced by many factors. Important and among them is the relationship to the bereaved person and specific circumstances of the death.
Several studies suggest that grief is most intense and difficult for people bereaved of a child or a life partner, and these are the people most likely to experience CG.
In general, death of a child is the most difficult kind of loss, and bereaved family members are at elevated risk for depression and anxiety for close to a decade after the loss. There are two ways to look at elevations in mood and anxiety symptoms that are seen more commonly after certain kinds of loss.
Some people say we should consider such symptoms normal because so many people exposed to this devastating life event experience them. However, there is another way to look at this. It is normal to break your leg when you fall off a ladder or to develop a bad sore throat and dangerous antibodies when you are exposed to a streptococcus infection. As clinicians, we don't tell a man with a broken leg not to worry; that his injury is normal. Nor would diagnosis of a strep infection be considered pathologizing a normal reaction.
The premise of this paper is that acute grief is a normal reaction to loss that does not require a clinical diagnosis. By contrast, major depression, post-traumatic stress disorder PTSD , panic disorder, and CG are mental disorders that should be diagnosed. Clinicians need to know how to tell the difference. Whichever way we view mood and anxiety in the wake of bereavement, it is clear that the person who died makes a difference to the likelihood of experiencing these symptoms.
The way a person dies can also be difficult for surviving friends and family. Death that is sudden and unexpected, especially if it is violent and untimely, is especially difficult.
The more difficult the death, the more potholes in the road, but the direction and destination of mourning is similar. Grief is the usual instinctive psychological response to bereavement. Typical kinds of thoughts, feelings, and behaviors occur, albeit in a pattern and intensity that vary and evolve over time.
Acute grief is a blend of yearning and sadness, with accompanying thoughts, memories, and images of the death and the deceased person, and a tendency to be more interested in this inner world than in the activities that populate ordinary life.
On the other hand, like the love that spawns it, grief's molecular expression is unique to each relationship.
Grief is usually erratic in its manifestations, intensity, and course. Yet, looked at from a bird's-eye perspective, most bereaved people make their way along a road, albeit bumpy and strewn with potholes, that leads to acceptance of the inevitability of the loss, integration of its reality into ongoing life, and reimagining a future with the possibility of joy and satisfaction.
During this journey, acute grief, intensely painful and dominant, becomes integrated, muted, and in the background. CG is the syndrome that occurs when this transformation does not occur.
Some people conflate the terms grief and depression. They are not the same. Both infuse our lives with sadness, and both cause disruption, but the similarity ends there.
Depression is a mental disorder. Grief is not. Bereaved people are sad because they miss a person they love, a person who added light and color and warmth to their world. They feel like the light has been turned off and they aren't sure how to turn It on again.
They feel like the world has no light or color or warmth. There is no light to turn on. Depression inhibits the capacity to experience positive emotions. Grief does not. Positive emotions occur as frequently as negative ones as early as a week after a loved one dies. Depression biases thinking in a negative direction. Depression interferes with the capacity to care about other people and to understand their good intentions.
Grief turns a person inward, but the desire to be with others and appreciation for the efforts of others is preserved. Both depression and grief take one out of ongoing life, but the reason for withdrawal is very different.
In the words of author and scientist Kay Redfield Jamison:. I did not, after Richard died, lose my sense of who I was as a person, or how to navigate the basics of life, as one does in depression. I lost a man who had been the most important person in my life and around whom my future spun. I lost many of my dreams, but not the ability to dream. The loss of Richard was devastating, but it was not deadly.
It is very important that depression and grief not be confounded, because depression requires treatment and grief requires reassurance and support. We do someone a disservice by diagnosing depression if they are experiencing acute grief. Correspondingly, we do someone a disservice by calling it grief when a person is depressed. Moreover, depression-related inhibition of positive emotions, 12 bias toward negative thinking, 13 and interference with relationships can all impede successful mourning and predispose to complicated grief.
