L13 Psych Med Grief and mourning

Overview

This lecture covers grief as a normal human process: its terminology, the range of emotional, physical, cognitive, social and spiritual responses to loss, and how common “abnormal-seeming” experiences like post-death contact actually are. It then surveys several theoretical models of grief (Kubler-Ross, Sheldon’s four stages, Parkes-Bowlby, the dual process model, Worden’s tasks of mourning, continuing bonds) before turning to when grief becomes pathological: the DSM-5-TR criteria for Prolonged Grief Disorder, risk factors, how to distinguish grief from depression, common comorbidities, and practical guidance on responding to a grieving person.

Terminology

• Bereavement: the objective situation of having lost someone significant through death.
• Grief: the emotional response to this loss.
• Mourning: the outward response to grief; how grief is expressed after a loss and how a person adapts to grief after a loss.

Why learn about grief

• Personal: most people have already experienced grief, or are likely to in their lifetime.
• Clinical: clinicians will encounter grief in patients; need to know what is normal, whether it could be pathological, and may experience their own grief responses if they have contact with patients who die.
• There is an interaction between the personal and clinical experience of grief.

Grief is normal, not an illness

Grief is a normal phenomenon common to everyone, not an illness or a condition, even though it can be intense, extreme, or impair functioning.

• Losses occur throughout life and it is not possible to go through life without suffering losses.

Domains of grief response

Grief is multifaceted, spanning emotional, physical, cognitive, social and spiritual domains.

• Emotional: pain, numbness, anger, sadness, shock, bewilderment, disorientation, rage, uncertainty, helplessness, guilt, despair, isolation, loneliness, emptiness, agitation, fear, worry, anxiety, disbelief, relief, freedom, gratitude, regret, weepiness.
• Physical: tiredness/exhaustion, sobbing, weeping, moaning, heart pounding, tight chest, shallow breathing, aching limbs/muscles, nervous laughter, energised or no-energy states, staying still, clumsiness, slowed reactions, increased susceptibility to illness, tension release, increased sensitivity to sound, weakness, tearfulness, screaming, headaches, nausea, stomach aches, sleep disturbance, changed eating patterns, digestion problems. A distinctive physical response is feeling pain in the location where the deceased person had pain.
• Cognitive: “why me,” confusion, poor memory and concentration, preoccupation with the person or loss, disbelief, forgetting the loss, feeling bad about oneself, recriminations (“what if”), worry about the future, replaying “if only” scenarios, comparing one’s grief to others’, wondering who will die next, not wanting to think, wanting to be with the dead person.
• Social: wanting to talk about the loss or actively avoiding talking about it, looking for the lost person, heightened sensitivity to what others say, wanting or not wanting contact/hugs, wanting to be alone, aggressive behaviour, arguments, not caring about things or relationships.
• Spiritual: feeling spiritually alive or numb, questioning religious beliefs, feeling comforted or supported by beliefs, wanting to pray, feeling let down or punished by God, questioning the meaning of life (“the why”), guilt and wanting forgiveness, feeling or sensing the presence of the person who died.

Post-death contact

• Hallucinatory experiences of seeing or hearing the deceased, or other forms of post-death contact (e.g. hearing the deceased’s voice), can occur as part of normal grief rather than indicating pathology.
• Klugman (2006), a US telephone survey study: randomly generated numbers, respondents had to be over 18 and have experienced the death of a family member or friend; 928 calls were answered, giving 202 participants.
• 97% of participants had at least two post-death contact experiences with the deceased. Breakdown by modality:
  • Acoustic: 34% heard the deceased’s voice; 82% heard music associated with the deceased and interpreted it as a sign.
  • Optical: 38% saw a vision/image of the deceased.
  • Olfactory: 20% experienced a strong smell associated with the deceased.
  • Other: 85% dreamed of the deceased; 54% felt the deceased was watching over/protecting them; 70% had conversations with the deceased; 25% felt the deceased’s touch; 10-20% experienced moving objects or changed radio volume.

