1/

Pathological Grief: Diagnosis and Explanation VeM#i** ^

MARDI J. HOROWITZ, MD, GEORGE A. BONANNO, PHD, AND ARE HOLEN, MD

Pathological grief deserves a place in the diagnostic nomenclature. Because posttraumatic stress disorder
requires an event beyond the range of usual experience and bereavement is virtually a universal experience,
a new diagnosis of signs and symptoms precipitated by a loss event is needed. Many varieties of pathological
grief have been noted in clinical research studies, and multiple diagnoses of pathological grief would make
research difficult. The authors advance a solution in a personality-based explanation of abnormal responses
to loss events; this allows for a single diagnosis of pathological grief.
The authors also present a predictive model to partially explain pathological grief by antecedent trait
combinations. The hypothesis is that persons with a preloss combination of both contradictions in relational
schemas about the deceased and tendencies toward excessive control to stifle unwanted affect will tend to
have unsuccessful processes of mourning. Types of contradictions and overcontrol may vary, yielding
personality-based varieties of response within a single diagnostic category.
Key words: bereavement, diagnosis, emotion, grief, schema.

The addition of posttraumatic stress disorder considering certain personality-based explanations

(PTSD) to the diagnostic nomenclature was an ad-
vance in the study of stress response syndromes (1).
Although the PTSD diagnosis facilitated research on
the consequences of unusual and catastrophic stres-
sors such as war and disasters, there are still clinical
and research problems in trying to understand mal-
adaptive responses to loss. One root cause is DSM-
III's criterion that the stressor event be "outside the
range of usual human experience." Bereavement is
part of the usual range of human experience. None-
theless, it may be shockingly stressful for the person
who sustains the full impact of the loss. Responses
may include intrusion and denial symptoms of
PTSD. To allow better recognition of psychopathol-
ogy precipitated by loss, we suggest the establish-
ment of a pathological grief disorder diagnosis or
modification of the PTSD stressor criteria to include
bereavement as a stressor that can incite a disorder
in predisposed persons.
In discussions on how to form DSM-IV, several
theorists, such as Beverly Raphael and her col-
leagues, have suggested diagnoses of multiple cate-
gories of pathological grief (2). Multiple categories
would complicate nosology and make research more
complex. In this paper, we take the position that by
From the Langley Porter Psychiatric Institute, University of
California, San Francisco.
Address reprint requests to: Mardi J. Horowitz, M.D., UCSF,
Langley Porter Psychiatric Institute, Center for the Study of
Neuroses, 401 Parnassus Avenue, Box 37-B, San Francisco, CA
94143.
Received for publication August 5, 1992; revision received
November 17, 1992
of symptom formation, a single set of criteria can be
developed, and a single diagnostic category
achieved. Specifically, we address personality in
terms of enduring but contradictory internalized
views or schemas of self as related to other, as well
as habitual styles of defensive overcontrol that pre-
vent resolution of such contradictions.
BACKGROUND
PTSD became a part of the descriptive categories
of DSM-III in 1980 and was grouped as an Anxiety
Disorder. The reason for such a grouping was to
maintain coherence of prominent symptoms. People
with PTSD often report symptoms of intrusive and
anxiety-provoking ideas, worry over loss of control,
new phobias plus fear of repetition of the traumatic
event, chronic tension, and hypervigilance (3, 4).
The symptoms of intrusion may co-occur with their
seeming opposites: symptoms of denial, disavowal,
avoidance, blunting, and numbing. These extreme
deflections to "too much" and "too little" conscious
experience themselves may occur simultaneously
or may show a sequence of phases (Figure 1). The
phases can also be defined by specifying the event
criterion as a bereavement, leading to a differentia-
tion of normal and pathological grief that is pre-
sented in Table 1.
Some people do not have intrusions and periods
of numbness during their response to serious life
stressors, and many people who do have these ex-
periences have them at the same time rather than
in phasic sequences. In addition, people who com-
plain of grief and seek professional help often do so

