Subscribe to Clinical Compass™ Volume 5, Issue 18 - September 7, 2010

Considering Bereavement Anew: Definition and Assessment Approach (Part 1 of 2)

by Sandra Haas Binford, MAEd


Approximately 5 weeks ago, National Public Radio (NPR) aired a story on Morning Edition about a woman who lost her 1-year-old infant to a drowning accident and who subsequently experienced thoughts and behaviors that threatened her personal safety for months, even as she began attending graduate school.(1) Like this woman, nearly all of us will experience the loss of a loved one at some point in our lives, and our reaction to this experience of bereavement will be as individual and unique as we are. Importantly, the story also described how, according to current DSM-IV-TR criteria, the diagnosis of major depressive episode (MDE) should not be made if symptoms are better explained by bereavement—the so-called bereavement exclusion criterion. Coverage in the national media related to removal of the bereavement exclusion criterion demonstrates the social significance of the decision before the DSM-V working group.(2)

Whatever the DSM-V will eventually include, the topics of grief, mourning, and depressed mood are important to consider, particularly in relation to how clinicians see and characterize these "symptoms." Evidence suggests that there are indeed performance gaps that exist. For example, Weber and colleagues point out the lack of attention given to bereavement education and treatment at all levels of medical education. While the authors state that the physician does not play the role of grief counselor, they promote preparation of physicians for the meaningful and practical support for the bereaved with specific medical options.(3) Undergraduate medical education courses now frequently include instruction and practice in doctor-patient communication, but medical education in the United States insufficiently prepares medical students and residents to communicate bad news to patients or families and help them cope with grief.(4)

This article seeks to differentiate bereavement, grief, and mourning and to address the importance of identifying a grieving patient whose symptoms warrant clinical intervention. Accurate identification of a patient's progress through bereavement requires judicious analysis of patient information and skillful appreciation of the contrast between normal and prolonged grieving that impairs functioning or is disabling.

Definitions of Bereavement, Grief, and Mourning
Bereavement is defined as an "…objective situation one faces after having lost an important person via death."(5) One might conceptualize it as the period in which grief is felt and mourning occurs.(6) Thus, grief and mourning can be viewed as two components of bereavement. It is increasingly clear that the eventual conclusion of bereavement begins in a continuum with anticipatory grief in relatives of those who are known to be dying.(7) Grief is the constituent of bereavement that describes the affective or emotional process of coping(8) and is the major focus of this article (see Figure 1).

Figure 1. Components of bereavement


Mourning, the other constituent of bereavement, is the social manifestation or appearance of bereavement in public. Mourning is greatly influenced by cultural norms and by one's beliefs and religious practices, so its effects "bleed" over into grief; the reverse is also true.(8) Some define mourning as the adaptation to loss, allowing one to complete bereavement by moving through four tasks as defined by Worden(9,10) (see Table I).

Table I: Worden's Bereavement Stages(9)

Stage 1

ACCEPTANCE
Accepting reality of the loss

Stage 2

PAIN
Experiencing the pain of grief

Stage 3

ADJUSTMENT
Adjusting to an environment in which the deceased person is missing

Stage 4

PROGRESS/RECOVERY
Investing the emotional energy of grief into another relationship


Grief can become stalled in Stage 4 as a bereaved survivor attempts to form new attachments.(9,10)

Bruce describes the four-step revision by Bowlby and Parkes of the five-step grief process originally outlined by Kübler-Ross. In their second phase, disorganization and despair, depression, disorganization, absentmindedness, and apathy can occur. However, these responses are normal signs of separation distress that should not be confused with a pathologic state.(10) As some of these signs are also characteristic of depression, detecting a patient's changing feelings, behaviors, and activities is important to a proper diagnosis and management.

Diagnosis and Assessment of Grief
Many clues may be discovered in determining a patient's bereavement progress and outside effects upon it: consult histories, any journals the patient has kept, circumstances of current life independent of the decedent's passing, the relationship of the decedent to the survivor, current affect and behavior, and specific statements.