Mourning is the process by which bereaved people seek and find ways to turn the light on in the world again. From a clinical perspective, mourning is an array of psychological processes that can be roughly grouped as emotion regulation and learning processes. When successful, mourning leads people to feel deeply connected to deceased loved ones while also able to imagine a satisfying future without them. After mourning successfully, a bereaved person is re-engaged in daily life, reconnected to others, and able to experience hope for a future with potential for joy and satisfaction.
Grief has been transformed and integrated. A successful mourning process entails effective emotion regulation and assimilation of new learning in long-term memory. Our loved ones exist in long-term memory, but there are different kinds of memory. Episodic, semantic, and implicit memory 14 - 18 are inter-related but serve different functions, entail different brain systems, and have different properties. Close attachments are mapped in each of these systems, so each must be updated when a loved one dies.
To update explicit memory means learning new stories and facts. To update semantic memory means learning new meanings and rules, and to update implicit memory means extinguishing conditioned reward responses and learning new motor patterns and other procedural responses that are permanently out of awareness. Given this multifaceted goal, it makes sense that mourning is a complex process that is often lengthy and arduous. We must repeatedly engage with information about the death and its myriad consequences in order to adequately assimilate it and amend existing information about the deceased in each memory system.
One of the challenges of mourning is that the required learning is both intensely emotional and deeply aversive. Awareness of mortality registers in a specific area of our brains and almost always registers as a threat.
We naturally resist thinking of our own death and even more so that of our loved ones. We must overcome this resistance in order to confront and assimilate the information that a loved one is gone. When we do confront the reality, we are often assailed by tidal waves of negative emotion.
Grief can overwhelm our usual emotion regulation capacity, forcing us to resort to escape and avoidance to get some respite. John Bowlby introduced attachment theory to the mental health field. He described the process of mourning from the perspective of a biobehavioral understanding of attachment relationships.
He noted that emotion regulation is typically accomplished only gradually following bereavement, and suggested that it takes considerable time to revise an existing mental model.
He further observed that during this process our minds naturally, and mercifully, oscillate between confronting and avoiding ie, defensively excluding the painful reality. When used exclusively, avoidance hinders the learning process. Moreover, defensive exclusion leaves the sufferer ever vulnerable to the sudden unexpected occurrence of painful reminders of the loss.
It is necessary to find a way to reappraise triggers of negative emotion so that the continued presence of the loss is no longer insistent and disruptive. A collection of emotion regulation strategies, both implicit, eg, extinction of conditioned reward; revision of other procedural memories, and explicit, eg, reflection, reappraisal, distraction, and problem solving, are usually employed as a part of the mourning process.
Information about the finality and consequences of the loss is assimilated into long-term memory, both explicit and implicit, leaving a residue of feelings and thoughts about the deceased person that are usually bittersweet and in the background. CG is a chronic impairing form of grief brought about by interference with the healing process.
Think about a physical wound that produces an inflammatory response as part of the healing process. A wound complication, for example an infection, increases the inflammation and delays healing. You can think of bereavement as analogous to an injury and grief as analogous to the painful inflammatory response and complicated grief as analogous to a superimposed infection. The result is delayed healing and increased pain which occurs because aspects of a person's response to the circumstances or consequences of the death derail the mourning process, interfering with learning, and preventing the natural healing process from progressing.
Box 1 describes the clinical picture of a patient with CG. Christy's situation is an example of complicated grief. She lost her husband George and a favorite aunt in quick succession. Her husband had a chronic illness in which he had numerous hospitalizations, usually with positive outcomes. She had come to expect some improvement after a hospital stay, or at least stabilization.
So when her elderly aunt developed a serious illness and took a turn for the worse, Christy thought her recently hospitalized husband would be OK without her. Unfortunately this was not to be. Christy was at her aunt's bedside when her husband died. Her immediate reaction was shock and disbelief, accompanied by a flood of remorse that she had not been with George, and a strong feeling that it was unfair that she had to lose him in this way. From the moment she learned of his death until she came for treatment 2 years later, she was overcome by guilt, blaming herself for abandoning her husband in his time of need.
