Grief and bereavement

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Grief and bereavement

Author Susan D Block, MD Section Editors Thomas L Schwenk, MD Kenneth E Schmader, MD Deputy Editor H Nancy Sokol, MD

Last literature review for version 17.3: September 30, 2009 | This topic last updated: February 23, 2009 INTRODUCTION Over 2,500,000 deaths occur annually in the United States and between 5 and 9 percent of the population sustains the loss of a close family member each year [1,2]. Loss of a close relationship often causes profound suffering and can have important effects on health status. The vast majority of bereaved individuals (80 to 90 percent) cope with their losses without requiring professional intervention [3]. However, bereavement can have serious and long-term adverse health effects, and patients often consult clinicians for help in managing distress associated with bereavement. By understanding both normal and dysfunctional grieving processes the clinician can appropriately reassure individuals with normal grief responses and intervene to help those experiencing dysfunctional reactions to loss. NORMAL BEREAVEMENT Death is the most powerful stressor in everyday life, causing both somatic and emotional distress in virtually everyone closely tied with the person who has died [4]. The effects may be intense and long lasting. Our culture uses three discrete terms to talk about the loss of a close relationship: Bereavement is the reaction to the loss of a close relationship. Grief is the emotional response caused by a loss including pain, distress, and physical and emotional suffering. Mourning refers to the psychological process through which the bereaved person undoes his or her bonds to the deceased. Anticipatory grief Grieving is thought to begin when an individual is forewarned of an impending death. Anticipatory grieving may take the form of sadness, anxiety, attempts to reconcile unresolved relationship issues, and efforts to reconstitute or strengthen family bonds. Caretaking behavior may be a form of anticipatory grieving, as the caretaker expresses affection, respect, and attachment through the physical acts of providing care. Anticipation and an opportunity to prepare psychologically for death is thought to ease the adaptation of the grieving individual after death. Normal grief reaction Immediately following death, whether or not it has been anticipated,

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survivors often experience feelings of numbness, shock, and disbelief. They "go through the motions," taking care of funeral arrangements, greeting relatives and friends, and tending to financial matters. However, the reality of the death has not been fully comprehended. Shock and numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness commonly arise in the weeks after the death. "Searching behaviors," including visual and auditory hallucinations of the deceased person, are common and may lead the bereaved person to fear that he or she is "going crazy." Despair and sadness are common as it becomes clear that the deceased will not return. Sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic complaints (especially those similar to the symptoms of the deceased) are common [5]. The survivor often replays and remembers the relationship with the deceased, particularly the events of the terminal illness and death, and commonly ruminates over regrets and missed opportunities. Anger at the person for dying, at God, and at professional caregivers may occur. The individual may withdraw from family and friends. Being with others and being alone are both difficult. Grief comes in waves that are often precipitated by reminders of the deceased; the bereaved may feel fine one moment, and be overcome with sadness and grief the next moment. Feelings of pleasure are often experienced as a betrayal of the relationship with the person who has died. Normal grief resolution Distressing feelings gradually diminish in intensity for most bereaved persons, usually over months; the grieving individual slowly comes to accept the reality of the loss, reestablishing mental and physical balance. Similar to stages of grief in dying described by Kubler Ross [6], resolution of grief, to some degree, occurs in stages [7]. In the early phases after a loss, the intensity and symptomatology of grief can overlap with signs and symptoms of complicated grief (see 'Complicated or prolonged grief' below. These signs and symptoms, and their intensity, subside slowly over time for patients experiencing normal grief. Usually, these impairments are beginning to resolve by six months [3,7]. As the loss becomes more fully accepted the bereaved begins reorganizing his or her life and reinvesting in living. The bereaved person slowly becomes able to remember the deceased without being overwhelmed by grief, can work productively, can sustain a sense of self-esteem and purpose, and can carry on with pleasure and enjoyment. Anniversaries and important events continue to precipitate waves of sadness; the amplitude of these waves diminishes over time, although the grief may never go away entirely. There is considerable range in the duration and intensity of the bereavement process. Some variables that may have an impact are: Age of deceased The death of an elderly person after a full life will have a different impact than the death of a child or a young adult. Pregnancy and newborns Miscarriage or death of a newborn are often not recognized as major losses but can precipitate prolonged grief.

