VHA en 2001 The Varieties of Grief Experience Bonanno y Kaltman

Clinical Psychology Review, Vol. 21, No. 5, pp.
705 ± 734, 2001

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THE VARIETIES OF GRIEF EXPERIENCE

George A. Bonanno
Columbia University
Stacey Kaltman
The Catholic University of America
ABSTRACT. The bereavement literature has yet to show consensus on a clear definition of
normal and abnormal or complicated grief reactions. According to DSM-IV, bereavement is a
stressor event that warrants a clinical diagnosis only in extreme cases when other DSM categories
of psychopathology (e.g., Major Depression) are evident. In contrast, bereavement theorists have
proposed a number of different types of abnormal grief reactions, including those in which grief is
masked or delayed. In this article, we review empirical evidence on the longitudinal course,
phenomenological features, and possible diagnostic relevance of grief reactions. This evidence
was generally consistent with the DSM-IV's view of bereavement and provided little support for
more complicated taxonomies. Most bereaved individuals showed moderate disruptions in
functioning during the first year after a loss, while more chronic symptoms were evidenced by a
relatively small minority. Further, those individuals showing chronic grief reactions can be
relatively easily accommodated by existing diagnostic categories. Finally, we found no evidence to
support the proposed delayed grief category. We close by suggesting directions for subsequent
research. D 2001 Elsevier Science Ltd. All rights reserved.
KEY WORDS. Grief, Bereavement, Loss, Stressor.
INTRODUCTION
GRIEF IS A painful, but unfortunately common experience. Most people at different
points in their lives are confronted with the death of a close friend or relative. There
are, however, marked individual differences in how intensely and how long people
grieve. Some grieve openly and deeply for years, and only slowly return to a
semblance of their normal level of functioning. Others suffer intensely, but for a
relatively more proscribed period of time. Still others appear to get over their losses
Correspondence should be addressed to George A. Bonanno, Ph.D., Department of

Counseling and Clinical Psychology, Teachers College, Columbia University, Box 218, 525
West 120th Street, New York, NY 10027, USA. E-mail: gab38@columbia.edu
705
706 G. A. Bonanno and S. Kaltman
almost immediately, and to move on to new challenges and new relationships with
such ease as to raise doubts among their friends and relatives as to whether they may
be hiding something or running away from their pain.
The extent that grief varies across individuals suggests important questions about
what constitutes normal or common grief, and when, if at all, too much or too little
grief might be considered abnormal, or even pathological. Unfortunately, the
bereavement literature has yet to agree on a clear, empirically defensible definition
of grief, or its normal and abnormal course and manifestations (Bonanno, 1998;
Hansson, Carpenter, & Fairchild, 1993). The present review was motivated by this
deficiency. First, we review competing formulations of normal and complicated
grieving found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV, American Psychiatric Association, 1994) and in the bereavement literature.
According to the DSM-IV, bereavement is a stressor that produces relatively normal
and expectable distress. DSM-IV does not offer a complicated grief diagnosis, and
allows for bereavement-related diagnoses only in extreme cases when existing
diagnostic categories (e.g., Major Depression) may be relevant. In contrast, bereave-
ment theorists have argued for the clinical necessity of a complicated grief diagnosis,
and have proposed a number of different types of complicated grief. In an effort to
reconcile these competing positions, we review the available empirical evidence on
grieving. Specifically, we examine three kinds of evidence: longitudinal studies of
grief outcome, descriptive studies of the phenomenological features of grieving, and
diagnostic studies that focus on the distinction between normal and pathological or
complicated variants. Our analysis is generally supportive of the DSM-IV's conception
of grief as a normal reaction to an enduring stressor, and reveals little in the way of
empirical evidence to support the complex taxonomies of grief outcome developed
in the bereavement literature. We summarize the available evidence into a working
definition of grief course patterns, and close by suggesting several avenues for future
bereavement research.
THEORETICAL AND OBSERVATIONAL CLASSIFICATIONS OF GRIEF COURSE

DSM-IV: Bereavement as a Stressor
The DSM-IV views the death of a close friend or relative as a stressor with generally
normative and predictable consequences. According to this approach, bereavement
is considered among the V codes and is used diagnostically when the ``focus of
clinical attention is a reaction to the death of a loved one'' (American Psychiatric
Association, 1994, p. 684). The conceptualization of bereavement in terms of the V
code is clearly intended to represent mourning as a normal phenomenon. In
addition, DSM-IV emphasizes culturally determined forms of mourning and grief
behavior, and that ``the duration and expression of `normal' bereavement vary
considerably among different cultural groups'' (American Psychiatric Association,
1994, p. 684). An important limitation of DSM-IV's vagueness on this point, however,
is that it does not provide a means of precisely distinguishing between individuals
who show common grief reactions from those who do not. As we will show later in this
article, this distinction may prove crucial to the understanding of individual diffe-
rence in long-term grief course.
By using a V code, the DSM-IV also explicitly avoids the categorical distinction of
complicated versus uncomplicated bereavement. Instead, extreme cases in which
Varieties of Grief Experience 707
grief becomes exceptional or severe are conceptualized using other known categories
of psychopathology. For example, Major Depressive Disorder can be diagnosed after
an interpersonal loss if the depressive symptoms endure longer than 2 months or are
marked by significantly disrupted functioning, suicidal ideation, psychotic symptoms,
psychomotor retardation, or extreme feelings of worthlessness. Alternatively, DSM-IV
indicates that Posttraumatic Stress Disorder may be diagnosed following the sudden,
unexpected death of a family member or close friend in the presence of the
characteristic constellation of intrusion, avoidance, and hyperarousal symptoms.
Thus, beyond the normal bereavement response, DSM-IV provides for the diagnosis
of more severe pathology in exceptional cases, but only in the form of existing
diagnostic categories.
The Taxonomy of Complicated Grief in the Bereavement Literature

In contrast to DSM-IV's conception of bereavement as a normal stressor, clinically
oriented bereavement theorists have articulated a relatively complex set of taxo-
nomies to describe aberrant or complicated mourning. One of the earliest exposi-
tions of normal versus pathological or complicated grieving was proposed by Parkes
(1965). Parkes distinguished normal or typical grief from three forms of atypical grief
based upon interviews with patients who had been hospitalized for psychiatric
illnesses within 6 months following the death of a parent, spouse, sibling, or child.
He identified chronic grief as the most common form of grief in the interviewed
sample, defined as an extended variant of typical grief in which symptoms are
particularly pronounced: ``The reaction is always prolonged and the general impres-
sion is one of deep and pressing sorrow'' (Parkes, 1965, p. 14). In contrast to chronic
grief, Parkes defined inhibited grief when a bereaved person evidenced little overt
reaction to the loss. Although Parkes observed no examples of inhibited grief in the
interviewed sample, he highlighted inhibited grief as an atypical grief reaction that is
present primarily in children. Finally, Parkes described delayed grief as occurring when
a typical or chronic grief reaction follows a period in which grief is inhibited.
Although Parkes made these classifications using unstructured clinical interviews
and a nonrepresentative sample of bereaved persons, his taxonomy has proved highly
influential and has served as the basis for subsequent categorizations of grief.
In a widely cited book, Bowlby (1980) identified two ``disordered variants'' of grief.
Chronic mourning was described as ``more intense and disrupting than in healthy
mourning'' (p. 147). This classification was based upon studies of bereaved indivi-
duals who showed chronic despair 12 months post-loss (Gorer, 1965) and depression,
disorganization, and alcoholism two or more years following the loss of a spouse
(Glick, Weiss, & Parkes, 1974). Bowlby highlighted a number of factors that were
associated with a chronic grief course which included ``the death having been
sudden, a delayed response, nightmares connected with the death, quarrels with
relatives and others, an attempt to escape the scene; and prior to the bereavement, a
history of an unsettled childhood and of having been brought up to bottle up
feelings'' (Bowlby, 1980, pp. 149 ± 150). Bowlby also described the prolonged absence of
grieving as a disordered variant of grief, noting that while a brief period of numbing is
expected following a significant loss, it is not expected to last longer than a few days
to a week. Although a bereaved individual may show no overt signs of grieving,
Bowlby described ``tell-tale signs that the person has in fact been affected and that his
mental equilibrium is disturbed'' (Bowlby, 1980, p. 153). Signals of the prolonged
absence of conscious grieving included the avoidance of reminders, physical symp-

