DEPRESSION AND ANXIETY 29:461–464 (2012)

The Cutting Edge

GETTING STRAIGHT ABOUT GRIEF

M. Katherine Shear, M.D., is currently Marion E Kenworthy Professor of Psychiatry

at Columbia University School of Social Work and Columbia University College of
Physicians and Surgeons. She is Director of the Complicated Grief Treatment Re-
search Program at New York State Psychiatric Institute and Director of the Bereave-
ment and Grief Program at Columbia University School of Social Work. Her clinical
work is in bereavement and grief and her research focuses on treatment studies of
complicated grief. She has published more than 250 peer-reviewed journal articles on
anxiety, depression, bereavement, and grief. She has been instrumental in developing
assessment instruments and treatment strategies for complicated grief and she has tested these in several NIMH-funded
grants. Clinicians and researchers around the world have adopted these assessment and treatment strategies.

INTRODUCTION: GRIEF IS NOT
DEPRESSION
On January 24, 2012 a New York Times article mis-
takenly claimed that psychiatrists are proposing to diag-
nose grief as a Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) disorder. Some of the confusion is
because the word “depression” has more than one defi-
nition. “Small d” depression, “a state of feeling sad, de-
jection” (Merriam Webster) is a core feature of grief, and
it is not the same as the psychiatric diagnosis of depres-
sion. Most bereaved people do not experience a major
depressive disorder (MDD) and when they do, it is simi-
lar to MDD in other contexts.[1] Correspondingly, anx-
iety commonly occurs as a component of grief though
most bereaved people do not meet criteria for an anxiety
disorder.[2] Anxiety disorders that do occur are similar to
those in other contexts. Because bereavement is a stres-
sor it is a risk factor for mood and anxiety disorders.
Yet, symptom overlap means accurate diagnosis of these
disorders is challenging in the presence of acute grief.
Symptom overlap is not unique to bereavement. We also
see overlap of mood and anxiety symptoms with many
medical conditions. Yet, numerous studies show that the
occurrence of a DSM-IV mood or anxiety disorder has
important implications for the course and treatment of
medical illness[3] and it seems likely that this is also the
case for bereavement. It is important to recognize acute
grief and provide appropriate support, and it is also im-
portant to diagnose and treat mood and anxiety disorders
when they are present after bereavement.
communication imprecise. Our group uses the follow-
ing definitions: bereavement is the experience of having
lost someone close; grief is the reaction to bereavement,
comprising thoughts, feelings, behaviors, and physiolog-
ical changes that vary in pattern and intensity over time;
acute grief is the initial response, a mix of separation and
traumatic distress, that is eventually transformed to inte-
grated grief, which is permanent. Mourning is the process
by which the finality and consequences of the loss are as-
similated into memory systems, and capacity restored for
joy and satisfaction in ongoing life. When mourning is
successful, the deep pain and disruption of acute grief
lessen, memories become bittersweet and the bereaved
person finds a place for the loss in her or his ongoing life
(Fig. 1). Death is forever, and correspondingly grief is a
lasting response.
Bereavement is a fact of life. Each year about 2.5 mil-
lion people die in the United States, and an estimated
60 million die worldwide.[4] Each death leaves a small
group of bereaved people with whom the deceased has
enjoyed a close relationship. Estimating an average of
four bereaved people for each death, means 10 million
people are bereaved yearly in the United States, or about
3% of the population. A recent cross-sectional survey of
a random general population sample found 57% of the
German population reported ever having lost a signifi-
cant person.[5]
Close relationships give our lives purpose, mean-
ing, joy, and satisfaction. They enrich our lives in a
myriad ways, providing feelings of security, enhanc-
ing our self-esteem and confidence, and supporting us

BEREAVEMENT, GRIEF, AND
MOURNING
Confusion about terminology goes beyond the double
meaning of depression. The terms bereavement, grief,
and mourning are often used interchangeably, making
∗ Correspondence to: M. Katherine Shear, M.D., Columbia Univer-
sity School of Social Work, 1255 Amsterdam Avenue, New York,
NY 10027. Email: ks2394@columbia.edu.
DOI 10.1002/da.21963
Published online in Wiley Online Library (wileyonlinelibrary.com).