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Suicide Bereavement due to suicide or other socially disapproved deaths may lead to more isolation and to increased vulnerability to suicide among some survivors [8]. ABNORMAL BEREAVEMENT The primary care clinician is in an excellent position to prevent both physical and psychological morbidity associated with bereavement, and to help the bereaved individual adapt to his or her loss. Despite experiencing worse health, persons with abnormal bereavement are less likely to use health services. Thus, outreach efforts are particularly important in identifying individuals at risk and preventing the adverse effects of abnormal bereavement. Risk factors for poor bereavement outcomes A number of risk factors for the development of poor bereavement outcomes have been identified, including the following: Poor social supports Past history of psychiatric problems, especially depression Past history of childhood separation anxiety High initial distress Unanticipated death, lack of preparation for death Other major concurrent stresses and losses History of abuse or neglect in childhood Lifestyle rigidity (aversiveness to lifestyle change) Highly dependent relationship with the deceased Death of a child Psychological sequelae of abnormal bereavement Depression, suicide, anxiety, and complicated grief are the most common adverse psychological sequelae of loss. Rates of depression during the first year after the loss of a spouse, 15 to 35 percent, are four to nine times higher than the rate in the general population [9]. Suicide rates after loss of a spouse are elevated, particularly in older men and in the first year [2,10]. Complicated or prolonged grief Complicated/prolonged grief is a discrete cluster of symptoms that define a syndrome with characteristic symptoms and risk factors, a predictable course, and outcomes. Complicated/prolonged grief represents a disturbance of attachment associated with an unstable sense of self and insecurity [11,12]. Complicated/prolonged grief is defined as the persistence, for at least six months, of a constellation of disruptive emotional reactions including yearning and four of the following eight symptoms: Difficulty moving on Numbness/detachment Bitterness Feelings that life is empty without the deceased Trouble accepting the death A sense that the future holds no meaning without the deceased Being on edge or agitated Difficulty trusting others since the loss

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Other indicators of complicated grief include social withdrawal and difficulty reengaging with life. Symptoms of complicated/prolonged grief at six months post-loss are highly predictive of impairment and complications at 13 and 24 months post-loss [13,14]. Bereavement related depression While many patients with complicated/prolonged grief also meet diagnostic criteria for major depression and/or generalized anxiety disorder [15], only a small minority (<20 percent) of patients with bereavement-related depression are treated with antidepressants [16]. This observation probably reflects the belief, on the part of both patients and clinicians, that depression is an understandable part of the grieving process rather than a psychiatric disorder that can be treated and ameliorated. A full depressive syndrome that occurs early in the grieving process is likely to result in prolonged and substantial morbidity [16]. The diagnosis of major depression in a grieving person represents a clinical challenge. Helpful clinical clues to the diagnosis of major depression in this context include generalized feelings of hopelessness, helplessness, worthlessness, and guilt, as well as persistence of the initial and severe symptoms of early grief (see 'Normal grief reaction' above. Treatment with antidepressants and psychotherapy represents a reasonable diagnostic and therapeutic approach in equivocal cases. Medical sequelae Bereavement is associated with higher rates of mortality (especially among older men) [10,17], morbidity [2], health care utilization [18], consumption of alcohol, tobacco, and sedatives (increases ranging from 25 to 30 percent in some studies) [2,19], and impaired immune function (although this finding is of uncertain clinical significance) [20]. Patients with congestive heart failure and hypertension are at particular risk for disease exacerbation in response to real or threatened loss of a relationship [21]. In addition, increased substance abuse may contribute to the rise in disease-related mortality and suicide among the bereaved. Patients with continued symptoms of complicated grief six months after a loss may be at increased risk of cancer; hypertension; heart disease; changes in eating, smoking, and drinking habits; hospitalization; disability; and reduced quality of life over the ensuing one to two years [14]. CARING FOR THE BEREAVED BEFORE THE DEATH The clinician's role in assessing and managing the bereaved ideally begins before the death takes place. Attention to family members during the dying process offers the clinician an opportunity to assess both the coping resources and the vulnerabilities of these individuals. The clinician should consider referring individuals with poor coping resources and risk factors for poor bereavement outcomes for psychosocial support before the death. In addition to offering direct help to family members in anticipation of a death, attention to the quality of the dying process also influences grief after the death. Preparation for death clearly facilitates bereavement adjustment. Helping a patient to "die well" reduces the burden on the family during bereavement. Dying well has different meanings for different families; for some it might mean aggressive, high technology care up until the last minute; for others it might mean having the opportunity to provide supportive care in the home with many family members participating in the process. The opportunity to participate in providing care has a positive effect upon bereavement outcomes. Expert palliative care clinicians can be a resource in facilitating a "good death" for the patient, and