toms, distressing dreams, and appearing overcontrolled. Following Bowlby's work,
Belitsky and Jacobs (1986) applied an attachment framework to the grieving process
and similarly defined two forms of ``pathological grief.'' They described distorted grief,
which is manifested in either a prolonged or unusually intense reaction to loss, and
delayed grief in which an overt grief reaction is absent for a long period of time.
In a book intended to aid clinicians in the diagnosis and treatment of grief,
Worden (1982) delineated abnormal grief reactions into four distinct patterns:
chronic, exaggerated, delayed, and masked. Chronic grief was defined solely in terms
of the duration of the reaction, in contrast to prior defiitions which were based on
both the duration and intensity of grief. Worden described chronic grief as a
prolonged reaction that is `èxcessive in duration'' and which ``never comes to a
satisfactory conclusion'' (p. 59). Exaggerated grief was defined as a reaction to loss that
is excessive in intensity. Worden defined delayed grief as an emotional reaction that is
not commensurate with the loss but may be experienced more fully at a later time.
Finally, masked grief was defined as occurring when a bereaved person experiences
symptoms or behaviors that lead to difficulties in functioning but does not recognize
these symptoms as being related to the loss. Worden further identified two possible
manifestations of this type of reaction in which the grief is masked either as a physical
symptom or as a maladaptive behavior.
Based on a theoretical position that elucidates the processes that tend to produce
different types of grief, Rando (1992) proposed the most elaborate system of
complicated grief reactions to date. Rando observed that complicated mourning
develops when there is a ``compromise, distortion, or failure of one or more of six 'R'
processes of mourning'' (p. 45). The six hypothetical `R' process include: recognizing
the loss, reacting to the separation, recollecting and reexperiencing the deceased and
the relationship, relinquishing the old attachments to the deceased and the old
world, readjusting to move adaptively into the new world without forgetting the old,
and reinvesting. In Rando's system, all forms of complicated mourning result from
attempts to ``deny, repress, or avoid aspects of the loss, its pain, and the full realization
of its implications for the mourner'' and help the unwilling bereaved survivor ``hold
onto, and avoid relinquishing, the lost loved one'' (Rando, 1992, p. 45).
Rando used her model of ``R'' processes to delineate seven unique syndromes of
complicated mourning, which are divided into three categories. Absent mourning,
delayed mourning, and inhibited mourning are related to ``problems in expression''
(Rando, 1992, p. 46). Distorted mourning of the extremely angry or guilty types,
conflicted mourning, and unanticipated mourning are syndromes with ``skewed aspects''
(Rando, 1992, p. 46). Chronic mourning is a syndrome with a ``problem in ending''
(Rando, 1992, p. 46). In addition to these patterns, Rando observed that complicated
mourning can take the form of symptoms, mental or physical disorder, or death. She
further highlighted factors which predispose the bereaved to a complicated mourn-
ing reaction. High-risk factors associated with the death include: `à sudden and
unanticipated death, especially when it is traumatic, violent, mutilating, or random;
death from an overly lengthy illness; the loss of a child; and the mourner's perception
of preventability'' (Rando, 1992, p. 47). High-risk factors related to antecedent or
subsequent variables include: `à premorbid relationship with the deceased which has
been markedly angry or ambivalent or markedly dependent, the mourner's prior or
concurrent mental health problems and/or unaccommodated losses and stresses,
and the mourner's perceived lack of social support'' (Rando, 1992, p. 47).
When considered together, the various formulations suggest a complex, multi-

faceted taxonomy of grief reactions that encompasses a range of behaviors and
manifestations. Beyond the simple distinction between normal and complicated
bereavement, it is assumed that there are a number of different types of aberrant
grieving determined primarily by presence or absence of overt signs of grieving,
the duration of the grief reaction, and the intensity of the grief reaction over
time. The fact that these formulations were based largely on clinical inference or
global observational studies, however, raises important questions about their
generalizability. Indeed, many of the suggested categories are rife with assump-
tions about what grieving should be, or how bereaved individuals should feel, and
how long they should feel it. For example, Rando's complex system of aberrant
grief patterns was based on an equally complex set of assumptions about the
processes (``R'' processes) assumed to underlie successful grief resolution. It is
worth noting, however, that many of Rando's ``R'' processes suggest a relatively
traditional perspective on ``working through'' grief that has become highly
controversial. Reviews of the bereavement literature over the past decade have
argued, for instance, that there is no evidence to support traditional assumptions
that it is necessary to express the pain of loss, that it is necessary to work through
the thoughts and memories associated with the loss, or that it is necessary even to
relinquish attachments to the deceased (Bonanno, 1998; Bonanno & Kaltman,
1999; Klass, Silverman, & Nickman, 1996; Stroebe & Stroebe, 1987; Wortman &
Silver, 1989).
TOWARD AN EMPIRICALLY BASED, WORKING MODEL OF GRIEF

The contrast between the DSM-IV's relatively simple conception of grief as a
normative stressor and the various complex taxonomies for complicated mourning
proposed in the bereavement literature suggests an imperative need to resolve the
differences between these approaches. Somewhat surprisingly, however, there have
been few attempts to examine the validity of the specific grief outcome categoriza-
tions in relation to the available empirical data. In Section 4 of this article, we
review the empirical evidence that is available with the aim of elucidating the
parameters of common or typical grief, as well as extreme forms of grieving. To
achieve this aim, we review three different types of studies. First, we consider
longitudinal studies of grief course. Second, we review descriptive studies of the
basic dimensions or phenomenological features of grieving. Third, we evaluate
diagnostically oriented studies that have focused on the categorical distinction
between normal and complicated grief. A working model of grief outcome, based
on this analysis, is shown in Fig. 1.
Our review is generally supportive of the approach to bereavement taken by the
DSM-IV. That is, consistent with the DSM-IV and in marked contrast to the complex
taxonomies proposed in the bereavement literature, we find ample evidence that the
majority of bereaved individuals show what might be considered a normal or
nonpathological form of grief. Specifically (as we review below), depending upon
the measures used, between 50% and 85% of the bereaved individuals in these
studies appeared to exhibit a common grief pattern consisting of moderate disruptions
in cognitive, emotional, physical, or interpersonal functioning during the initial
months after a loss. Although some disruptive aspects of grief continue for several
FIGURE 1. A working taxonomy of grief reactions.
years after the loss, most bereaved individuals returned to normal (baseline) levels of
functioning by the end of the first year. In addition, most bereaved individuals
experienced positive thoughts and emotions associated with the lost relationship,
even in the early months of grieving. Only a relatively smaller subset (approximately
15%) of the bereaved individuals in these studies tended to continue to show serious
disruptions in functioning at the 1 ± 2 year point, thereby suggesting some form of
chronic grief. In further concordance with DSM-IV, these individuals appeared to
experience symptoms similar to individuals suffering from depression and anxiety
disorders, and to some extent trauma reactions, and thus were adequately captured
by existing diagnostic categories. Importantly, our review also revealed a significant
minority of bereaved individuals who showed mininal grief (i.e., little or no overt signs
of disrupted functioning) in the early months after a loss. Due to variations in
measurement and other uncontrolled factors, the size of this group has varied,
ranging from 15% to 50% of the bereaved participants across studies.
DSM-IV does not discuss the absence of grief symptoms, as could be expected given
its view of bereavement as a stressor event and its primary emphasis on psychopathol-
ogy. In contrast, the bereavement literature has tended to view individuals showing
little or no grief with suspicion, and as having some form of inhibited or masked grief
or as prone to develop delayed grief symptoms. Wortman and Silver (1989) were
among the first to note the absence of empirical support for the existence of delayed
or inhibited grief. A decade later, however, we still find no concrete evidence to
support these categories and, rather, we suggest that the absence of intense grief in
the early months after a loss should be considered an indicator of adjustment, and
not a potentially abnormal or pathological response.
LONGITUDINAL STUDIES OF GRIEF COURSE

