What is grieving in psychopathology?

Introduction

Much of life depends on successful adaptation to change. When that change is experienced as a loss, the emotional and cognitive reactions are properly referred to as "grief." When the specific loss is acknowledged by a person’s culture, the loss is often met with rituals, behaviors that follow a certain pattern, sanctioned and choreographed within the culture. The term “bereavement” is applied to the loss of a significant person (such as a spouse, parent, child, or close relative or friend). In this case the grief and the sanctioned rituals are referred to as "mourning," although some writers use the terms “mourning” and “grieving” as synonyms.

Reaction to a loss often depends on whether the loss is experienced as central as opposed to peripheral to the self, with more central losses exerting greater impact on the people’s ability to function. People who have experienced an important loss may experience obsessive thoughts about who or what was lost, a sense of unreality, a conviction that they were personally responsible for the loss, a sense that there is no help or hope, a belief that they are bad people, and a sense that they are not able to concentrate and remember. Searching for and even perceiving the lost person (often in a dream) are not uncommon.

People’s emotional response may at first be engrossing. Shock, anger, sadness, guilt, anxiety, or even numbness are all possible reactions. Crying, fatigue, agitation, or even withdrawal are not unusual. Some people find it difficult to accept or absorb the reality of the loss in a reaction known as "denial." Depending on cultural, family, and individual traditions, some people suppress, repress, and deny part of their awareness, grief reaction, or both.

The centrality of loss within the self is also related to its circumstances. If people are prepared for the loss, they have made themselves less vulnerable to the loss of that person, place, or object in a process known as "anticipatory grief." This is experienced, for example, by those caring for terminally ill patients, as well as by the patients themselves. Although some argue that grief that is anticipated may be less challenging than that following an unexpected loss, the experience of grieving for someone and caring for that person at the same time can be extremely challenging.

History of Grief Studies

The study of grief as a scholarly concern was started by an essay, “Mourning and Melancholia,” written in 1917 by the Austrian founder of psychoanalysis, Sigmund Freud
. In it, Freud proposed that hysteria (a disorder of emotional instability and dissociation) and melancholia are symptoms of pathological grief. He indicated that painful dejection, loss of the ability to love, inhibition of activity, and decrease in self-esteem that continue beyond the normal time are what distinguish melancholia from mourning (the pathological from the normal). In melancholia, it is the ego (or self) that becomes poor and impoverished. In the pathological case, the damage to self is becoming permanent instead of being a temporary and reversible deprivation.

The study of grief as a normal process of loss evolved over two-and-a-half decades. It was not until 1944 that psychiatrist Erich Lindemann published a study based mostly on interviews with relatives of victims of the Cocoanut Grove nightclub fire in Boston in 1942. He characterized five different aspects of the grief reaction. Each of the five was believed by Lindemann to be normal. Each would give way as the individual readjusted to the environment without the deceased, formed new relationships, and released the ties of connection with the deceased. Morbid or pathological grief reactions were seen as distortions of the normal patterns. A common distortion had to do with delay in reacting to the death. In these cases, the person would either deny the death or continue to maintain composure and show little or no reaction to the death’s occurrence. Other forms of distorted reactions were overactivity, acquisition of symptoms associated with the deceased, social isolation, repression of emotions, and activities that were detrimental to the person’s social status and economic well-being. Examples of such detrimental activities might be getting drunk, being promiscuous, giving away all one’s money, and quitting one’s job.

In the early 1950s, British psychoanalyst and physician John Bowlby began to study loss in childhood, usually with children who were separated from their mothers. His early generalization summarized the child’s response in a threefold way: protest, despair, and detachment. From his later work, which included adult mourning, he came to the conclusion that mourning follows a similar pattern whether it takes place in childhood, adolescence, or adulthood. In his later work, he specified wide time frames for the first and second phases and expanded his threefold description of the process to identify four phases of mourning. All four phases overlap, and people may go back for a while to a previous phase. These phases were numbing, which may last from a few hours to a week and may be interrupted by episodes of intense distress or anger; yearning and searching for the lost figure, which may last for months and even for years; disorganization and despair; and reorganization to a greater or lesser degree.

What was new and interesting about the fourth phase is Bowlby’s introduction of a positive ending to the grieving process. This is the idea of reorganization, a positive restructuring of the person and the individual’s perceptual field. This is a striking advance beyond Lindemann’s notion that for the healthy person, the negative aspects of grieving would be dissipated in time.

Meanwhile, in the mid-1960s, quite independently of Bowlby, Swiss-born psychiatrist Elisabeth Kübler-Ross
was interviewing terminally ill patients in Chicago. She observed closely, listened sensitively, and reported on their experiences in an important book, On Death and Dying (1969). Her work focused on the experiences of the terminally ill.