Range and duration of normal grief

• Normal grief varies across individuals and cultures, and spans a range from intense emotional responses with significant functional impairment through to transitory situational sadness with little or no functional disruption.
• Duration (Bonanno, 2005, and clinical experience): the majority have a significant level of grief-related disruption in the first 2-3 months, usually remitting within 6-7 months. Physicians and grief counsellors commonly see a duration of 1-2 years. Intense sadness when reminded of the loss can persist lifelong.

Models of grief

• Kubler-Ross stages of dying (1969, 1974): Denial, Anger, Bargaining, Depression, Acceptance. Widely known and patients may already know it, but it is overly prescriptive (implies grief that doesn’t follow these stages is “not normal”); in reality grief is individual and stages may occur in any order, or not at all, or not occur.
• Sheldon’s four stages (1998), each with a “task”:
  1. Initial shock: numbness, disbelief, relief. Task - accept the reality of the loss.
  2. Pangs of grief: sadness, anger, guilt, anxiety, withdrawal, transient hallucinations of the dead person, searching behaviour. Task - experience the pain of grief.
  3. Despair: loss of direction and meaning in life. Task - adjust to an environment in which the deceased is missing.
  4. Adjustment: developing new relationships or interests. Task - emotionally relocate the deceased to an important but not central part of the bereaved person’s life and move on.
• Parkes-Bowlby attachment model: Numbness -> Yearning (including anger and guilt) -> Disorganisation and despair -> Reorganisation.
• Dual process model of coping (Stroebe et al, 1999): coping with bereavement is depicted as an oscillation (not a fixed sequence) between two states within everyday life experience:
  • Loss-oriented: grief work, intrusion of grief, letting go/continuing/relocating bonds and ties, denial or avoidance of restoration changes.
  • Restoration-oriented: attending to life changes, doing new things, distraction from grief, denial or avoidance of grief, new roles/identities/relationships.
• Worden’s Tasks of Mourning (2009), four sequential tasks:
  1. To accept the reality of the loss.
  2. To work through the pain of grief.
  3. To adjust to an environment in which the deceased is missing.
  4. To find an enduring connection with the deceased while embarking on a new life.
• Continuing bonds: the idea that a bereaved person maintains an ongoing connection with the deceased rather than fully “letting go,” illustrated in the lecture with a quote from a bereaved son about carrying forward his late father’s words of wisdom.
• All models are theoretical: they have limitations (developed based on adults and specific populations) but serve to guide and explain, not to prescribe.

Normal versus maladaptive grief

• 85-95% of people go through an uncomplicated bereavement process; the majority of grief responses resolve and require support rather than clinical intervention.
• Maladaptive grief reaction (complicated grief/prolonged grief): the presence of severe grief reactions that are persistent over time, affecting 5-15% of people.

Prolonged Grief Disorder (DSM-5-TR)

• Now recognised as a disorder under “Trauma- and Stressor-Related Disorders” in DSM-5-TR.
• Criteria overview (A-F):
  • A - Actual loss and appropriate timeframe.
  • B - Yearning and/or preoccupation.
  • C - Additional cognitive, emotional and behavioural symptoms.
  • D - Disruption (functional impairment).
  • E - Exceeds cultural expectations and duration.
  • F - Fits no other diagnosis (exclusion).
• Full criteria:
  • A: death occurred at least 12 months ago (6 months for children and adolescents), of a person close to the bereaved individual.
  • B: since the death, a persistent grief response with one or both of the following, present most days to a clinically significant degree, and occurring nearly every day for at least the last month: intense yearning/longing for the deceased; preoccupation with thoughts or memories of the deceased.
  • C: since the death, at least 3 of the following present most days to a clinically significant degree, occurring nearly every day for at least the last month:
    1. Identity disruption (not feeling like oneself, or feeling part of oneself died).
    2. Marked sense of disbelief about the death.
    3. Avoidance of reminders that the person is dead.
    4. Intense emotional pain related to the death.
    5. Difficulty with reintegration into life.
    6. Emotional numbness.
    7. Feeling that life is meaningless.
    8. Intense loneliness.
  • D: causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
  • E: duration and severity of the bereavement reaction exceeds expected social, cultural or religious norms of the individual’s context.
  • F: symptoms not better explained by another disorder (e.g. major depressive disorder or PTSD) and not attributable to a substance or medical condition.