The longitudinal assessment of the psychological and physiological difficulties
experienced by bereaved individuals is an optimal strategy for investigating basic
patterns of grief course. Unfortunately, there have been relatively few studies of
grieving beyond the first year. The longitudinal studies that are available,
however, provide important evidence: (a) that grief over the loss of a loved
one tends to disrupt psychological and physiological functioning in most but not
all bereaved individuals, (b) that a small, but significant minority of bereaved
individuals will continue to evidence disrupted functioning for many years after a
loss, and (c) that there does not appear to be any concrete justification for the
assumption that minimal grief in the early months of bereavement will eventually
lead to delayed grief.
The earliest studies of bereavement suggested relatively optimistic conclusions
about the normal duration of grief. Lindemann (1944) conducted what is generally
viewed as the first formal bereavement study and concluded that ``with a period of
from four to six weeks, it was ordinarily possible to settle an uncomplicated and
undistorted grief reaction'' (p.144). Parkes (1964) later endorsed a similar position,
concluding that his preliminary studies of health difficulties after loss provided
evidence ``consonant with the traditional picture of grief as a severe but self-limiting
affective disorder'' (p. 276).
Although these investigators presaged later observations of the time-limited aspects
of normal grieving, subsequent studies provided convincing evidence that for some
bereaved individuals the death of a spouse or close relative may lead to more
protracted disruptions in psychological and physical health. Parkes and Brown
(1972) used structured interviews to examine long-term health decrements among
a sample of middle-aged conjugally bereaved individuals and a matched married
comparison sample. The bereaved sample had higher levels of depressive symptoms
14 months after their loss, but was no longer distinguished from the comparison
sample after 2 years of mourning. However, by the second year after their loss, the
bereaved participants still reported significantly greater numbers of sick days, hospital
admissions, disturbances in sleep and appetite, and greater consumption of alcohol,
tobacco, and tranquilizers, compared to their nonbereaved counterparts.
Lehman, Wortman, and Williams (1987) used a cross-sectional design to assess
bereaved individuals between 4 and 7 years after the sudden and unexpected death of
either a spouse or a child. Although the results were strongest for the bereaved
spouses, this study provided important evidence for the enduring nature of severe
grief reactions. Compared to a matched married sample, the bereaved spouses
showed significantly more depression on several different indices, reported higher
levels of all types of psychiatric symptoms (e.g., anxiety, somatization, hostility), had
increased worry, less optimism, felt that their lives were significantly more negative,
and evidenced significantly greater mortality. A similar but less consistent pattern of
deficits was observed for the bereaved parents.
Although these studies provided convincing evidence that grief symptoms may
persist for years after a loss, they did not address the question of individual variation
in grief severity or duration. In an early effort to examine individuals differences in
grief symptoms and difficulties, Zisook, Devaul, and Click (1982) developed the
Expanded Texas Inventory of Grief (ETIG) to measure the ``frequency and time
course of present grief-related behaviors and feelings'' (p. 1590). Using a cross-
sectional design, they administered the ETIG to 211 people who had lost a loved one
between 1 month to 22 years previously. Zisook et al. observed that grief-related
behaviors and feelings peaked for most participants between 1 ± 2 years following the
death and then gradually declined. Nonetheless, there were still a small number of
the bereaved participants who endorsed items related to present feelings of grief as
late as 10 years after their loss.
Subsequently, Lundin (1984) used the ETIG in a cross-sectional, retrospective
study of bereaved participants who had lost either a spouse or a child 8 years earlier.
To assess outcome, Lundin selected items from the ETIG that satisfied Parkes and
Weiss'(1983) proposed criteria that recovery from bereavement involved a decreased
preoccupation with grief, the return of the ability to function well in everyday life,
and a sense of well being. Using these criteria, 65% of the sample had evidenced
recovery at the 8-year mark after their loss. These results, however, point to a
significant minority of subjects who were still preoccupied with the death and unable
to achieve a complete adjustment in this same lengthy time period.
What about delayed grief? Many of the grief course taxonomies reviewed earlier
included the delayed appearance of grief symptoms, typically accompanied by the
assumption that grief at early points in bereavement had been avoided (Bowlby, 1980;
Rando, 1992; Raphael, 1983; Sanders, 1993; Worden, 1982). Like many aspects of
bereavement theory, the assumption of delayed grief appears to have persevered
despite the relative absence of empirical support (Bonanno & Kaltman, 1999;
Wortman & Silver, 1989). There is some evidence that therapists can reliably identify
delayed grief from clinical vignettes (Marwit, 1996). However, diagnostic reliability in
this study was not surprising because a portion of the case vignettes were explicitly
designed to illustrate the delayed grief pattern. Further, none of the case vignettes
represented normal or uncomplicated bereavement. Thus, it is impossible to
determine the true reliability of the diagnoses. Finally, even if the reliability of the
delayed grief category was accepted, there is still a glaring absence of validity data for
the category.
Only two studies have directly attempted to examine the presumed existence
of delayed grief, and neither study was able to provide concrete support for the
construct. Middleton, Burnett, Raphael, and Martinek (1996) examined the grief
course of bereaved spouses (N = 44), bereaved adult children (N = 40) and
bereaved parents (N = 36). All three groups were interviewed about their grief
experiences within one month of the loss and again at 10 weeks, 7 months and
13 months of bereavement. Cluster analyses were used to classify participants into
the most representative categories of grief course. The results were similar across
the different types of bereavement. The most common pattern (43% to 70%)
was a moderate level of grief symptoms that declined over time. Relatively smaller
number of bereaved participants showed either low levels of grief across all four
assessments (17% to 25%), or relatively elevated grief across all four assessments
(14% to 31%). Importantly, despite the authors' conviction that delayed grief is a
genuine clinical phenomenon, Middleton et al. (1996) concluded that ``no
evidence was found for the pattern of response which might be expected for
delayed grief'' (p. 169).
In our own longitudinal research, we examined the relationship between grief
reactions and emotional avoidance among 42 conjugally bereaved individuals at 6,
14, 25, and 60 months of bereavement (Bonanno & Field, 2001; Bonanno, Keltner,
Holen, & Horowitz, 1995; Bonanno, Znoj, Siddique, & Horowitz, 1999). To oper-
ationally define delayed grief, we first defined severe and mild grief reactions using
the 6-month median score on a structured clinical interview for grief-related
disruptions in daily functioning (e.g., sleep disruption, weight loss, dysphoric affect).
The validity of the mild and severe grief categories was established by their
concordance with a number of common symptom measures used in bereavement

research, such as the Texas Revised Inventory of Grief (Faschingbauer, 1981), with
clinical assessments of mild versus severe grief made independently by psychothera-
pists specializing in bereavement (Bonanno et al., 1995), and with untrained
observers' ratings of the degree that they thought the participants appeared to be
suffering from their loss (Keltner & Bonanno, 1997). Using these categories,
bereaved participants were assigned to the delayed grief pattern when they showed
mild grief at the initial assessment, but severe grief at any of the later assessments.
Not a single participant from this sample evidenced delayed grief at 14 or 25 months
(Bonanno et al., 1995, 1999).
In a recent follow-up study, Bonanno & Field (2001) examined possible delayed
symptom elevations at 60 months post-loss using the structured grief interview and
additional questionnaire measures of grief, depression, and somatic complaints.
Using these multiple outcome measures, 3 of the participants were found to show
elevated symptoms on at least one of the scales. According to clinical formulations of
delayed grief, these participants should have shown grief avoidance at earlier
assessments. It was possible to examine this presumption using data on the
emotional processing of the loss. At the 6-month point in bereavement, participants
were asked to talk freely about their relationship to the decreased and their feelings
about the loss of that relationship. Changes in automatic arousal during the inter-
view were monitored relative to a baseline period. Participants were also asked to
report how much negative emotion they experienced during the interview. Combin-
ing these measures, the avoidance or dissociation of grief-related distress was
operationally defined as a subjective experience of negative emotion that was
relatively low in comparison to concurrent increases in autonomic responsivity. In
previous studies, this type of affective ± autonomic response dissociation has been linked to
reduced awareness of distress and to repressive defensiveness (Asendorpf & Scherer,
1983; Newton & Contrada, 1992; Weinberger & Davidson, 1994; Weinberger,
Schwartz, & Davidson, 1979). In addition, the affective ±autonomic dissociation score
has shown convergence with clinical ratings of the avoidance of emotional awareness
(Bonanno et al., 1995).
How did participants showing affective ± autonomic dissociation fare in our
bereaved sample? Overall, bereaved participants who showed this type of emotional
avoidance had reduced symptom levels even when initial symptoms were statistically
controlled. Thus, emotional avoidance in the early months of bereavement predicted
relatively healthy adaptation. The same results were also observed for other variables
related to emotional processing of the loss. Both the degree that participants
expressed negative emotion in their faces when they talked about the loss, and the
degree that participants described negative thoughts and emotions when they talked
about the loss, were consistently associated with increased grief-related symptoms at
later dates. Again, these relationships remained significant after initial grief symp-
toms were statistically controlled.
What about the three participants who showed elevations in grief symptoms for the
first time at 60 months? None of these participants had shown unusually low levels of
emotional processing in either their facial expressions of negative emotion or their
verbal descriptions of negative thoughts and emotions. One of these participants did
show clear evidence of affective ±autonomic dissociation at 6 months. However, of the
13 remaining participants in this study who had shown affective ±autonomic dissocia-
tion at 6 months, none had elevated grief scores on any of the four measures at any
point in the study. Thus, there was not a reliable association between emotional
avoidance and either elevated grief or delayed elevations in grief.
Still another avenue we explored was the possibility of delayed increases in somatic
symptoms. Somewhat unexpectedly, bereaved individuals who showed affective ±
autonomic dissociation in the early months of bereavement reported concurrent
elevations in somatic complaints. However, at follow-up assessments, these partici-
pants no longer had high levels somatic complaints (Bonanno et al., 1995, 1999).
There was a small number of participants at each assessment who did show marked
increases in somatic complaints, relative to the previous assessment, but there was no
systematic relationship between changes in somatic complaints and affective ±auto-
nomic dissociation. Further, the level of change was always within a standard
deviation of the sample mean, suggesting normal measurement variance. Finally,
affective ± autonomic dissociation was found to be unrelated to other indices of
health, such as the frequency of visits to medical professionals.
It might be argued that even one participant showing both avoidant behavior
and delayed elevations in grief at 60 months lends the category at least a
modicum of clinical utility. However, even in this limited application, a relation-
ship between emotional avoidance and delayed elevations in grief was observed
for only 1 participant in 14 (or 7%), hardly a solid basis for clinical intervention.
Indeed, there are several more plausible, and more parsimonious, explanations
for delayed increases in just a few participants, explanations that may also be
applied to clinical reports of isolated cases of delayed grief. One such explana-
tion is that other stressors over-and-above the original loss produced the observed
increase in symptoms.
An even more parsimonious explanation is that elevations in symptom levels for a
few participants is simply the result of normal, random measurement error (Nunn-
ally, 1978). Bereavement theorists have assumed that when delayed grief emerges, it
is usually `às fresh and intense as if the loss had just occurred'' (Humphrey &
Zimpfer, 1996, p. 152). Thus, delayed grief should be evident on multiple grief
indices. A measurement error explanation of delayed grief suggests, however, that
participants who show delayed symptom elevations will tend to do only on isolated
measures, and will score within the normal range on other, related symptom
measures (i.e., the elevated symptoms should occur in a random manner across
measurements). The data supported this point. When assessed at 60 months, the
three participants showing delayed elevations from the original Bonanno et al.
(1995) study each showed an elevation on only one measure (Bonanno & Field,
2001). Further, when measurement error was minimized by weighting each of several
grief-related symptom measures by their alpha reliability and then summing the
weighted measures into a composite grief score, there were effectively no cases of
delayed grief (Bonanno & Field, 2001).
When this evidence is considered together with the fact that delayed grief has yet
to be demonstrated convincingly in any empirical study (Bonanno & Kaltman, 1999;
Wortman & Silver, 1989), it would appear that a diagnostic category for delayed grief
is unwarranted. Nonetheless, we echo Bonanno and Field's (2001) conclusion that it
may be premature to completely dismiss the possible existence of delayed grief on
the basis of only two empirical studies, especially when it is considered that the
construct is still strongly endorsed in the bereavement literature. However, given the
increasingly important role empirical evidence plays in modern clinical science, we
also echo Bonanno and Field's (2001) conclusion that the burden of proof now lies
most heavily on the shoulders of those who believe the construct to be valid and
clinically useful.
DESCRIPTIVE STUDIES OF THE GRIEVING PROCESS