260 Psychosomatic Medicine 55:260-273 (1993)

0O33-3174/93/5503-026O$O3.OO/0
PATHOLOGICAL GRIEF
WORKING
THROUGH
Facing the reality of
Fig. 1. Phases of response after stressor life events. From Horowitz M): Stress Response Syndromes, 2nd Edition. North vale, N], Jason
Aronson, 1986.
not only because of intense symptoms but also be-
cause they recognize an undue prolongation and
lack of progression in their personal responses to the
stressor event. A model of normal to pathological
stress responses that includes such observations is
presented in Table 2. It shows (a) resilient responses
during stress without postevent perturbations, (b) a
normal period of stress-event-induced perturbation
that does not warrant diagnostic labeling, and (c) a
pathological stress response with impaired func-
tional capacity and prolonged experience of disturb-
ances.
Psychosomatic Medicine 55:260-273 (1993)
Intense and prolonged
experiences may become
symptomatic as follows:
A pathological stress response can take several
forms. There are psychological perturbations, as in
persons who have continuing distortions in thought
and mood. There can be deflections from ordinary
conscious experience into states in which there are
either intrusive ideas and feelings or omissions of
expectable ideas and feelings. There are also pro-
longed states in which inhibitions so reduce mental
expressions that the processing of stressful events is
not completed. Nonconscious processing (or ephem-
eral moments of consciousness that are not contin-
ued or remembered) may occur, leading to sharp
261
 M. J. HOROWITZ et al.

TABLE 1. Normal and Pathological Grief*

Phases of Reaction Normal Response Pathological Intensification
Outcry Outcry of emotions with Panic; dissociative reactions;
news of the death and reactive psychoses.
turning for help to others
or isolating self with self-
succoring.
Denial Avoidance of reminders, so- Maladaptive avoidances of
cial withdrawal, focusing confronting the implica-
elsewhere, emotional tions of the death. Drug
numbing, not thinking of or alcohol abuse, counter-
implications to self of cer- phobic frenzy, promiscu-
tain themes. ity, fugue states, phobic
avoidance, feeling dead
or unreal.
Intrusion Intrusive experiences in- Flooding with negative im-
cluding recollections of ages and emotions, un-
negative relationship ex- controlled ideation, self-
periences with the de- impairing compulsive
ceased, bad dreams, re- reenactments, night ter-
duced concentration, rors, recurrent night-
compulsive enactments. mares, distraught from in-
trusion of anger, anxiety,
despair, shame or guilt
themes, physiological ex-
haustion from hypera-
rousal.
Working through Recollection of the de- Sense that one cannot inte-
ceased and contempla- grate the death with a
tions of self with reduced sense of self and contin-
intrusiveness of memories ued life. Persistent
and fantasies, increased warded off themes may
rational acceptance, re- manifest as anxious, de-
duced numbness and pressed, enraged, shame-
avoidance, more "dosing" filled or guilty moods, and
of recollections and a P5ychophysiological syn-
sense of working it dromes.
through.
Completion Reduction in emotional Failure to complete mourn-
swings with a sense of self ing may be associated
coherence and readiness with inability to work,
for new relationships. create, to feel emotion or
Able to experience posi- positive states of mind. In
tive states of mind. extreme cases, persisting
delusions or bizarre ideas
may occur.
* From Horowitz M), Stinson CH, Fridhandler B, et al: Pathological grief: An intensive case study. Psychiatry, in press.