Clinical Presentation of Normal Grief
Survivors experiencing the early stages of normal grief may say they feel as if they are going crazy or are in a bad dream. They may question their religious beliefs. Some thoughts expressed by patients can be loosely categorized into these areas:(11)
  1. Shock and disbelief, which some may name "denial"
  2. Profound sadness, crying, despair, loneliness, and yearning
  3. Guilt about thoughts, statements, and behaviors before and after the loved one's death
  4. Anger, resentment, and feelings of abandonment and blame
  5. Fear that may manifest as helplessness, insecurity, mortality, worries about loneliness and responsibilities, panic attacks, and anxiety
Grief may also present with physical symptoms. Symptoms include fatigue, nausea, lowered immunity, weight loss or weight gain, aches and pains, and insomnia.(11)

Features of Prolonged (Complicated) Grief
Yearning, mentioned above in the second loose category of normal grief, is a main indicator of prolonged grief.(12) Symptoms of complicated grief include:(11)
  1. Intense longing and yearning for the deceased
  2. Intrusive thoughts or images of the loved one
  3. Denial of the death or sense of disbelief
  4. Imagining that the loved one is alive
  5. Searching for the person in familiar places
  6. Avoiding things that remind you of your loved one
  7. Extreme anger or bitterness over the loss
  8. Feeling that life is empty or meaningless
If the clinician knows the bereaved one's personal and medical history, predictors of prolonged grief may help identify greater distress during bereavement and improve the doctor-patient relationship. Survivors with symptoms of grief have a higher incidence of psychological and physical complaints during bereavement and become patients themselves.(12)

In widows with high symptom levels of traumatic grief measured at 6 months, a physical health event (e.g., cancer, heart attack) was predicted at 25 months after intake of spouses to hospital. In widowers with high symptom levels of anxiety measured at 6 months, suicidal ideation was predicted at 25 months.(13) In a comparative study, Biondi and Picardi found that factors such as unexpectedness, absence of social support, concurrent loss or illness, and grief proneness may predict poor adjustment after bereavement. In humans, there is evidence of increased adrenocortical activity and altered immune function following bereavement. Critical life events can both affect brain neurotransmitters and contribute to psychological and somatic symptoms of depression. Emotional events may be transduced into long-lasting brain changes that involve neurotransmitters, neuropeptides, and receptors.(14)

Predictors of prolonged grief are numerous and vary; they depend on the deceased person's characteristics, illness, and terminal care received, as well as on the characteristics of the bereaved person (e.g., well-being before the loved one's death, caregiving experience, and existing interpersonal relationships of the bereaved person).(15) One predictor directly suggested by this range of issues is, "What was the nature of the relationship before the loved one's death?"

Prigerson and colleagues considered the following symptoms for inclusion in a diagnostic algorithm: "yearning; avoidance of reminders of the deceased; disbelief or trouble accepting the death; a perception that life is empty or meaningless without the deceased; bitterness or anger; emotional numbness or detachment from others; feeling stunned, dazed or shocked; feeling part of oneself died along with the deceased; difficulty trusting others; difficulty moving on with life; on edge or jumpy; [and] survivor guilt."(12)

Diagnostic Criteria
In light of the current proposed changes to the DSM-V(2) regarding removal of the bereavement exclusion criterion,(15) much work is to be done. However, bereavement is a universal and highly individual process with great variability in symptoms: Therefore, members of the psychiatry community have proposed a category for prolonged (complicated) grief in DSM-V.(7) These are diagnostic criteria for symptoms of grief that exceed the norm but differ from or do not meet the criteria for an MDE.(12) The challenge is to identify those patients exhibiting symptoms that may require explanation or intervention given current psychiatric guidelines.