In the next section, we consider more closely the distinction between common, time-
limited disruptions in functioning and more severe or chronic grief reactions. We
review a relatively large body of research unified by its emphasis on the descriptive or
phenomenological features of grieving. This research provides further evidence
consistent with DSM-IV's conception of bereavement as a stressor event with relatively
normal and predictable consequences. Our review reveals that most bereaved
individuals commonly experience four types of disrupted functioning in the first
year after their loss: cognitive disorganization, dysphoria, health deficits, and disrup-
tions in social and occupational functioning. There was also considerable evidence of
positive experiences during bereavement, which further underscores the normative
aspects of the common grief experience. In addition, and similar to the longitudinal
data, large numbers of bereaved individuals also tended not to show any major
disruptions in functioning, while a relatively smaller subset of bereaved individuals
tend to exhibit more extreme and enduring variations on these same disruptions in a
manner consistent with chronic grief.
Cognitive Disorganization
A number of investigators have noted the disorganizing impact of interpersonal
losses. These difficulties appear to be largely due to the way interpersonal losses
challenge the survivor's personal sense of identity and to the difficulty most bereaved
survivors experience comprehending a loved one's death. These types of cognitive
alterations have been found in most bereaved people during the initial months after
the loss and, although many bereaved people report continued struggles to make
sense of a loss even years after its occurrence, gradually decline during the first year.
In addition, there appear to be two subsets of bereaved individuals: one group who
show no signs of altered cognitive functioning, and one group who evidence more
pronounced alterations in cognitive functioning similar to trauma reactions.
Confusion and preoccupation. A number of investigators have reported that bereaved

individuals often experience difficulty accepting the reality of their loss, as well as an
accompanying sense of derealization, disorganization, and preoccupation (Linde-
mann, 1944; Parkes, 1972; Parkes & Weiss, 1983; Shuchter & Zisook, 1993). Shuchter
and Zisook recruited a large sample (N = 350) of conjugally bereaved individuals
using death certificates and observed that 2 months after the loss, 70% of the sample
found it ``hard to believe'' that their spouses had actually died, and that almost half
(49%) continued to do so into the second year of bereavement. However, more
extreme cognitive difficulties were only exhibited by a considerably smaller portion of
the sample. For instance, about one fifth of the sample reported at 2 months post-loss
that they had difficulties concentrating (20%), or making decisions (17%). Likewise,
a relatively small subset of the sample reported that they made ``more mistakes that
usual'' at work or in other areas of functioning (12% at 7 months, 11% at 13 months).
These proportions were greater, however, than a matched, married sample, in which
only 1% to 4% endorsed any of these items. Finally, although it has been assumed
that many bereaved individuals feel that something is wrong with them, or that they
are `àpproaching insanity'' (Lindemann, 1944, p. 142), when Shuchter and Zisook
(1993) asked participants directly if they felt that something was wrong with their
minds, only 5% endorsed this item. Again, however, this was greater than the 1%
endorsement of this item by the married counterparts.
Similar findings were reported by Horowitz and colleagues (Horowitz et al.,
1997). Among a sample of middle-aged, conjugally bereaved adults, the majority
(72%) experienced `ùnbidden'' memories and images of the deceased at 6 months
post-loss. However, fewer participants experienced extreme difficulties concentrat-
ing (34%) or perceptual aberrations in which it seemed that the deceased was still
alive (24%) or had appeared in a public place (17%). Even smaller subsets of
participants evidenced cognitive alterations commonly associated with trauma
reactions (DSM-IV; APA, 1994), such as hypervigilance (13%), or a foreshortened
sense of the future (12%).
Disturbances of identify. A related feature of grief-related cognitive disruptions is the

bereaved individual's sense of lost identity or merger of identity with the deceased
loved one. Shuchter and Zisook (1993) reported that most (87%) of their conjugal
bereavement sample endorsed the item `à piece of me is missing,'' while large
portions (55%) found themselves doing things more like their deceased spouses, or
becoming more like their deceased spouses (39%). More extreme forms of identity
merger have been noted among severely grieved individuals, including taking on the
physical symptoms that the deceased had experienced (Anderson, 1949; Bowlby,
1980; Lindemann, 1944). Although the clinical nature of these reports makes it
difficult to gauge the validity of the evidence, Shuchter and Zisook (1993) found that
a small subset (10%) of their conjugally bereaved sample experienced the same
physical symptoms as their recently deceased spouses. Likewise, Horowitz et al. (1997)
found that 14% of their conjugally bereaved sample experienced recurrent thoughts
that their own death would follow, or mirror, their spouse's death. These latter
findings are especially striking given that they were observed in samples of middle-
aged, and presumably, healthy individuals.
Sense of disrupted future. In the early months after a loss, the majority of bereaved
individuals report uncertainty about the future (Horowitz et al., 1997; Shuchter &
Zisook, 1993). However, by the end of the first year of bereavement, most bereaved
individuals no longer report this experience (Horowitz et al., 1997). Small subsets of
bereaved individuals (less than 15%) also tend to experience a sense of hopelessness
or perception of foreshortened future (Horowitz et al., 1997; Shuchter & Zisook,
1993). Lehman et al. (1987) found that 4 to 7 years after a sudden loss, conjugally
bereaved individuals may still endorse feeling less `òptimistic about the future'' than
matched controls.
The long-term search for meaning. Another cognitive alteration commonly associated
with bereavement is the concerted and enduring search for some way to understand
or find meaning in the loss. Schwartzberg and Janoff-Bulman (1994) questioned
undergraduates who had experienced the death of a parent within the past 3 years
and a group of matched controls on several meaning-oriented dimensions. Com-
pared with their matched counterparts, the bereaved participants in general
described the world as less meaningful and believed more strongly that personal
events were determined by chance. Further, the more grief the bereaved individuals
reported, the less likely they were to perceive the world as meaningful or to perceive
themselves as worthy, and the more likely they were to believe that personal events
were determined by chance or by powerful others.
Lehman et al. (1987) demonstrated convincingly that the search for meaning after
a loss is a typically long term if not impossible proposition. As late as 4 to 7 years after
a sudden loss of a spouse or child, the vast majority of bereaved individuals continued
to talk about the loss, to review memories, thoughts, or mental pictures of the
deceased, or to ask themselves the question ``Why me?'' or ``Why my spouse/child?''
Perhaps due to the potentially traumatic nature of unexpected or violent losses, close
to half the participants in this study also reported that they continued to relive, or
review events leading up to, their loved one's death. Finally, 68% of the bereaved
spouses and 59% of the bereaved parents reported that they had not found any
meaning or made any sense at all of the loss.
Dysphoria
Another dimension of bereavement, closely related to disordered cognitive function-
ing, is prolonged or intensified emotional malaise or dysphoria. Most but not all
bereaved individuals experience dysphoric states in the early months after a loss that
gradually subside during the initial year of bereavement, while more extreme or
enduring forms of dysphoria tend to characterize only the smaller minority of
severely grieved individuals.
Dysphoric emotion. Myriad clinical accounts of bereavement have associated inter-

personal losses with a broad scope of distressing emotions, most often centering
around anger, irritability, hostility, sadness, fear, and guilt (Abraham, 1924; Belitsky &
Jacobs, 1986; Bowlby, 1980; Cerney & Buskirk, 1991; Kavanagh, 1990; Lazare, 1989;
Osterweis, Solomon, & Green, 1984; Raphael, 1983). Shuchter and Zisook (1993)
questioned conjugally bereaved participants about their emotional experiences in the
first year after the loss. Surprisingly, only a small portion of the participants in this
study (less than 15%) endorsed having experienced the emotions commonly linked
to grieving, such as anger, guilt, and fear. One explanation for the infrequency of
dysphoric emotion in this study may be that retrospective self-report measures are not
adequate to accurately record ephemeral emotional experiences. A far greater
prevalence of dysphoric emotion during conjugal bereavement was observed, in fact,
in a subsequent study that measured facial expressions of emotion as they occurred
during a 6-month interview about the lost relationship (Bonanno & Keltner, 1997).
Using this immediate, nonverbal assessment, anger and sadness were exhibited by
almost two-thirds of the bereaved participants, and contempt and disgust by approxi-
mately one third (Bonanno & Keltner, 1997).
The common experience of dysphoric emotions during bereavement has also been
demonstrated by recent investigations of bereaved individuals' narratives as they
discussed their loss. Stein, Folkman, Trabasso, and Christopher-Richards (1997)
found that bereaved gay men described on average 13.7 negative emotional states
in interviews during the first month after their loss. Bonanno, Mihalecz, and LeJeune
(1999) coded emotion themes from bereaved widows' and widowers' narrative
descriptions of the lost relationship at the 6-month point in bereavement and found
a wide range of dysphoric themes. Distress was the most common theme, evidenced
in 39% of the narratives, followed by sadness (36%), contempt (34%), and anger
(14%). In addition, the themes of anxiety, shame, guilt, disgust, envy, fear, and
jealousy were evidenced in lesser frequencies.
Pining or yearning. From an emotional perspective, although grief may evoke a range
of different emotional responses, it is nonetheless distinguished from emotion by its
enduring nature and by its recruitment of long-term coping efforts (Bonanno, in
press; Izard, 1977; Lazarus, 1991). Several investigators have, however, identified
more complex and enduring aspects of dysphoria during bereavement. For example,
Parkes (1970) concluded that ``the central and pathognomonic feature of grief'' is an
intense ``pining'' or yearning for the deceased, such that ``without it grief cannot
truly be said to have occurred and when present it is a sure sign of a person grieving''
(p. 451). Parkes and Weiss (1983) later identified a ``high yearning'' group of
conjugally bereaved individuals who appeared to yearn for their deceased spouses
``constantly,'' ``frequently'', or ``whenever inactive.'' A team of interviewers also
found the high yearning group to have a poorer grief outcome during the second to
fourth years of bereavement. Although these findings would suggest that intense
yearning for the deceased is found only in complicated or severe grief, Parkes and
Weiss (1983) stressed that ``high yearning'' was by far the most frequent categoriza-
tion of their participants, describing about two thirds of the sample during the initial
months after the loss. Other studies have also demonstrated the normative, and time-
limited aspect of yearning. Of the 350 widows and widowers questioned by Shuchter
and Zisook (1993), 77% reported yearning for their deceased spouses in the first 2
months after the loss, while 58% still yearned for their spouses into the second year of
bereavement. Using a structured clinical interview format, Horowitz et al. (1997)
found that 58% of their conjugally bereaved sample experienced strong yearning for
their lost spouses nearly every day at the 6-month point in bereavement, while this
percentage dropped to 35% by 14 months post-loss.
Loneliness. A similar dysphoric feature commonly associated with grieving is intense