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in addressing family concerns. Hospice use by patients is associated with decreased bereavement mortality among surviving spouses [22]. Caregivers of spouses with longer hospice enrollment have a lower incidence of major depressive disorder [23]. Thus, family members should be supported in their involvement in providing care and should be encouraged to be present at the time of death. Conflicts between the patient and family or among family members about the type of care desired for the patient often pose particular difficulties for family members after the death. Similarly, feelings of guilt and doubt may color the bereavement experience when family members are required to assume responsibility for discontinuation of life support or other treatment withdrawal. The clinician should provide family members with appropriate information and support to guide decision making and help prevent negative sequelae in these situations. Clear recommendations from the clinician about difficult treatment decisions are often helpful in situations where family members are distraught by difficult choices. CARING FOR THE BEREAVED AFTER THE DEATH The clinician caring for the deceased can facilitate acceptance of the death with attention to several follow-up recommendations: The clinician should contact family members not present at the bedside immediately after the death via telephone to inform them, express condolences, answer any immediate questions, and offer them the option of viewing the body. A letter of condolence is a core component of quality end-of-life care. Attending the funeral or memorial service is usually deeply appreciated. The United States Preventive Services Task Force (USPSTF) recommends that clinicians "be alert" for suicidal ideation in people who have had a recent bereavement [24]. Reaching out to bereaved persons, through a personal phone call or an offer of an appointment to "check in," is recommended as the bereaved often find it difficult to initiate actions [25]. Patients should be encouraged to maintain regular patterns of activity, sleep, exercise, and nutrition as much as possible, as these activities appear to enhance adaptation during bereavement [26]. Most grieving persons do not want or need professional help in the grieving process; instead they turn to family, friends, and religious institutions. At times, however, grieving persons who do not have adequate social supports turn to the clinician as an outlet for their grief. Crying is an integral part of the grieving process and should be encouraged. Short-term supportive counseling that promotes ventilation of feelings is usually helpful. Sleep disruption is a common symptom of grief. Short-term prescription of a sleep hypnotic may be effective in promoting sleep. For individuals who experience high levels of anxiety, a timelimited prescription of an anxiolytic can be useful as a crisis measure. However, these medications generally should not be prescribed at high doses or for long periods since their use has the potential to retard and inhibit the grieving process. Support groups are a valuable resource for many bereaved individuals and have been shown to facilitate grief resolution [27]. Some support groups target particular types of deaths, such as