Differential Diagnosis
Differential diagnosis for bereavement requires an analysis of patient function, as well as of symptom severity and duration. The functional effects of bereavement in different environments and at different times after loss may be the best areas of examination for bereavement and major depression. Prigerson and colleagues (2009) set forth cognitive and other symptoms that must be associated with enduring, functional impairment.(12)

According to the previously mentioned NPR interview with Dr. Kenneth Kendler, the severity and duration of signs and symptoms are the main factors in determining the proper diagnosis.(1) Because several symptoms commonly occur in both bereavement and depression, distinctions must be followed closely. However, Dr. Kendler refers to a "clear bright line" between grief and depression: Are symptoms in the "normal continuum of grieving"? Or has grieving veered off-course into "depression, which is dangerous"?(1) For example, if the patient's symptoms include suicidal ideations, homicidal ideations, or psychosis, then this constitutes a psychiatric emergency in the realm of major depressive disorder.

The challenge, then, lies in distinguishing the many symptoms of grief from symptoms of major depression or of adjustment disorder, making an accurate diagnosis along current practice guidelines, and providing care or referral that is appropriate for the current state of the patient. Prigerson and colleagues document 8 studies showing that, "in studies of bereaved individuals from a variety of different countries, yearning loads highly on the grief factor, but not on depression or anxiety factors, whereas sadness loads highly only on a depression factor and feeling nervous and worried loads highly only on an anxiety factor."(12) These findings suggest that yearning for the deceased person is a main characteristic of prolonged grief that may cause the bereaved person much distress but is not a feature or criterion of depression.

Identity is built in many ways upon the way people interact with their loved ones. If identity requires the constant presence and cooperation of a loved one who is immediately deceased, the survivor will require more adaptation—coping—during the search for a different identity that will a survivor who had abilities, interests, support structures, and activities that did not include the deceased parent, child, spouse, or other loved one.

Conclusion
The goal is to design and place into action a strategy to assess and manage bereavement that routinely monitors a patient's progress. The current description of the types of grief, the process of bereavement, and the efforts in the psychiatric community to define predictors of prolonged grief are offered as a prelude to the second part in this series that will focus on clinical tools to assist in grief assessment; they can be either used as formal tests or embedded in face-to-face conversation and history-taking. Such tools can help with both the widely varying experience of the bereavement process and variations in clinician experience and attitude. They help objectively answer several key questions where personal experience and patient variation might interfere: Does the clinician have either life experiences or the depth and length of clinical experience to competently assess the challenges that face the bereaved patient? Does the patient recognize the challenge of coping with a new identity in which a loved one is gone? Can the patient find the strength to move through life enough to discover the new identity that must develop after the loved one is gone? Is the patient mired down in one of the typical stages of bereavement to the point where functional performance is affected? I challenge you to ponder these questions as you anticipate the next article in this series.

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References

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  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, draft 5th ed. Washington, DC: American Psychiatric Association; scheduled for publication in May 2013. Available at: http://www.dsm5.org/pages/default.aspx. Accessed August 13, 2010.
  3. Weber M, Weiher E, Smeding RM. [Doctor and grief] [review in German]. Med Klin (Munich). 2008;103:532-539.
  4. Orlander JD, Fincke BG, Hermanns D, Johnson GA. Medical residents' first clearly remembered experiences of giving bad news. J Gen Intern Med 2002;17:825-831.
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  8. National Cancer Institute. Bereavement, Mourning, and Grief (PDQ®). National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/ supportivecare/bereavement/healthprofessional/allpages#Section_154. Accessed August 12, 2010.
  9. Worden JW. Grief Counseling and Grief Therapy; A Handbook for the Mental Health Practitioner. New York, NY: Springer; 1982.
  10. Bruce CA. Helping patients, families, caregivers, and physicians, in the grieving process. J Am Osteopath Assoc 2007;107(12 suppl. 7):ES33-ES40.
  11. Smith M, Jaffe–Gill E, Segal J, contributors. Coping with Grief and Loss: Support for Grieving and Bereavement. HelpGuide.org Web site. Available at: http://helpguide.org/mental/grief_loss.htm. Last modified: January 2009. Accessed on: August 13, 2010.
  12. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 2009;6(8):e1000121. Epub 2009 Aug 4.
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