loneliness. Shuchter and Zisook (1993) reported that 59% of the widows and
widowers they questioned during the first two months of bereavement experienced
loneliness, while 37% felt lonely even when around other people. By the second year
of bereavement, these proportions dropped to 39% and 23%, respectively while, in
contrast, only 3% of a match married sample endorsed experiencing any form of
loneliness. Horowitz et al. (1997) report similar findings, with 59% of their sample
experiencing loneliness at 6 months post-loss, and 38% experiencing loneliness at 14
months post-loss.
Recently, Stroebe, Stroebe, Abakoumkin, and Schut (1996) assessed two different
types of loneliness during bereavement based on a distinction proposed by Weiss
(1975). Social loneliness was considered a general form of loneliness defined by the
absence of an engaging social network and feelings of boredom and social margin-
ality. In contrast, emotional loneliness involved `à sense of utter aloneness, whether or
not the companionship of others is in fact accessible'' (p. 1242) and suggests a
deeper form of inner loneliness similar to the dysphoria observed during bereave-
ment. Consistent with this distinction, emotional loneliness turned out to be the most
relevant to the grieving process: Conjugally bereaved participants reported signifi-
cantly more emotional loneliness than did a matched married comparison sample,
while social loneliness was not significantly different between the married and
bereaved participants.
Health Deficits
There is considerable evidence that the stress of interpersonal loss incurs a
significant health cost. This has been observed most commonly in the form of
increased doctor visits and complaints about general health. As with the other
aspects of grieving, health deficits are commonly observed among recently bereaved
individuals, but appear to be particularly enduring among a small subset of severely
grieved individuals.
Health behaviors and complaints. A number of studies have provided clear evidence
associating interpersonal loss with increased somatic difficulties, including shortness
of breath, palpitations, digestive difficulties, loss of appetite, restlessness, and
insomnia (Clayton, 1974; Horowitz et al., 1997; Lindemann, 1944; Parkes, 1970).
Several studies offered preliminary evidence for increased mortality and morbidity
rates during bereavement (Marris, 1958; Young, Benjamin, & Wallis, 1963). However,
several studies had also failed to find bereavement-related health deficits (Clayton,
1982; Heyman & Gianturco, 1973). To investigate these inconsistencies, Thompson,
Breckenridge, Gallagher, and Peterson (1984) compared the health of an elderly
bereaved sample 2 months into bereavement with an elderly comparison sample and
statistically controlled for a number of potentially confounding socioeconomic and
demographic variables. With potential confounding variance controlled, the
bereaved participants still reported more new or worsened illnesses, more severe
illnesses, more new or increased use of medications, poorer perceived health, and
poorer health relative to others of the same age.
Parkes (1964) examined doctor visits prior to and after the death of a spouse. In
the first 6 months of bereavement, doctor visits increased by 60%. Although the
number of doctor visits fell during the second and third 6-month periods, partici-
pants on the whole still visited their doctors more often than they had prior to the
loss. Bereaved individuals have also been found to report significantly greater health
complaints, into the second year of bereavement, relative to matched comparison
groups (Maddison & Viola, 1968; Parkes & Brown, 1972). In Lehman et al.'s (1987)
more lengthy 4 to 7 year study, however, neither parentally bereaved nor conjugally
bereaved individuals differed from matched controls in perceived health scores.
To explore individual differences in somatic complaints over time, Bonanno et al.
(1999) categorized conjugally bereaved individuals as has having high or low levels of
somatic symptoms based on the sample median at the 6-month point in bereavement.
Using this definition, approximately one third (35%) of the participants had low
levels of somatic complaints at each assessment through 25 months, while another
third (32%) showed initial elevations in somatic symptoms but dropped to low levels
between the first and second year of bereavement. A smaller group of bereaved
participants (19%) had varied levels of somatic complaints across assessments, while
only a small subgroup, comprising 13% of the sample, reported chronically elevated
somatic complaints.
Neuroendocrine activity and immune functioning. Several studies have examined the
possible role of neuroendocrine activity, such as changes in cortisol or serum
growth hormone levels, during bereavement. However, as yet these studies have
failed to provide clear evidence that neuroendocrine activity is altered signifi-
cantly during bereavement, or that it influences the course of grieving (Kim &
Jacobs, 1993).
In contrast, there is a growing body of evidence to suggest a link between grief and
a relatively short-lived compromise in immune functioning. Bartrop, Luckhurst,
Lazarus, Kiloh, and Penny (1977) examined cellular immunity in a conjugally
bereaved sample at 2 and 6 weeks post-loss and in a matched control sample. The
bereaved group showed reduced T-cell responsivity at both assessments, but did not
differ from the comparison sample in B-cell responsivity, or in T-cell or B-cell counts.
Schleifer, Keller, Camerino, Thornton, and Stein (1983) obtained repeated assess-
ments of immune functioning among 15 men before and after the death of their
wives from metastatic breast cancer. In the first month following the loss, over half of
the bereaved men showed reduced lymphocyte responsivity. However, there were no
differences pre and postloss in absolute T-cell or B-cell counts. Further, lymphocyte
responsivity was not different from preloss levels when assessed beyond the first 2
months of bereavement, suggesting that immune suppression due to loss is specific
and relatively short-lived.
Subsequent studies have refined this conclusion, indicating that the link between
bereavement and brief immune suppression may be mediated by depression (Irwin,
Daniels, Smith, Bloom, & Weiner 1987; Irwin & Weiner, 1987; Linn, Linn, & Jensen,
1984). For instance, Zisook et al. (1994) examined several different immune
functioning variables in a sample of middle-aged conjugally bereaved women and
in a sample of matched controls. There were no significant differences between the
bereaved women at 2 months post-loss and their married counterparts on any of the
immune variables. However, when the bereaved sample was separated into depressed
and nondepressed widows using the DSM-III-R, depressed widows had a lower
concentration of T-cells, lower NK activity, and a trend toward lower lymphocyte
stimulation responses compared to the nondepressed widows.
As compelling as the link between grief-related depression and a short-term
suppression of immune functioning may be, it has not yet been demonstrated that
the depressive aspects of grief exert a longer term influence on immune function-
ing, or that the short-term suppression effects produce any lasting health conse-
quences (Irwin & Pike, 1993). Additional research will be necessary to address this
question further.
Mortality. A dramatic aspect of the health consequences of grieving is the associa-

tion of bereavement with increased mortality, an association that appears to be
particularly robust in the early months after a loss. In one of the more impressive
demonstrations of the bereavement± mortality effect, Kaprio, Koskenvuo, and Rita
(1987) examined longitudinal data on 95,647 conjugally bereaved individuals in
Finland during their first 4 years of bereavement. Compared to the average expected
mortality rate in Finland, the conjugally bereaved individuals showed an overall 6.5
percent higher likelihood of dying. This increase was smaller (3.2% increase) for
deaths by natural causes, e.g., cardiovascular disease. However, deaths by natural
causes were almost twice as high as the normal expectancy rate in the first week of
bereavement. Deaths by violent causes, e.g., traffic accidents, were even more likely
(93% increase) among the bereaved individuals. Finally, bereaved individuals showed
considerably more deaths (242% increase) by suicide.
Since the extensive literature on the bereavement ± mortality effect has been
reviewed in detail elsewhere (Mergenhagen, Lee, & Gove, 1985; Stroebe & Stroebe,
1993; Stroebe, Stroebe, Gergen, & Gergen, 1981; Stroebe & Stroebe, 1987), we will
not consider individual studies further in this article. Rather, we reiterate the
conclusions of Stroebe and Stroebe (1993). Following an extensive review of a large
number of cross-sectional and longitudinal bereavement studies conducted in several
different countries, they concluded that despite inconsistencies across studies, there
was plentiful evidence that the ``bereaved are indeed at higher risk of dying than are
nonbereaved persons'' (p.188), and that the risk of increased mortality extends to all
types of bereavement, particularly in the early months after the loss and particularly
among younger bereaved individuals.
Disrupted Social and Occupational Functioning

In addition to its cognitive, emotional, and somatic manifestations, grief has also
been associated with disruptions in social and occupational functioning. These
difficulties have been observed most commonly in the form of social withdrawal
and isolation, or as the inability to fulfill normal social and occupational roles. As with
the other features of grief, disruptions in social and occupational functioning are
common for most but not all bereaved individuals in the initial months after a loss,
and tend to appear in a more extreme and enduring form among a subset of severely
grieved individuals.
Social Withdrawal and Isolation