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death of a spouse, suicide, death of a child, AIDS, violent crime. However, a randomized trial of cognitive behavioral therapy for relatives of people who committed suicide did not reduce the risk for complicated grief, though may have had other beneficial effects related to blame and maladaptive grief reactions [28]. Local hospice organizations usually can identify community resources for bereavement support. Chaplains, social workers, and grief counselors also provide services to bereaved individuals. Treatment of complicated or prolonged grief Because complicated grief can lead to prolonged dysfunction, and is often difficult to differentiate from major depression, patients with complicated grief should be referred to a psychiatrist for evaluation. Treatment aims to facilitate understanding of the loss and its impact on the survivor's sense of self and sense of the future. Focus is also on mastering concrete tasks (eg, managing finances, learning how to cook) that were carried out by the deceased and that can lead to a new sense of competence and independence. Encouragement to develop new routines, new relationships, and to practice good self-care (diet, exercise, sleep, etc) is also helpful. Support groups can be an important resource for the bereaved by reducing the sense of isolation, supporting the development of new relationships, and teaching concrete survival strategies. Effective treatments for complicated grief are beginning to emerge. Complicated grief treatment (CGT) is a psychotherapeutic approach that includes cognitive behavioral methods similar to those used for post-traumatic stress disorder (ie, confronting the loss through exposure). (See "Overview of post-traumatic stress disorder".) A randomized trial in 95 people with complicated grief found a higher response with CGT than with interpersonal psychotherapy (51 versus 28 percent) [29]. Other studies have shown reductions in grief symptoms with crisis intervention, brief dynamic psychotherapy, and support groups [25]. An open-label trial of paroxetine demonstrated a 53 percent reduction in symptoms of complicated grief [30]. Treatment of bereavement-related depression Bereaved patients who have symptoms of depression for at least two weeks, six to eight weeks after a major loss, should be considered candidates for a therapeutic trial of antidepressants and psychotherapy. Major depression following a loss responds to the same therapeutic approach as major depression in general. (See "Initial treatment of depression in adults".) Treatment with antidepressants is associated with improvement in symptoms of depression, but appears to be ineffective in ameliorating the symptoms of grief [31,32]. One study, as an example, found that treatment of bereavementrelated depression in 13 patients resulted in a 68 percent decrease in the Hamilton rating score for depression after a median treatment interval of 6.4 weeks; the intensity of grief did not change [32]. INFORMATION FOR PATIENTS Educational materials on this topic are available for patients. (See "Patient information: Depression in adults".) We encourage you to print or e-mail this topic review, or to refer patients to our public web site, www.uptodate.com/patients, which includes this and other topics. SUMMARY AND RECOMMENDATIONS Normal bereavement can manifest as intense symptoms that subside slowly but usually cause

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little impairment by six months (see 'Normal bereavement' above. Complicated/prolonged grief is the persistence for at least six months of yearning associated with four of eight symptoms: difficulty moving on, detachment, bitterness, feeling that life is empty, trouble accepting the death, feeling of meaningless with future, agitation, difficulty trusting others. We recommend psychiatric referral for these patients (see 'Complicated or prolonged grief' above and 'Treatment of complicated or prolonged grief' above. The diagnosis of major depression in the grieving individual is difficult. Patients with symptoms of bereavement-related depression for at least two weeks, six to eight weeks after a major loss, should be treated for depression (see 'Bereavement related depression' above and 'Treatment of bereavement-related depression' above. Clinicians can help ameliorate grief reactions in relatives of their dying patients. They should be alert to risk factors for abnormal grieving. Immediate communication, expression of condolence after death, and follow-up by phone or appointment within two weeks can be helpful. Clinicians should encourage the bereaved to maintain regular patterns of activity, sleep, exercise, and nutrition. (See 'Risk factors for poor bereavement outcomes' above and 'Caring for the bereaved after the death' above.)

Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Committee on Care at the End of Life. Approaching death: Improving care at the end of life. Institute of Medicine, National Academy Press: Washington, DC, 1997. 2. Osterweis, M, et al. Bereavement: Reactions, Consequences, and Care. National Academy Press, Washington, DC 1984. 3. Prigerson, HG. Complicated grief: when the path of adjustment leads to a dead end. Bereavement Care 2004; 23:38. 4. Holmes, TH, Rahe, RH. The Social Readjustment Rating Scale. J Psychosom Res 1967; 11:213. 5. Lindemann, E. Symptomatology and management of acute grief. Am J Psychiatry 1944; 101:141. 6. Kubler Ross, E. On Death and Dying. Macmillan Publishing Company, New York 1969. 7. Maciejewski, PK, Zhang, B, Block, SD, Prigerson, HG. An empirical examination of the stage theory of grief. JAMA 2007; 297:716. 8. Ness, DE, Pfeffer, CR. Sequelae of bereavement resulting from suicide. Am J Psychiatry 1990; 147:279. 9. Zisook, S, Shuchter, SR. Depression through the first year after the death of a spouse. Am J Psychiatry 1991; 148:1346. 10. Stroebe, M, Schut, H, Stroebe, W. Health outcomes of bereavement. Lancet 2007; 370:1960. 11. Prigerson, HG, Shear, MK, Frank, E, et al. Traumatic grief: a case of loss-induced trauma. Am J Psychiatry 1997; 154:1003.

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12. van Doorn, C, Kasl, SV, Beery, LC, et al. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis 1998; 186:566. 13. Chen, JH, Bierhals, AJ, Prigerson, HG, et al. Gender differences in the effects of bereavement-related psychological distress in health outcomes. Psychol Med 1999; 29:367. 14. Prigerson, HG, Bierhals, AJ, Kasl, SV, et al. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997; 154:616. 15. Kim, K, Jacobs, S. Pathological grief and its relationship to other psychiatric disorders. J Affect Disord 1991; 21:257. 16. Zisook, S, Shuchter, SR. Uncomplicated bereavement. J Clin Psychiatry 1993; 54:365. 17. Helsing, KJ, Szklo, M. Mortality after bereavement. Am J Epidemiol 1981; 114:41. 18. Parkes, CM. The first year of bereavement. A longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry 1970; 33:444. 19. Parkes, CM, Brown, RJ. Health after bereavement. A controlled study of young Boston widows and widowers. Psychosom Med 1972; 34:449. 20. Irwin, M, Daniels, M, Weiner, H. Immune and neuroendocrine changes during bereavement. Psychiatr Clin North Am 1987; 10:449. 21. Parkes, CM, Weiss, RS. Recovery from bereavement. Basic Books, New York 1983. 22. Christakis, NA, Iwashyna, TJ. The health impact of health care on families: a matched cohort study of hospice use by decedents and mortality outcomes in surviving, widowed spouses. Soc Sci Med 2003; 57:465. 23. Bradley, EH, Prigerson, H, Carlson, MD, et al. Depression among surviving caregivers: does length of hospice enrollment matter?. Am J Psychiatry 2004; 161:2257. 24. US Preventive Services Task Force. Guide to clinical preventive services, 2nd ed, Williams and Wilkins, Baltimore 1996. 25. Prigerson, HG, Jacobs, SC. Caring for bereaved patients: "All the doctors just suddenly go." JAMA 2001; 286:1369. 26. Chen, JH, Gill, TM, Prigerson, HG. Health behaviors associated with better quality of life for older bereaved persons. J Palliat Med 2005; 8:96. 27. Vachon, ML, Sheldon, AR, Lance, WA et al. A controlled study of self-help: Intervention for widows. Am J Psychiatry 1980; 137:1380. 28. de Groot, M, de Keijser, J, Neeleman, J, et al. Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial. BMJ 2007; 334:994. 29. Shear, K, Frank, E, Houck, PR, Reynolds CF, 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA 2005; 293:2601. 30. Zygmont, M, Prigerson, HG, Houck, PR, et al. A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief. J Clin Psychiatry 1998; 59:241. 31. Jacobs, SC, Nelson, JC, Zisook, S. Treating depressions of bereavement with antidepressants: A pilot study. Psychiatr Clin North Am 1987; 10:501. 32. Pasternak, RE, Reynolds, CR III, Schlernitzauer, M, et al. Acute open-trial nortriptyline therapy of bereavement-related depression in late life. J Clin Psychiatry 1991; 52:307.

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