and unexpected pangs of emotion. These pangs of
emotion have physical sensory components result-
ing from increased levels of autonomic nervous sys-
tem activation, neurotransmitters, and stress hor-
mones. Chronic high levels of stress hormones may
produce physiological and immune system changes
and even lead to enduring structural change in vul-
nerable organ systems. For that reason unresolved
grief may be reflected in bodily perturbations from
a variety of psychophysiological and psychosomatic
symptomatologies, perhaps exacerbating preexisting
conditions. The enduring effects of unresolved grief
reactions can also include social perturbations.
Some persons may be stigmatized by loss, others
may destroy available social support systems and
not resume social responsibilities.
How a person reacts to a stressor will depend on
the nature of the event, its place in relation to
cascades of other events, and its social and physical
environmental contexts. How a person reacts will
also depend on how the event and context interact
with the person's preexisting personality structure
and style(s) of coping. Personality will affect the type
of experiences formed, the duration of each phase

262 Psychosomatic Medicine 55:260-273 (1993)

PATHOLOGICAL GRIEF

of response, and whether or not adaptive completion TABLE 2. Types of Response to Stressor Events
of a mourning process is achieved. Resilient Normal Stress
Pathological
Certain personality characteristics might make Time
Response Response
Stress
subjects respond with turbulent emotions; other per- Response
sonality characteristics might make subjects re- Before event Equilibrium Equilibrium Equilibrium
spond by stifling emotional responses. Conse- (or pre-
event tur-
quently, which phase of stress response led to symp- bulence)
toms (and so presentation for diagnosis) might vary, During event Emotional Outcry Prolonged or
depending on the personality features of subjects. perturba- too intense
These personality differences can be individually tion outcry
formulated in clinical work and eventually might After event Equilibrium Denial phase Excessive and
be included in a multiaxis diagnosis, as Axis II of prolonged
denial,
DSM-III-R is improved into better defined, empiri- repression,
cally derived, and reliably assessed typologies or dissocia-
prototypes. tion
Intrusion Excessive and
phase prolonged
intrusion
and flood-
PERSONALITY FACTORS

era
Combined Combined
How They May Affect Successful or denial and denial and
Unsuccessful Processes of Mourning intrusion, a intrusion
working without re-
No generally agreed upon classification of person- through duction
ality has yet been achieved in psychology, and the phase with over time
psychiatric classification of disorders of personality reduced
denial and
has yet to achieve highly reliable descriptive cate- intrusion
gorization. Nonetheless, clinical research on normal Equilibrium Reschema-
and abnormal responses to stressor life events such tization
as loss do indicate that the inciting changes do not into a path-
fall on a blank slate but, rather, on an internalized, ological
equilibrium
enduring, and slowly changing knowledge structure. (e.g., char-
Bereavement activates the generalized meanings acter dis-
pertaining to the relationship between self and the tortion)
lost other, object, or function in life. Bereavement
itself casts aspects of personality into a bolder man-
ifestation so that features of personality may be
rendered more recognizable. Among the features so indicated the higher prevalence of rage, and defen-
highlighted are derivatives of the subject's schema- ses against rage leading to somatic changes, in the
tizations of self and others, as well as habitual styles ambivalence and guilt themes that tended to occur
of how the subject handles emotional tendencies, more frequently in pathological than in normal grief
especially how he or she tends to express or stifle reactions. Others indicated the importance of unre-
strong negative affects. Understanding such aspects solved dependency themes in uneasy schemas of
of personality, especially in combinations, can help attachment as more prevalent in persons clinically
us consider the utility of a single diagnosis of path- found to have pathological grief reactions (9-12).
ological grief, even though various typologies of Such variations in configurations before the loss
grieving will be found even within such a diagnostic could lead to variations after the loss, which is why
"umbrella," and can help us understand the differ- some have suggested different types of pathological
ence between successful and unsuccessful mourn- grief (2). The variety of antecedent meaning struc-
ing processes as well as the outcome of such proc- tures about a relationship can be understood, in part,
esses in terms of states of normal or pathological by considering these meaning structures as person
grief. schemas.
Freud (5) emphasized issues of ambivalence and Person schemas generalize, organize, and retain a
guilt in pathological, as differentiated from normal, great deal of information about the relative roles and
grief. Lindemann (6), Deutsch (7), and Klein (8) also attributes of self and others, and plans for how

