Grief may be defined as the physical and emotional pain precipitated by a significant loss (Figure 38-1). The loss may be of a person or pet, but it can also be of a meaningful place, job, or object. A term closely related to grief is bereavement, which literally means to be robbed by death. Many subtypes of grief have been suggested; some of the more commonly used subtypes can be found in Table 38-1.^1,²

Figure 38-1 Untitled painting by Amy Newell that evokes feelings of loss and grief.

Table 38-1 Subtypes of Grief

Anticipatory grief	A grief reaction that occurs in anticipation of an impending loss; its symptoms include anger, guilt, anxiety, irritability, sadness, feelings of loss, and a decreased ability to perform usual tasks.¹
Acute grief	The first stage of the process of bereavement. Symptoms may begin immediately following the loss, or may be delayed.
Delayed grief	The absence of the expression of grief at the time of a loss.
Unresolved grief	Grief symptoms that reach extremes of intensity, duration, or tenacity.²
Complicated grief	Unresolved grief plus clinical complications (e.g., physical symptoms) that interfere with daily function.²

Epidemiology and Risk Factors

Death and loss are part of the human condition; therefore, everyone is at risk for the experience of grief. As death is universally feared, societies and cultures have developed rituals to help deal with the experience of loss and have provided support for survivors. In today’s Western society, however, individuals are often distanced from their families or cultures of origin, leaving them to deal with death on their own.

Psychoanalytic and attachment theories ³^–⁵ continue to dominate current thinking about the risk factors for pathological grief. A major theme is the belief in the influence of early relationships on a person’s ability to process loss. This theory has had important implications for the diagnosis and treatment of grief.

In the general population of the United States, estimates suggest that more than 1 million people each year develop complicated grief. Researchers have found that 40% to 55% of psychiatric outpatients have experienced one or more losses (through death); the average in one study was nearly three losses.^2,⁶ A study of psychiatric outpatients found that one-third met or exceeded the criteria for complicated grief²; the symptoms of complicated grief were distinct from those of major depression and anxiety.⁷^–⁹

Clinical Features and Diagnosis

While grief may be universal, each individual’s experience of bereavement is unique. When confronted by a grieving person, the physician is often challenged to determine whether the person’s grief is proceeding normally. This determination is often complicated by the fact that the severity and duration of grief vary widely; grief is shaped by sociocultural influences, and it does not necessarily proceed smoothly from one phase to another.^10,¹¹ The dearth of information about abnormal bereavement in the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV) reflects the lack of a general consensus regarding the differences between pathological and normal grief. Recent research on the subject is highlighted below.

Many investigators have described the stages of normal bereavement.^4,¹²^–¹⁴ One useful guideline proposes three overlapping phases: (1) shock, denial, and disbelief, followed by (2) a stage of mourning that involves physical as well as emotional symptoms and social isolation, eventually arriving at (3) a reorganization of a life that acknowledges, but is not defined by, the loss of the loved one.

Nonpathological grief can bring many symptoms reminiscent of depression: decreased appetite, difficulty with concentration, sleep disturbances, self-reproach, and even hallucinations of the deceased’s image or voice (though reality testing remains intact in normal grief). Assessment of various dimensions of the mourner’s experience can provide a more complete diagnostic picture ¹³ (Table 38-2).

Table 38-2 Dimensions of Grief

Emotional and cognitive responses to the death of a loved one	May include anger, guilt, regret, anxiety, intrusive images, feelings of being overwhelmed, relieved, or lonely
Coping with emotional pain	Mourners may employ several strategies (e.g., involvement with others, distraction, avoidance, rationalization, the direct expression of feelings, disbelief, or denial, use of faith or religious guidance, or indulgence in “forbidden” activities)
A continuing relationship with the deceased	The mourner’s connection with the deceased may be maintained through symbolic representations, adoption of traits of the deceased, cultural rituals, or various means of continued contact (e.g., dreams or attempts at communication)
Changes in daily function	Survivors may experience changes in their mental or physical health or their social, family, or work functions
Changes in relationships	The death of a loved one can profoundly shift the dynamics of a survivor’s relationships with family, friends, and co-workers
Changes in self-identity	As the mourning process proceeds, the grieving person may experience himself or herself in new ways that may lead to the development of a new identity (e.g., an orphan, an only child, a widow, or a single parent)

Adding to the difficulty in assessing grief is the lack of consensus regarding a normal duration of bereavement. At the very least, it may be safely said that the symptoms of grief usually last longer than anyone (mourner or observer) would like. Features of normal grief (e.g., anniversary reactions) may continue indefinitely, even in otherwise well-functioning individuals. The severity and duration of grief may also vary among cultural groups. The DSM-IV ¹⁵ suggests that in the aftermath of loss, the diagnosis of major depressive episode should be reserved for those individuals whose grief symptoms are severe and persist beyond 2 months following the loss. Also, symptoms that extend beyond the context of the loss (e.g., guilt about worldly events that bear no direct connection to the mourner or the deceased) should alert the clinician to the possibility of an Axis I disorder.