Lindemann (1944) first reported disturbed interpersonal relations among bereaved
individuals. Subsequently, Parkes and Weiss (1983) observed that the majority of the
conjugally bereaved individuals they interviewed had withdrawn from participation in
social activities in the early months after the loss, but that more than half of their
sample showed increased social activity by the end of the first year of bereavement
and that the vast majority had returned to their previous normal level of social activity
sometime after the second year. Recent studies have more precisely mapped the
short-term course of social withdrawal in the normal grieving process. Horowitz et al.
(1997) found that 50% of a middle-aged, conjugal bereavement sample felt that they
were less emotionally available in significant relationships after 6 months of bereave-
ment than they were before the loss. By the 14-month point, however, the portion of
the sample feeling emotionally unavailable had dropped to only 19%. Similarly,
Shuchter and Zisook (1993) found that at the 13-month point of bereavement, only
relatively small percentages of the conjugally bereaved individuals they interviewed
endorsed items such as, ``My feelings are easily hurt'' (12%), `Ì feel that people are
unfriendly'' (4%), or, ``(I am) very self-conscious with others'' (6%).
Negative impact on others. One factor that may contribute to the distinction
between normal social withdrawal and more chronic social difficulties is the way
grief may impact on others. In other words, the constant expression of pain on the
part of severely grieved individuals may drive away potential avenues of social
support (Bonanno & Keltner, 1997; Coyne, 1976; Harber & Pennebaker, 1992;
Kelly & McKillop, 1996). This possibility received preliminary support in a recent
study in which untrained observers were asked to rate their subjective reactions to
videotapes of conjugally bereaved individuals as they described their loss to an

interviewer (Keltner & Bonanno, 1997). Those bereaved participants who were
perceived by the observers as less well adjusted also evoked in the observers greater
frustration and less compassion. In a subsequent study (Capps & Bonanno, 2000),
another group of untrained judges were shown narrative transcripts of these
interviews. The more the bereaved participants described negative thoughts and
emotions during the interview, the more the judges reported they would be
inclined to avoid the participant.
Role disruptions. Bereaved individuals also appear to struggle in their social roles as
parents or in their careers (Parkes & Weiss, 1983). Several cross-sectional studies have
provided data consistent with this conclusion. Compared to a matched sample of
married men, widowers recruited during their first year of bereavement reported
greater difficulties in their work roles both outside the home and in the home,
greater difficulties managing spare time, and greater difficulties with their family
roles (Tudiver, Hilditch, & Permaul, 1991). In another cross-sectional study, Lehman
et al. (1987) also found that 4 ± 7 years after the sudden death of a spouse, conjugally
bereaved individuals were still less likely to look forward to doing things with others,
less confident that they could handle or cope with a serious problem or major change
in their life, and rated the general state of their lives more negatively, compared to a
matched married group. The conjugally bereaved parents in the Lehman et al.
(1987) study showed similar but nonsignificant trends toward the same results.
A more precise estimation of the impact of bereavement on work performance and
its decrease over time was provided by Shuchter and Zisook (1993) in their
prospective study of a large, representative sample of recently conjugally bereaved
adults. They found that over a third (36%) of their sample reported dissatisfaction in
their work performance at 7 months, and that 28% still endorsed this problem at 13
months post-loss. Although these percentages show that dissatisfaction with work may
not be as widespread as other grief-related difficulties, is was still more common
among bereaved individuals relative to the 10% of the married comparison sample
who reported such difficulties.
Difficulties with new relationships. The death of a spouse is commonly associated with
temporary difficulties initiating and maintaining new intimate relationships. Hor-
owitz et al. (1997) found that 59% of the conjugally bereaved individuals they
interviewed at the 6-month point in bereavement had difficulties developing new
intimate relationships. However, by 14 months, only about a third of the sample
(32%) reported such difficulties. Schneider, Sledge, Shuchter, and Zisook (1996)
reported similar findings. Because these investigators considered a relatively large
conjugal bereavement sample (N = 350), they were also able to identify relevant
gender differences (W. Stroebe & Stroebe, 1993). Two months after the deaths of
their spouses, 55% of the widowers and 46% of the widows had difficulties developing
new relationships. By 25 months, however, the portion of widowers who experienced
difficulties with new relationships had dropped to 37%, while the proportion for
widows had risen significantly to 58%. Widows were also relatively slower to engage in
new romantic involvements. By the 2-month point in bereavement, only 3% of the
widows were invovled in new romantic relationships and this portion rose only
modestly to 19% at 25 months. On the other hand, 12% of the widowers were in
new romantic relationships at 2 months, and by 25 months this portion had risen
sharply to 61%. Widowers were also more likely than widows to remarry. Younger
widows were more likely to develop new romantic involvements than older widows,
while for widowers new romantic involvements were associated with income and
education level. Finally, but again similar to other facets of grief, there appears to be a
more severely grieved subgroup for whom developing new relationships is a particu-
larly exacting task. Regardless of gender, bereaved individuals who were depressed
found it more difficult to begin new relationships.
Positive Aspects of Bereavement

Until recently, positive experiences were thought to be quite rare during bereave-
ment. Further, positive behaviors and responses that would be considered adaptive in
most situations have been viewed as indicators of denial or avoidance when they are
observed during bereavement (Deutsch, 1937; Parkes & Weiss, 1983; Raphael, 1983;
Sanders, 1979). However, recent studies have demonstrated quite clearly that positive
cognitive and emotional experiences associated with bereavement are far from
infrequent, and that such experiences tend to be associated with a relatively mild
or normal grief course (Bonanno & Kaltman, 1999).
Positive thoughts, beliefs, and appraisals. Several recent studies have shown that
significant interpersonal losses often induce relatively positive changes in identity,
sometimes even in the first few months after the loss. Shuchter & Zisook (1993)
found that at the 2-month point in bereavement, 42% of the conjugally bereaved
respondents they questioned had already reported that they were better people for
having gone through the experience of grief. Further, over a third of their 2-month
sample (36%) reported that they had begun to enjoy the freedom of being on their
own. And these percentages only increased over time. By the second year of
bereavement, over half the bereaved sample had endorsed each item.
Evidence from recent narrative studies has provided even more striking contrast to
the traditional assumption that positive experiences are rare during bereavement. In
their study of bereaved gay men's narratives, Stein et al. (1997) coded a number of
appraisal variables and found that overall the men in their sample described
significantly more positive than negative appraisals in the first month of bereavement.
More specifically, the bereaved men reported almost twice as many positive ``belief
appraisals'' (e.g., belief in self-growth from past events) than negative belief apprai-
sals (e.g., fear of the future), and three times as many positive goal outcomes (e.g., `Ì
gave him a massage, and he felt better'') than negative goal outcomes (e.g.,
`Àlthough I gave him the medicine, he got worse.''). The proportion of positive
appraisals in the bereaved men's narratives was also associated with a greater
emphasis on both current and future-oriented goals and plans. Finally, the greater
the proportion of positive appraisals in the bereaved men's narratives during the first
month of bereavement, the more likely they were to show improved a health outcome
12 months after the loss.
In a related study, Capps & Bonanno (2000) coded bereavement narratives for the
extent that they included positive and negative thought content (thoughts, beliefs,
appraisals, opinions, and other forms of personal information that could not be
verified without access to the narrators' internal state) (Stiles, Shuster, & Harrigan,
1992). Thought content was slightly more often positive (29%) than negative (25%).
Further, positive thought content at the 6-month point in bereavement was predictive
of less interviewer-rated grief two years later. In addition, transcripts that showed a
greater prevalence of positive thoughts were rated by naive judges as indicative of
better adjustment and reduced suffering.
Positive emotions and laughter. It has become increasingly evident that positive
emotions serve an important adaptive function in the negotiation of negative life
events (Bonanno, in press; Fredrickson & Levenson, 1998; Lazarus, Kanner, &
Folkman, 1980). Recent bereavement studies have shown that, like positive thoughts
and appraisals, positive emotional experiences play an important role in the grieving
process (Bonanno & Kaltman, 1999). Shuchter and Zisook (1993) found that 28% of
their conjugally bereaved sample reported experiencing relief as early as 2 months
after the loss, while the majority of the sample (82%) reported that they were
``comforted'' by a sense that their spouse was in heaven. Stein et al. (1997) found
that, while bereaved gay men described overall more negative emotion states than
positive emotion states, positive emotion states were far from infrequent and
occurred in 39% of all the emotion states coded. In the Capps & Bonanno (2000)
study of conjugal bereavement narratives, mention of emotion in general was
relatively infrequent, occurring in only 11% of all narrative units. However, when
emotions were mentioned, almost half (49%) were positive emotions and an
additional 21% included both positive and negative emotion. Finally, in Bonanno
et al.'s (1999) investigation of core emotion themes during conjugal bereavement,
positive themes were the most common themes mentioned, including pride in the
deceased (82%), love/affection, (81%), and happiness (55%).
Conjugally bereaved participants have reported experiencing positive emotions
while describing their loss to an interviewer (Bonanno et al., 1995). Bonanno and
Keltner (1997) examined the facial expressions of emotion that occurred in these
same interviews and found that most of the bereaved participants also showed facial
expressions associated with enjoyment (smiling: 63%) and amusement (laughter:
58%). Further, smiling and laughter during the 6-month interviews were predictive of
reduced grief into the third year of the loss, and this predictive relationship remained
significant even when initial levels of grief and self-reported emotion were statistically
controlled. In a subsequent study, Keltner and Bonanno (1997) further explored the
adaptive role of laughter during bereavement. Bereaved individuals who showed
genuine or Duchenne laughter, which involves the orbicularis occuli muscles around
the eyes, at some point during their discussion of the loss reported less anger and
more enjoyment during the interview, evidenced the dissociation of distress (affec-
tive ±autonomic response dissociation), reported better social relations, and evoked
more positive responses from strangers who viewed them on videotape.
DIAGNOSTIC STUDIES OF SEVERE OR COMPLICATED GRIEF