Psychosomatic Medicine 55:260-273 (1993) 263


Ordinary Relations
EVENTS
CURRENT
WORKING MODEL Mutuality t
OF RELATIONSHIP
ENDURING
SCHEMA OF
RELATIONSHIP
ACCORD OF WORKING
AND ENDURING SCHEMAS
EMOTIONAL SYSTEMS
STATES OF MIND
Fig. 2. Modeling a state shift from calm to alarm. From Horowitz MJ. Person schemas. In Horowitz MJ, (ed), Person Schemas and
Maladaptive Interpersonal Patterns. Chicago, University of Chicago Press, 1991.
interactions might occur in sequences (13-20).
Mourning is an evolutionary success story: it takes
such schemas of the relationship with the deceased
and modifies or reschematizes them so one can go
on living with zest and meaning in spite of the loss,
although there is a period of painful transition (21).
Attachment bonds are not "forgotten;" the relation-
ship lives on in the mind, but habitual procedures
of living are modified to accord to new realities and
even new opportunities through the process of re-
schematization (22-28).
Extreme emotions may occur during the resche-
matization process, especially during the outcry and
intrusive phases of grief if these are experienced.
The denial, numbing, and avoidant phases are in
part an effort to ward off these strong feelings. The
emotional responses are due to the social loss in real
situations, and to internal or mental assessments of
the meanings of the loss both to the self and to other
loved ones. In addition, some important aspects of
the emotionality that occurs have to do with the
differences between internalized knowledge struc-
ture and external realities, the mismatches between
existing but now outmoded schemas and the actual
perceptions found in real contexts.
Alarm emotions may occur when enduring and
264
M. J. HOROWITZ et al.
News of Death
With Other of Other
Help
Other Harmed
Other
Mismatch
Alarming Rate
Equilibrium
of Arousal
Calm Fearful Outcry
expected schemas do not accord with new realities.
Take for example a period early in bereavement, as
shown in Figure 2. Before the news of the death, a
subject would feel calm even when apart from the
loved one. The current belief, or the current working
model of the relationship, to use Bowlby's term, is
one of being in an enduring mutual relationship that
accords with the enduring relationship schemas.
After news of the other's death, the current working
model no longer accords with the enduring schema.
The result is a pang of powerful and negative emo-
tion. Often, as also shown in Figure 2, the current
model may not fully accord with external reality.
The deceased may be modeled as harmed and des-
perately in need of help. Outcries of fear, helpless
excitement, and despair'may result from the sud-
denly recognized discrepancies between the current
working model, as derived from the news of death,
and the as yet unchanged enduring schema of the
relationship. Persistence of the schema of the other
as alive can lead to the prolonged and erroneous
belief that the deceased will return (29), as well as
to a continued and episodic sense of the presence of
the deceased (28-30).
Let us repeat for clarity how person schemas relate
to grief emotions. A bereaved person's cognitive-
Psychosomatic Medicine 55:260-273 (1993)
PATHOLOGICAL GRIEF
EVENTS
CURRENT
WORKING MODEL
OF RELATIONSHIP
ENDURING
SCHEMA OF
RELATIONSHIP
ACCORD OF WORKING
AND ENDURING SCHEMAS
EMOTIONAL SYSTEMS
STATES OF MIND
Fig. 3. Reduction of Alarm states with development of schema of others as lost. From Horowitz MJ: Person schemas. In Horowitz MJ,
(ed), Person Schemas and Maladaptive Interpersonal Patterns. Chicago, University of Chicago Press, 1991.
emotional state changes sharply with the news of
the death of the loved one. Often the other is viewed
as if harmed rather than dead. The emotional re-
sponse is intense and there may be considerable
agitation related to helplessness. As mentioned,
there are alarm emotions, the sharp surges of inter-
rupting affect, that occur when enduring schemas
do not match well with current working cognitive
models of what is happening "now." There is a rapid
increase in arousal resulting in the outcry phases as
indicated in Figure 1 and Table 1. Various types of
arousal activate different brain areas and functions.
Different types of peripheral autonomic nervous sys-
tem, endocrine, and immune system responses re-
sult. These lead to bodily sensations and changes,
and hence to social as well as individual psycholog-
ical appraisals and reactions to bodily changes.
Worry for the self as well as the other may occur as
a response to perceived bodily changes.
After a time, repetitions of the fact that the other
is lost forge a schematization of the self, longing for
and needing but not finding the other. Gradually,
upon reminders of the loss, this tendency to enter
states of agitated sadness becomes a tendency to
have states of poignant sadness and resignation. This
shift in the emotional intensity of alarm reactions
Psychosomatic Medicine 55:260-273 (1993}
Empty Situations Empty Situations
Need
Absent Absent
Other Other
Absent
Other
Mismatch Match
Alarming Rate Equilibrium
of Arousal
Poignant Sadness or
Agitated Sadness Resignation
indicates to the bereaved person a progress in
mourning. This simplified model of working through
and reschematization is shown in Figure 3.
The revision of existing schematic structures re-
quires both some awareness of the inability of pre-
viously held knowledge structures to account for
new information, and time to develop new meaning
structures. Yet we often avoid repetitions of such
awareness and cling to existing beliefs even in the
face of obvious incongruities (18, 31). This is largely
a product of the important role played by schemas
in most aspects of our daily lives. We rely on these
condensed knowledge structures to maintain a sense
of the world as safe and predictable (32). Periods of
change in these knowledge structures, above and
beyond all the searing pain of the loss itself, make
the world and the emotional self feel less in control.
Alarm reactions are themselves anxiety provok-
ing, leading to secondary pathological effects, and,
speculatively, physical ones. Alarm reactions in-
clude the intense bodily responses that lead to strong
physical sensations such as startle-induced muscu-
lar contractions, palpitations, or gastrointestinal
spasms. The autonomic nervous system physiology
is associated with emotional pangs in a way that is
probably extensive but this has never been fully
265