The DSM-IV does not classify grief as a major psychiatric disorder, but bereavement is given a “V” code as a condition that may be the focus of clinical attention. Despite this lack of recognition by the DSM-IV, many observers have described what Lindemann termed “distortions of normal grief.”¹⁶ Delayed grief may simply be a manifestation of a person’s cultural expectations, or may signal a potentially pathological problem. If an individual is unable to deal with the reality of a significant loss, the grief may be distorted in its expression. The survivor may begin to experience physical symptoms similar to those experienced by the deceased, or may have unexplained anniversary reactions.

The syndromes of unresolved grief and complicated grief are distinguishable from, yet may co-exist with, major depression, and respond to specific treatment.¹⁷ In unresolved grief, the grief symptoms are especially recalcitrant and do not seem to follow a path toward resolution. Key features of complicated grief include a sense of disbelief regarding the death, anger and bitterness over the death, recurrent pangs of painful emotions, and a preoccupation with thoughts of the lost loved one (that often include distressing intrusive thoughts related to the death).¹⁷ Clinical complications may include anxiety, physical morbidity, social/occupational/familial dysfunction, or health-compromising behaviors (e.g., noncompliance with prescribed medical treatment).^18,¹⁹

An algorithmic presentation of the differential diagnosis of grief and bereavement is provided in Figure 38-2.

Figure 38-2 Algorithm for differential diagnosis of grief and bereavement.

Treatment

Perhaps the most common treatment of grief involves simply listening to the mourner’s experience, and providing support. Most care of mourners is provided by the family, community members, and primary care providers. Two categories of mourners come to the attention of a psychiatrist: those individuals already in treatment for a previously diagnosed psychiatric condition, and those whose concern about pathological grief is the initiating complaint.

Psychiatric patients with any kind of pathological grief may benefit from a review of their psychoactive medications. Besides provision of support during the time of grief, an additional goal of treatment is the prevention of a relapse of the patient’s primary mental disorder (e.g., a temporary increase in sleep medications may be helpful if insomnia threatens to overwhelm a patient’s ability to cope).

Studies have shown that psychiatric outpatients with complicated grief who entered interpretive group psychotherapy aimed at addressing unconscious conflicts that underlie grief symptoms demonstrated greater improvement than those who entered supportive group psychotherapy (that focused on problem-solving skills).⁷

Research on treatment of pathological grief in previously undiagnosed individuals is scarce. Self-help groups, which are generally inexpensive and community-based, are frequently used as an alternative to professional help. The research on self-help groups is quite variable, however, and it does not lend itself to an assessment of their efficacy.

Psychotherapeutic approaches to pathological grief in the previously undiagnosed patient range from psychodynamic to behavioral, and from individual to group settings. Again, the lack of widely accepted diagnostic criteria for pathological grief leaves the therapist to use his or her own background, training, and experience to tailor the treatment for each patient. Besides careful attention to the possibility of an emerging Axis I disorder, other key issues in working with a grieving person are summarized in Table 38-3.²⁰

Table 38-3 Primary Psychotherapeutic Tasks When Working with a Bereaved Person

• Establish a relationship with the grieving individual, on his or her own terms

• Explore the loss as fully as possible

• Review the lost relationship

• Explore other contributing factors (e.g., financial problems related to the death, and a personal history of responses to death/losses)

• Identify strengths and supports

• Provide support

• Look ahead to new roles, relationships, and challenges

Prognosis

While most people do not become seriously ill or die in the initial grieving period, it is difficult to know what long-term health risks exist. However, certain risk factors for poor bereavement outcomes have been identified ²¹ (Table 38-4).

Table 38-4 Risk Factors for Poor Bereavement Outcome

Demographic factors	Advanced age
	Lower socioeconomic status
Individual factors	Ambivalence or dependency in the relationship with the deceased
	Health problems before bereavement
Mode of death	Sudden death
	Death of a child
	Stigmatized death (e.g., due to suicide)
Circumstances following the loss	Lack of social support
Circumstances following the loss	Concurrent crises (e.g., financial problems)