The descriptive studies reviewed in Section 5 provide considerable evidence that a
small but important minority of bereaved individuals evidence many of the same
difficulties seen in common grieving, but to a more extreme and enduring degree,
thus suggesting a chronic grief pattern. In this section, we review attempts by
bereavement researchers to identify severely grieved individuals using a diagnostic
approach. Several studies have attempted to identify a general category of compli-
cated or ``pathological'' grief. However, these studies have tended to include many
normative or common aspects of grief among the assumed pathological symptoms

and, as a result, have been overinclusive. In contrast, other studies have identified
chronic depressive and anxiety disorders and, more recently, grief reactions similar to
those associated with Posttraumatic Stress Disorder. Consistent with both the DSM-IV
and the descriptive studies reviewed earlier, these disorders have been observed in
approximately 15% of the individuals studied.
Complicated or Pathological Grief

Several investigators have attempted to identify a general category of complicated or
``pathological'' grief. Prigerson et al. (1995) assessed a set of common bereavement-
related symptoms in an elderly sample within the first 6 months of bereavement.
Based on a principal components analysis of these data, Prigerson et al. identified a
depression factor and a grief-specific factor as distinct consequences of bereave-
ment. Field, Bonanno, Williams, and Horowitz (2000) reached a similar conclusion
in a study of middle-aged conjugal bereavement. They used the Texas Revised
Inventory of Grief (Faschingbauer, 1981) to assess ``grief-specific'' symptoms, and
questionnaire measures of depression, anxiety, and somatic complaints to assess
``general distress'' symptoms. It is noteworthy, however, that the grief-specific
symptoms in both these studies were dominated by yearning and preoccupation
with thoughts of the deceased, features identified in the descriptive studies reviewed
in Section 5 of this article as common for most individuals during the early months
of bereavement. Thus, the grief-specific symptoms identified in these studies suggest
a normal rather than pathological grieving pattern that can be distinguished from
depression and anxiety.
Kim and Jacobs (1991) developed a structured interview to assess ``pathological
grief'' based on the ``symptoms of separation distress.'' Their list of symptoms
included ``crying, sighing, yearning and searching for the deceased, preoccupation
with thoughts of the deceased, and functioning with a perceptual set for the
deceased'' (p. 258). Although Kim and Jacobs did not report full demographic
information, it appears that they interviewed a small sample (N = 25) of conjugally
bereaved individuals between 6 and 13 months post-loss. Using this method, a
surprisingly large portion (64%) of the sample met criteria for pathological grief.
A prevalence rate this high suggests that what Kim and Jacobs have termed
``pathological'' are best interpreted as normative aspects of grieving. Indeed, the
symptoms these investigators listed for pathological grieving were, again, similar to
those identified earlier as common to most bereaved individuals during the early
months of bereavement. Further, when Kim and Jacobs examined participants' scores
on the Texas Inventory of Grief (Faschingbauer, Devaul, & Ziskook, 1977), they did
not find meaningful differences between their pathological grief group and the
remaining ``nonpathological'' bereaved participants.
Horowitz et al. (1997) also attempted to identify possible criteria for a diagnostic
category of ``complicated grief'' using structured interview data. Based on sensitivity
and specificity analyses of the individual interview items, they identified a set of seven
complicated grief symptoms. These included unbidden memories or intrusive
fantasies related to the lost relationship, emotional pangs, distressing yearning for
the deceased, feelings of being alone or personally empty, excessive avoidance of
reminders (people, places, or activities associated with the deceased), unusual levels
of sleep disturbance, and loss of interest in work, social, or recreational activities.
Using a criteria that at least three of these symptoms be observed at a level of severity
that interferes with daily functioning, Horowitz et al. identified ``Complicated Grief
Disorder'' in 41% of the 14-month sample. Only 21% of these participants evidenced
a comorbid diagnosis of Major Depression. However, much like the Kim and Jacobs
(1991) data, the high prevalence of Complicated Grief diagnosis in this study appears
to have resulted from the inclusion of common grief features among the ``symptoms''
of Complicated Grief.
Major Depressive Disorder

Prevalence rates more consistent with the descriptive evidence reviewed earlier have
been found in studies attempting to identify depressive disorders. In one of the
earliest diagnostic studies, conducted prior to the DSM-III, Clayton, Halikas, and
Maurice (1972) categorized 20% of a conjugally bereaved sample in the first month
of bereavement as having ``definite depression'' and another 15% of the sample as
having ``probable depression.'' In a subsequent study, using DSM-III criteria, Jacobs,
Hanson, Berkman, Kasl, and Ostfield (1989) concluded that Major Depressive
Disorder was evident in 32% of a conjugal bereavement sample at 6 months post-
loss, and in 27% of another conjugal bereavement sample at 12 months post-loss. In a
later study, using DSM-III-R criteria, Zisook and Shuchter (1991) identified major
depression in 24% of a conjugal bereavement sample at 2 months, and in 16% of the
sample at 13 months. These percentages were higher than the 4% depression
prevalence found in a matched sample of married individuals.
Recently, Zisook, Paulus, Shuchter, and Judd (1997) reexamined Zisook and
Shuchter's (1991) data using DSM-IV criteria and identified major depression in
20% of the bereaved sample at 2 months post-loss and in 1% of the matched
comparison sample. They also applied DSM-IV criteria for minor depression
(depressed mood or loss of interest and two to four depressive symptoms) to
categorize an additional 20% of the 2-month bereaved sample and 2% of the
comparison sample. Finally, they applied an even weaker subsyndromal depression
category, based on the endorsement of at least 2 DSM-IV depressive symptoms (Judd,
Rapaport, Paulus, & Brown, 1994), to categorize 11% of the 2-month bereaved
sample and 3% of the comparison sample. Using this encompassing set of depression
categories, the remaining 49% of the 2-month bereaved sample and 94% of the
comparison sample were categorized as having ``no depression.'' When Zisook et al.
examined these data longitudinally, they found that the proportions decreased in
the bereaved participants at 13 months post-loss to 12% major depression, 17%
minor depression, 10% subsyndromal depression, and 62% no depression. At 25
months post-loss, the proportions were 6% major depression, 13% minor depression,
11% subsyndromal depression, and 70% no depression.
Generalized Anxiety Disorder

A similar prevalence of anxiety-related symptoms have been identified in a number of
bereavement studies (Clayton, Desmarais, & Winokur, 1968; Maddison & Viola, 1968;
Parkes, 1964; Sable, 1989; Zisook, Schneider, & Shuchter, 1990), and appear to be a
particularly tenacious aspect of chronic grief (Zisook & Shuchter, 1986). Jacobs et al.
(1990) identified anxiety disorders in 25% of a 6-month conjugal bereavement
sample, and in 44% of a 12-month conjugal bereavement sample. Generalized
Anxiety Disorder (GAD) was by far the most common diagnosis. Compared to the
community prevalence rate of 9%, GAD was identified in 23% of the 6-month
bereaved sample and 39% of the 12-month bereaved sample. Panic Disorder was
the next most common. Compared to the less than 1% prevalence in the community
sample, Panic Disorder was identified in 6% of the 6-month bereaved sample and
13% of the 12-month bereaved sample.
In addition, the Jacobs et al. (1990) data evidenced considerable overlap between
chronic anxiety and depression. The majority of depressed participants in the 6-
month sample (63%) were also diagnosed with an anxiety disorder, and all of the
bereaved individuals in the 12-month sample who had Major Depression were also
diagnosed with an anxiety disorder. Thus, although depression typically declines
during bereavement, it appears that the more anxious, chronically grieved individuals
also continue to experience enduring depression. Additional longitudinal data will
be needed to examine this conclusion further.
Posttraumatic Stress Disorder

Most recently, bereavement investigators have attempted to identify the symptoms
of Posttraumatic Stress Disorder (PTSD) as a possible response to bereavement.
Rynearson and McCreery (1993) examined grief and trauma symptoms in a small
sample (N = 18) of individuals who had lost a family member to homicide. Relative
to scores obtained in previous studies of natural-death bereavement, the homicide-
bereavement participants reported more intrusive thoughts on the Impact of Event
Scale (Horowitz, Wilner, & Alvarez, 1979) and increased grief-specific symptoms on
the Texas Revised Inventory of Grief (Faschingbauer, 1981). In addition, the
homicide bereavement participants reported dissociative experiences at a level 3
times that of nonbereaved individuals. In a related study, Green (1997) assessed
lifetime diagnoses among women who had experienced sexual assault, or a
potentially traumatic loss (accidental death, homicide, or suicide). Although the
women in this study were considerably younger (mean age = 19) than in other
bereavement studies, the results were comparable. The traumatic loss group had
high instances of trauma-related disorders: 16% had Acute Stress Disorder and
another 6% had PTSD. In addition, the traumatic loss group had the highest scores
on the Dissociative Experiences Scale (Bernstein-Carlson & Putnam, 1986). Inter-
estingly, the proportion of the traumatic loss group that at any point received the
Major Depression diagnosis (13%) was lower than in previous bereavement studies,
suggesting that traumatic losses tend to produce trauma responses rather than
depression responses. However, given the young age of the sample and the fact that
the lifetime diagnoses were obtained retrospectively, these results need to be
considered with great caution.
More recently, several studies have reported associations between PTSD symptoms
and the loss of a loved one through violent death. Zisook, Chenstova-Dutton, and
Shuchter (1998) examined conjugally bereaved individuals 2 months into bereave-
ment and found that approximately 10% of those whose spouses had died of natural
causes met the criterion for PTSD. In contrast, over one-third of the participants
whose spouses had died of suicide or accidents met PTSD criteria. In our own recent
study (Kaltman & Bonanno, 1999), we found that conjugally bereaved individuals
who lost spouses to violent deaths (suicide, accident, homicide) showed more PTSD
symptoms at each assessment across 25 months of bereavement, and also tended to
show more chronic depressive symptoms than bereaved individuals whose spouses
had died of natural causes. Together, these studies suggest that loss due to violent
death may be one of the factors that most strongly contribute to the eventual
development of chronic grieving.
FUTURE DIRECTIONS IN BEREAVEMENT RESEARCH