Kübler-Ross was there as patients first refused to believe the prognosis, as they got angry at themselves and at others around them, as they attempted to argue their way out (to make a deal with God or whoever might have the power to change the reality), as they faced their own sadness and depression, and finally as they came to a sense of acceptance about their fate. (Her idea of acceptance is similar to Bowlby’s concept of reorganization.) From her interviews, she abstracted a
five-stage process in which terminally ill patients came to deal with the loss of their own lives: denial and isolation, anger, bargaining (prayer is an example), depression, and acceptance.

The Process

The grief process is complex and highly individualized. It is seldom as predictable and orderly as the stages presented by Bowlby and Kübler-Ross might imply. Studies conducted by psychologist Janice Genevro in 2003 and Yale University researchers in 2007, as well as a survey of Canadian hospices in 2008, contradict the stage theory of grief altogether and suggest that grief is actually a complex mix of recurring emotions and symptoms that eventually alleviate. The duration of intense grief is quite variable, which can be a source of frustration to bereaved individuals who just want to know when their intense grief will end. Some people take a while to fully realize their loss. In a process known as "denial" or "disbelief," the grieving itself may be delayed. In a normal grief process, bereaved people eventually reach acceptance and accomplish reassessment and reorganization of their lives.

Grieving is the psychological, biological, and behavioral way of dealing with the stress created when a significant part of the self or prop for the self is taken away. Austrian endocrinologist Hans Selye
made a vigorous career defining stress and considering the positive and negative effects that it may have on a person. He defined stress as “the nonspecific response of the body to any demand made upon it.” Clearly any significant change calls for adjustment and thus involves stress. Selye indicated that what counts is the severity of the demand, and this depends on the perception of the person involved.

Complicated Grief or Depression?

Researchers and practitioners are beginning to understand the antecedents and consequences of complicated grief. To some extent, the likelihood of complicated grief depends on the nature of the loss. Losses that are unexpected and those involving sudden or violent death or suicide are especially problematic, as are those associated with childhood abuse or neglect. Individuals who are socially isolated, who were abused or neglected as children, who had a difficult emotional relationship with the deceased, or who lack resilience are particularly vulnerable to complicated grief. Prior history of mental illness, religion, gender, age, and social support are other factors. Between 10 and 20 percent of individuals experiencing a loss exhibit complicated grief reactions. Apart from its negative emotional attributes, this type of grief reaction is associated with higher rates of illness and suicide. In 2013, the American Cancer Society estimated that major clinical depression develops in up to 20 percent of bereaved persons, diagnosable after two months of extreme symptoms such as delusions, hallucinations, feelings of worthlessness, or dramatic weight loss.

Clinical trials suggest that cognitive behavioral therapy or complicated grief treatment may be helpful for those experiencing complicated grief. There is also limited evidence for using antidepressant medications for treating complicated grief, though the outcomes were not as good as those for people with clinical major depression unrelated to grief.

The
Diagnostic Statistical Manual of Mental Disorders (DSM) long stated that clinicians should rule out grief due to a recent loss (within the first few weeks after the death) before making a diagnosis of depression or an adjustment disorder. The fifth edition (DSM-5), published in 2013, eliminates this "bereavement exclusion," generating a great deal of controversy. The American Psychiatric Association states that the reasons for the change are that bereavement often lasts one to two years, not less than two months, and that major depression can be triggered by bereavement, particularly in those who have personal or family histories of depression. Proponents argue that bereavement is merely another stressor like unemployment or divorce and therefore should be considered similarly in diagnosing a patient. Many critics warn that normal grief reactions will be pathologized and patients given unnecessary treatment, particularly antidepressants.

Cultural and Social Influences

Because loss is such a regular part of life, a person’s reaction to it is likely to be regulated by family and cultural influences. Religious and cultural practices have developed to govern the expected and acceptable ways of responding to loss. Many of these practices provide both permission for and boundaries to the expression of grief. They provide both an opportunity to express feelings and a limit to their expression. Often a religion or culture will stipulate the rituals that must be observed, how soon they must be concluded, how long they must be extended, what kind of clothing is appropriate, and what kinds of expressions are permissible and fitting. They also provide a cognitive framework in which the loss may be understood and, perhaps, better accepted—for example, framing the loss as God’s will.

The funeral home industry has been subject to criticism for profiting from the ubiquity of death. In part as a result, several organizations have sprung up to deliver affordable alternatives to traditional funeral arrangements, such as cremation, home-based funeral services, and green (environmentally sensitive) burials.

Toward the end of the twentieth century, professional interest in grief and grief counseling began to grow. The Association for Death Education and Counseling was founded in 1976 to provide a forum for educators and clinicians addressing this concern. Major journals such as Omega and Death Studies provide sources for research on grief and loss.

Bibliography

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