Example case (David)

David, a 40-year-old married father of two, whose wife Melissa died 14 months ago in a sudden, traumatic high-speed collision caused by a drunk driver (he was notified by police and identified her at hospital). His grief has not eased over the past year: daily yearning (“It’s like a part of me is missing”), intrusive thoughts and rumination about the accident, avoidance of crash-related locations, his wife’s belongings left untouched, emotional numbness, intense sorrow, withdrawal from friends and family, feeling like “a shell,” medical leave due to poor concentration and chronic fatigue, feeling lost and that life has little meaning, disturbed appetite and sleep, increased alcohol use. He denies suicidal ideation but admits passive thoughts (“it wouldn’t matter if I didn’t wake up tomorrow”). No prior psychiatric history or recent substance use disorder; the grief reaction began within months of the loss but has intensified over subsequent months. This case illustrates a presentation consistent with Prolonged Grief Disorder.

Risk factors for Prolonged Grief Disorder

• Dependency on the deceased prior to their death.
• Death of a child.
• Violent or unexpected deaths.
• Economic stressors.
• Previous mental illness, especially depression.
• Low self-esteem.
• Death of a spouse/partner or child, compared with other kinship losses.

Grief versus depression

Some grief symptoms superficially resemble depression (low mood, crying, suicidal thinking), and a depression diagnosis can co-occur with bereavement, but careful distinction is needed between normal sadness/grief and depression.

Grief	Depression
Emptiness and loss	Persistent depressed mood
Experienced in waves	Moods and feelings are static, not tied to specific triggers
Diminishes in intensity over time	Pervasive unhappiness and misery
Pangs triggered by thoughts/memories of the deceased	Consistent sense of depletion
Can be accompanied by positive emotions and humour	Thoughts are self-critical, pessimistic
Thoughts preoccupied with the deceased	Sense of worthlessness, self-loathing, pervasive hopelessness
Healthy self-image; if derogatory, focused on what could have been done better for the deceased	Preoccupation with self
Responsive to support	Unresponsive to support
Overt expression of anger	Anger not as pronounced

Comorbid disorders

• Major Depressive Disorder.
• PTSD (avoidance is a reminder that the person is dead).
• Substance Use Disorders.

Responding to grief

• Respond to what is in front of you.
• Expect the unexpected.
• Don’t make assumptions.
• Don’t impose your own beliefs or views.
• Be aware you may have your own emotional responses.

Myth or fact

• “Grief should last about 7 months”: myth. There is no set timetable for an individual to grieve. Intense emotions often ease by 1 year, and Prolonged Grief Disorder can be explored from 12 months after a loss.
• “If a person doesn’t cry, they aren’t sorry about the loss”: myth. People grieve in different ways; not crying does not mean they don’t feel sorrow.
• “Grief is the price we pay for love”: not entirely true, since people grieve for more than just those they love.

Summary

• Grief is an inevitable human experience, not a medical crisis.
• There is a wide range of normal responses to loss.
• Respond with empathy and listening.
• Share your own emotional response and reflect, rather than distancing yourself.
• Grief is like a shadow: sometimes large and sometimes small, but always with you.

Self-test

1. Distinguish bereavement, grief and mourning.
2. List the five domains across which grief responses are described, and give two example responses in each of the physical and spiritual domains.
3. According to the Klugman (2006) study, what proportion of bereaved participants reported at least two post-death contact experiences, and what were the four modalities surveyed?
4. Describe the expected time course of normal grief-related disruption, from the Bonanno (2005) findings through to what physicians and grief counsellors commonly observe.
5. List the five stages of the Kubler-Ross model, and explain the main criticism of the model.
6. Describe the four stages of Sheldon’s model of grief, including the task associated with each stage.
7. Describe the dual process model of coping with bereavement, including what “oscillation” refers to.
8. List Worden’s four tasks of mourning.
9. What proportion of bereaved people experience an uncomplicated bereavement process, and what proportion develop a maladaptive/prolonged grief reaction?
10. State DSM-5-TR criterion A and criterion B for Prolonged Grief Disorder, including the minimum time since death required.
11. List at least 3 of the criterion C symptoms required for a diagnosis of Prolonged Grief Disorder.
12. In the case of David, identify three features of his presentation that support a diagnosis of Prolonged Grief Disorder.
13. List three risk factors for developing Prolonged Grief Disorder.
14. Distinguish grief from depression using at least three paired features (e.g. mood pattern, self-image, responsiveness to support).
15. Name the three disorders most commonly comorbid with prolonged/complicated grief.
16. List two pieces of practical guidance for responding to a grieving person.