When considered together, the longitudinal, descriptive and diagnostic studies
reviewed in this article were generally supportive of the approach to bereavement
adopted by the DSM-IV. That is, the majority of bereaved individuals appear to
endure similar types of disruptions in daily functioning, and these experiences when
considered together appear to constitute a normal reaction to the stress of inter-
personal loss. In further concordance with DSM-IV, and in contrast to the numerous
types of complicated grief proposed in the bereavement literature, a small but
important subset of bereaved individuals appear to experience more intense and
enduring disruptions in functioning that overlap considerably with the existing
diagnostic categories of Major Depression, Generalized Anxiety, and Posttraumatic
Stress Disorder.
The supportive evidence for the use of existing DSM-IV categories to explain
chronic grief reactions raises an important question: Do chronically grieved indivi-
duals warrant unique treatment considerations compared to other individuals show-
ing the same diagnostic indicators? A number of theorists have proposed using
standard interventions for depression to treat chronic depression during bereave-
ment, such as interpersonal psychotherapy (Rounsaville & Chevron, 1982) and
``biologically informed'' psychotherapy (Zisook & Shuchter, 1996, p. 32). Similarly,
psychotherapeutic interventions for bereaved individuals considered to be at risk for
developing PTSD symptoms (e.g., bereavement after homicide) have been modeled
after standard trauma interventions (e.g., Horowitz, 1986; Rynearson, 1996). How-
ever, in each of these approaches, the standard interventions were modified to at least
some degree to encompass the unique features of bereavement. Unfortunately, there
have been few systematic studies to examine whether such modifications are
warranted. It will be imperative for future bereavement researchers to address
this issue.
Bereavement-specific treatment approaches have also been suggested by the
proponents of the more complex grief taxonomies. Indeed, these theorists have
argued for the necessity of various complicated grief categories based on their
perception that the clinical implications derived from the DSM categories are
`ùnacceptable'' (Rando, 1992, p. 55). By contrast, the conclusion we have advanced
in this review, that the various complicated grief taxonomies are unwarranted, carries
with it the further proposition that the treatment implications derived from these
taxonomies may also be unwarranted. For instance, uncritical acceptance of the
delayed or inhibited grief category has led to assumptions that the experience and
expression of the emotional pain of the loss is an essential component of treatment
(Rando, 1993; Worden, 1996), and that suspected cases of delayed grief need to be
referred to an expert grief counselor (Humphrey & Zimpfer, 1996). Given the lack of
empirical evidence for these assumptions, it would appear incumbent upon those
who espouse these interventions to provide systematic evidence in support of their
purported efficacy.
Our review also revealed a significant distinction that has not been well represented
in either the DSM-IV or the contemporary bereavement literature. The available
research suggests that considerable numbers of bereaved individuals experience little
or no overt disruptions in daily functioning as a result of their bereavement. In other
words, these individuals do not show the common grief symptoms, but neither do
they show any indication of abnormal or pathological mourning or any concrete signs
of delayed difficulties. One implication of this distinction is that there needs to be
greater research on prebereavement factors, and their role in informing the initial
reaction to loss. There has been remarkably little research on prebereavement
variables, perhaps due in part to the fact that such measurements are notoriously
difficult to obtain. Certainly, some of the contextual factors that might inform initial
grief can be measured retrospectively (e.g., type of loss, change in financial status,
etc.). However, a number of other variables that might potentially serve as predictors
of grief response (e.g., coping styles, attachment behavior, the quality of the marital
relationship) tend to be confounded with initial grief reactions and, thus, are best
measured a priori.
One of the few bereavement studies to incorporate prebereavement measure-
ments, conducted by Folkman and her colleagues (Folkman, Chesney, Collette,
Boccellari, & Cooke, 1996), is illustrative of this point. Folkman et al. (1996) first
recruited a sample of gay men who were caring for their partners, many of whom
were expected to die of AIDS in the near future. They measured a number of
variables, including life stressors, depression, and coping strategies, and followed the
caregivers through their partner's death and into bereavement. Using this design,
Folkman et al. were able to control for initial increases in depression after the
partner's death, and to show that depression at 7 months post-loss was predicted by
prebereavement stressors (daily hassles) and by the prebereavement use of distancing
and self-blame to cope with the burden of care giving. More research of this type will
greatly enhance our understanding of the initial stages of bereavement, and may
provide invaluable information to inform strategies for early clinical intervention.
Although much of the recent bereavement research has focused on determining
the factors that predict grief severity over the long term (for a review of this research,
see Bonanno & Kaltman, 1999), there has been relatively little research on the role of
the initial grief response. Indeed, if initial grief reactions are considered at all,
generally they are viewed in terms of variance that needs to be controlled while
predicting later grief. The research we reviewed in this article suggests, however, that
intense or pronounced initial grief reactions may be an important indicator of
whether individuals go on to develop chronic grief reactions. The available evidence
on this point was far from conclusive, however, therefore indicating another
important area for future research.
A further implication of our review is suggested by the absence of clear support for
the concept of delayed grief. In addition to assumptions about treatment, uncritical
acceptance of the existence of delayed grief has also unnecessarily limited the scope
of bereavement research. For example, delayed grief is widely assumed to arise from
the minimization or avoidance of grief-related distress in the early months after a loss.
This assumption has tended to preclude investigation of the potentially adaptive
value of grief-related avoidance, or of positive experiences such as laughter. It is only
recently that these phenomena have been examined empirically and, in contrast to
traditional assumptions about the importance of ``working through'' grief, the
evidence thus far indicates that adjustment during bereavement is fostered by
minimizing the experience and expression of grief-related negative emotions

(Bonanno & Keltner, 1997; Bonanno et al., 1995, 1999; Capps & Bonanno, 2000),
by fewer attempts to comprehend a loss or one's reactions to the loss (Nolen-
Hoeksema, McBride, & Larson, 1997), and by positive emotions and appraisals
(Bonanno et al., 1999; Keltner & Bonanno, 1997; Stein et al., 1997).
Finally, the evidence reviewed in this article suggests an imperative need for cross-
cultural and comparative bereavement research. No study has yet compared grief
severity across cultures using standardized measured and a prospective, longitudinal
design. When such data become available, it will be possible to determine whether
the types of grief course suggested in Fig. 1 characterize human bereavement in
general, or whether specific cultures might show unique patterns of outcome. By the
same token, it may be equally fruitful to begin systematic comparisons of grief severity
across different types of loss events, such as the loss of a job (Harvey & Miller, 1998),
or symbolic losses, such as the loss of a child to mental illness or intellectual disability.
It is our hope that our review will stimulate further longitudinal research of these
important points, and that a greater understanding of the course of normal and
complicated grief reactions will be forthcoming in the not so distant future.
AcknowledgmentsÐThe authors thank Diane Arnkoff for her many useful insights
during the development of this manuscript.
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VHA en 2001 The Varieties of Grief Experience Bonanno y Kaltman

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VHA en 2001 The Varieties of Grief Experience Bonanno y Kaltman

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Clinical Psychology Review, Vol. 21, No. 5, pp.

705 ± 734, 2001

THE VARIETIES OF GRIEF EXPERIENCE

Correspondence should be addressed to George A. Bonanno, Ph.D., Department of

THEORETICAL AND OBSERVATIONAL CLASSIFICATIONS OF GRIEF COURSE

The Taxonomy of Complicated Grief in the Bereavement Literature

absence of conscious grieving included the avoidance of reminders, physical symp-

When considered together, the various formulations suggest a complex, multi-

TOWARD AN EMPIRICALLY BASED, WORKING MODEL OF GRIEF

FIGURE 1. A working taxonomy of grief reactions.

LONGITUDINAL STUDIES OF GRIEF COURSE

concordance with a number of common symptom measures used in bereavement

DESCRIPTIVE STUDIES OF THE GRIEVING PROCESS

Confusion and preoccupation. A number of investigators have reported that bereaved

Disturbances of identify. A related feature of grief-related cognitive disruptions is the

Dysphoric emotion. Myriad clinical accounts of bereavement have associated inter-

Loneliness. A similar dysphoric feature commonly associated with grieving is intense

Mortality. A dramatic aspect of the health consequences of grieving is the associa-

Disrupted Social and Occupational Functioning

Social Withdrawal and Isolation

videotapes of conjugally bereaved individuals as they described their loss to an

Positive Aspects of Bereavement

DIAGNOSTIC STUDIES OF SEVERE OR COMPLICATED GRIEF

normative or common aspects of grief among the assumed pathological symptoms

Complicated or Pathological Grief

Major Depressive Disorder

Generalized Anxiety Disorder

Posttraumatic Stress Disorder

FUTURE DIRECTIONS IN BEREAVEMENT RESEARCH

minimizing the experience and expression of grief-related negative emotions

Izard, C. (1977). Human emotions. New York: Plenum.

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