C 2012 Wiley Periodicals, Inc.
462
Figure 1. Bereavement, grief, and mourning.
during times of stress. They help regulate our emo-
tions and solve problems. Being with people we love
is a source of pleasure, and we prefer not to be sep-
arated for long periods of time.[6] Loss of a close at-
tachment is an intensely emotional experience. Most
people react with a sense of aching void and a feel-
ing of disorientation. In the early bereavement period,
the familiar world seems unfamiliar, and unanticipated
small reminders cause sudden unexpected pain. The be-
reaved person is caught up in thoughts and memories
of the person who died, and it is difficult to be inter-
ested in anything else. Grief dominates the mental land-
scape. Importantly though, it is still possible to regu-
late emotions and to experience some pleasure. Typi-
cally, people engage in problem solving and introspec-
tion. Kay Redfield Jamison is eloquent in discussing her
grief [7]
. . . you come out of it genuinely stronger, and
with a much better understanding of the per-
son you lost and a much better understanding of
yourself, your vulnerabilities and your strengths
and what it is you are missing .... Grief forces
you to do a kind of introspection that is re-
ally remarkable. (http://www.youtube.com/watch?v
= WmmWQLtK03E)
Grief comprises an array of emotions, cognitions, and
behavioral tendencies that change over time. Yearning
and sadness are the core emotions. Many people also
experience anxiety, which may be related to separation
from a protective companion or to a range of worries
about what the future may hold. Anxiety is a natural re-
sponse to confrontation with the reality of death. Guilt
or remorse can occur if the death registers as failure to
Depression and Anxiety
Shear
protect or care well enough for the deceased, or there is
a troubling circumstance related to the loss. Many be-
reaved people experience some degree of protest, bitter-
ness, envy, or anger over the fact of the death, or anger
about the behavior of someone in relation to the death.
Importantly, positive emotions are also present during
acute grief.[8] Studies have reported daily positive emo-
tions occur as frequently as negative ones as early as the
first month after the death.[9]
The cognitive hallmark of acute grief is recurrent in-
trusive thoughts and memories of the deceased, some-
times accompanied by hallucinatory experiences of the
lost loved one.[10] As is the case during transitions into
a new love relationship, the intrusive thoughts are often
welcomed, rather than resisted. Details of the lost re-
lationship are reviewed and considered, and over time,
positive memories predominate in recalling a deceased
loved one.
Though most bereaved people continue to engage
with others and carry out daily tasks, certain behav-
ioral changes are common and entail avoidance of re-
minders of the loss alternating with proximity seeking.
In Bowlby’s words,
He or she may then oscillate between treasuring such
reminders and throwing them out, between welcom-
ing the opportunity to speak of the dead and dread-
ing such occasions, between seeking out places where
they have been together and avoiding them.[11] p. 92
Other behavioral changes that can occur during acute
grief include an inclination to alter the time or the con-
tent of meals and recreational activities, sometimes seri-
ously disrupting the pattern and frequency of usual daily
activities.[12] It may be difficult to sleep, especially in a
bed that was previously shared with the deceased, though
 The Cutting Edge: Getting Straight About Grief
sleep architecture is not altered as it is in depression.[13] A
myriad of small activities can serve as painful reminders
of the loss and require strategies to manage this.
Mourning is the process by which a bereaved person
comes to terms with the loss. Mourning is fundamen-
tally a learning process in which new memories, both
implicit[14] and explicit, are incorporated into the mental
representation of the deceased. Effective emotion regu-
lation is required in order to accomplish the transforma-
tion and integration of grief.
An important minority, estimated at about 7%,[5] of
bereaved people fail to mourn effectively because of grief
complications. These may include an excessive focus on
counterfactual thinking (“if only” ruminations), trou-
bling rumination about the future, excessive avoidance,
compulsive proximity seeking, or inability to effectively
regulate emotions. Any of these problems can derail the
mourning process and lead to persistence of acute grief
symptoms. This is the syndrome of complicated grief.[15]