She repeatedly told herself that if she had been with George, she would have gotten him back to the hospital and prevented his death. Ruminating over this failing, she was consumed with feelings of yearning to have him back, and unable to function in her usual effective way. Thoughts and memories of George filled her mind, and she found it difficult to care about anything else. Her friends had become harsh, accusing her of wallowing in her grief. She was hurt, but, in a way, she saw their point.
Feelings such as anger, jealousy, and indifference resulting from loss can also define grief. Grief is experienced in many unique ways.
It affects everyone differently. Depending on things like your experiences, emotional and psychological well-being, cultural beliefs, and relationship to the deceased or attachment to the loss, your level of suffering will vary from others. Generally, people tend to see grief and bereavement as the same thing.
Subtle things differentiate one from the other, while others clearly define each. In general, grief is an emotional reaction to loss. And, bereavement is the time period that a person can grieve and mourn that loss.
The two are often confused. Some differences to know are:. This is one of the biggest differences in telling apart grief from bereavement. A person who has just been given the news that their loved one has died will suffer an emotional reaction to that loss.
They may be in shock at hearing the news, they may lash out in anger, or begin to sob uncontrollably. These are all examples of an emotional response to that loss. These reactions are tied to grief. A person may grieve anywhere from several weeks to several years. They may be unable to function at work and ask for a few days of bereavement leave. The end of their bereavement leave and return to work does not signal the end of their grief. Bereavement ends when the initial part of suffering and mourning ends.
A person is said to be in bereavement for the time that it takes for them to process their grief and mourning. Four Tasks of Mourning: Worden identified four tasks that facilitate the mourning process.
Worden believes that all four tasks must be completed, but they may be completed in any order and for varying amounts of time. These tasks include:. Support Groups: Support groups are helpful for grieving individuals of all ages, including those who are sick, terminal, caregiving, or mourning the loss of a loved one. Support groups are available through religious organizations, hospitals, hospice, nursing homes, mental health facilities, and schools for children.
Viewing death as an integral part of the lifespan will benefit those who are ill, those who are bereaved, and all of us as friends, caregivers, partners, family members and humans in a global society.
Models of Grief There are several theoretical models of grief, however, none is all encompassing Youdin, Denial is often the first reaction to overwhelming, unimaginable news. Denial, or disbelief or shock , protects us by allowing such news to enter slowly and to give us time to come to grips with what is taking place.
The person who receives positive test results for life-threatening conditions may question the results, seek second opinions, or may simply feel a sense of disbelief psychologically even though they know that the results are true.
Anger also provides us with protection in that being angry energizes us to fight against something and gives structure to a situation that may be thrusting us into the unknown. It is much easier to be angry than to be sad, in pain, or depressed. It helps us to temporarily believe that we have a sense of control over our future and to feel that we have at least expressed our rage about how unfair life can be.
Anger can be focused on a person, a health care provider, at God, or at the world in general. It can be expressed over issues that have nothing to do with our death; consequently, being in this stage of loss is not always obvious. Bargaining involves trying to think of what could be done to turn the situation around. Living better, devoting self to a cause, being a better friend, parent, or spouse, are all agreements one might willingly commit to if doing so would lengthen life.
Asking to just live long enough to witness a family event or finish a task are examples of bargaining. Depression or sadness is appropriate for such an event. Feeling the full weight of loss, crying, and losing interest in the outside world is an important part of the process of dying.
This depression makes others feel very uncomfortable and family members may try to console their loved one.
Sometimes hospice care may include the use of antidepressants to reduce depression during this stage. Acceptance involves learning how to carry on and to incorporate this aspect of the life span into daily existence. Reaching acceptance does not in any way imply that people who are dying are happy about it or content with it.
It means that they are facing it and continuing to make arrangements and to say what they wish to say to others. Some terminally ill people find that they live life more fully than ever before after they come to this stage. As she notes, Figure Mourning As a society, are we given the tools and time to adequately mourn?
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