Answers

Reveal answers

1. Bereavement is the objective situation of having lost someone significant through death; grief is the emotional response to that loss; mourning is the outward expression of grief and how a person adapts to it after the loss.
2. The five domains are emotional, physical, cognitive, social and spiritual. Physical examples: tiredness/exhaustion and sobbing/weeping, or aching muscles and sleep disturbance. Spiritual examples: questioning religious beliefs, or feeling/sensing the presence of the deceased.
3. 97% had at least two post-death contact experiences. The four modalities were acoustic (hearing voice or associated music), optical (seeing a vision/image), olfactory (smell associated with the deceased), and other experiences (dreaming of, feeling watched over by, conversing with, or being touched by the deceased, or moving objects/radio volume changes).
4. The majority have significant grief-related disruption in the first 2-3 months, usually remitting within 6-7 months (Bonanno, 2005). Physicians and grief counsellors commonly observe a duration of 1-2 years, though intense sadness when reminded of the loss can persist for life.
5. Denial, Anger, Bargaining, Depression, Acceptance. The main criticism is that it is overly prescriptive, implying that grief not following these stages in this order is “not normal,” when in reality grief is individual and the stages may occur in any order or not at all.
6. Initial shock (numbness, disbelief, relief; task: accept the reality of the loss), Pangs of grief (sadness, anger, guilt, anxiety, withdrawal, transient hallucinations, searching behaviour; task: experience the pain of grief), Despair (loss of direction and meaning; task: adjust to an environment in which the deceased is missing), Adjustment (developing new relationships/interests; task: emotionally relocate the deceased to an important but not central part of life and move on).
7. The model describes coping with bereavement as alternating (“oscillating”) between a loss-oriented state (grief work, intrusion of grief, letting go/continuing bonds) and a restoration-oriented state (attending to life changes, doing new things, new roles/relationships), rather than following a fixed sequence.
8. To accept the reality of the loss; to work through the pain of grief; to adjust to an environment in which the deceased is missing; to find an enduring connection with the deceased while embarking on a new life.
9. 85-95% go through an uncomplicated bereavement process; 5-15% develop a maladaptive/complicated or prolonged grief reaction.
10. Criterion A: the death, at least 12 months ago (6 months for children/adolescents), of a person close to the bereaved individual. Criterion B: since the death, a persistent grief response with intense yearning/longing for the deceased and/or preoccupation with thoughts/memories of the deceased, present most days to a clinically significant degree and occurring nearly every day for at least the last month.
11. Any 3 of: identity disruption, marked disbelief about the death, avoidance of reminders that the person is dead, intense emotional pain related to the death, difficulty with reintegration into life, emotional numbness, feeling that life is meaningless, intense loneliness.
12. Any three of: grief unabated 14 months after the death, daily yearning, intrusive thoughts and rumination about the death, avoidance of crash-related locations, emotional numbness, withdrawal from friends and family, feeling like “a shell,” functional impairment (medical leave, poor concentration, fatigue), feeling life is meaningless, disturbed sleep/appetite and increased alcohol use.
13. Any three of: dependency on the deceased prior to death, death of a child, violent or unexpected death, economic stressors, previous mental illness (especially depression), low self-esteem, death of a spouse/partner or child compared to other kinship losses.
14. For example: grief is experienced in waves and diminishes over time, while depression is static and persistent; grief allows a healthy self-image (self-criticism focused on the deceased), while depression involves worthlessness and self-loathing; grief is responsive to support, while depression is unresponsive to support.
15. Major Depressive Disorder, PTSD, and Substance Use Disorders.
16. Any two of: respond to what is in front of you, expect the unexpected, don’t make assumptions, don’t impose your own beliefs or views, be aware of your own emotional responses.