WHAT CLINICIANS CAN DO
Clinicians working with bereaved people can help by
facilitating the natural mourning process. To do so effec-
tively means (1) supporting acute grief in its cultural con-
text, (2) encouraging effective mourning, (3) managing
complications that can derail mourning, and (4) recog-
nizing and accurately diagnosing concurrent psychiatric
and medical conditions. Supporting acute grief means
providing information about grief symptoms and ex-
plaining these as a natural experience that helps us adjust
to the monumental consequences of bereavement.[16] It
is natural for grief symptoms to vary over time, and there
is no map or predictable, step-wise course from acute to
integrated grief. However, in general there is progres-
sion, albeit erratic, over a period of months, toward bet-
ter acceptance of the loss and adjustment to life without
the deceased.
Positive emotions are natural during this time[9] and
opportunities to experience them should be gently en-
couraged, as should a reasonable balance of seeking so-
lace in solitude and in the company of others. A clinician
can serve as a trusted companion who listens actively,
bearing witness to the sorrow and longing, and to other
emotions, and gently facilitating the mourning process;
there is little need to actively guide the discussion. Ad-
ditionally, it is a good idea to be alert to landmines. If a
bereaved person is engaging in excessive counterfactual
thinking, excessive worries about the future,[17] excessive
avoidance,[18] or compulsive proximity seeking, or if it
appears that there is little progress in emotion regula-
tion, the clinician may want to gently acknowledge this
and help the person resolve the problem.
Bereavement is a significant stressor, and as such, can
trigger the onset or worsening of any physical or men-
tal disorders. About 30% of bereaved people experience
MDD.[19] People with a personal or family history are
at greatest risk. Importantly, acute grief should not be
mistaken for MDD. A 2-month time frame is not long
463
enough to consider grief in the differential diagnosis of
small-d depressive symptoms, as is done in DSM-IV. We
do not want to diagnose grief as depression. Nor do we
want to diagnose depression as grief.
Bereavement does not protect against major depres-
sion, and major depression is a serious illness. Failure to
diagnose MDD has important negative consequences.
There is a proposal to remove the bereavement exclu-
sion in DSM5 in order to allow treatment for people
experiencing both grief and depression. The idea that
this proposal fosters pharmaceutical industry interests
is unfounded. There are many good nonpharmacologi-
cal treatments for depression,[20, 21] and withholding care
for a patient seeking it for acute distress and depression
is not advisable. Bereaved people who are also experi-
encing MDD are burdened by symptoms that can inter-
fere with grief, including negatively biased thoughts and
inhibition of positive emotions. Treating depression is
important so that these people can be free to experience
their sorrow, savor memories of their lost loved ones,
and begin to remake their lives.
SUMMARY
Acute grief is emotionally intense, cognitively preoc-
cupying, and disruptive, but grief is not an illness; major
depression and anxiety disorders are. Grief and mourn-
ing have a purpose. They provide an intense, focused
opportunity to reregulate emotion and to engage in a
learning process that is aimed at reconfiguring life with-
out the deceased—both the internal life of the mind,
and ongoing life in the world. A bereaved person needs
to figure out how to find meaning, purpose, joy, and
satisfaction in life without someone who has previously
been central to these feelings. This reconfiguration is a
very natural process that tends to occur in fits and starts
as bereaved people move forward and deal with every-
day life. Nevertheless, a knowledgeable, empathic and
supportive clinician can foster good adjustment.
Successful mourning is, however, not a given. For
some people, the mourning process is derailed and acute
grief is inordinately painful and prolonged. For others,
the stress of bereavement triggers the onset or worsen-
ing of symptoms of MDD, an anxiety disorder or another
psychiatric or medical condition, suicidality or negative
health behaviors. Clinicians need to be alert to all of
these problematic responses to loss. In the wake of be-
reavement, we need to both facilitate effective mourning
and diagnose and treat co-occurring conditions.
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