worked out. The repetition of many alarm reactions
could have psychosomatic consequences from com-
plex combinations of peripheral neurological, en-
docrine, and immunological system responses to al-
terations in the brain. There are probably cycles
involving cortisone-releasing hormone (CRH),
ACTH, cortisol, and epinephrine, with feedback
loops through blood circulation back to the activity
of cells in the hypothalamus, limbic system, and
temporal lobe cortex. These feedback loops may
readjust levels of CRH and similar substances. Con-
stant repetition of pangs could prevent CRH reduc-
tion and so inhibit reciprocally the production of
restorative hormones such as growth hormones. The
enduring structure of these interactive systems
could be affected.
The process of psychological reschematization can
reduce emotional pangs, but it is usually slow.
Mourning takes months or years rather than days.
Schemas developed and maintained over long pe-
riods of time facilitate information processing by
becoming relatively "automated" and by operating
outside of conscious awareness (33, 34). By virtue of
their repeated activation, however, long-held sche-
matic representations tend to assimilate rather than
accommodate (35) new information. They are, thus,
less easily revised and up-dated and, in some cases,
may be adhered to rigidly (18, 31]. The schematic
representations of marital partners and members of
the nuclear family generally exemplify such auto-
mated knowledge structures.
The person's ability to revise schematic represen-
tations during mourning depends to some extent
upon the degree of ambivalence or schematic con-
tradiction in that person's relationship to the de-
ceased prior to the loss. The official glossary of
psychoanalytic terms (36) defines ambivalence as
"the simultaneous existence of opposite feelings,
attitudes, and tendencies toward another person,
thing, or situation." Ambivalence is virtually uni-
versal; it is noteworthy as a clinical phenomenon
only when contradictory feelings or tendencies be-
come so strong that they cannot be integrated (15,
37) or when they are experienced as intolerable (38).
In the language of schema theory, a highly ambiva-
lent relationship would indicate a preexisting state
in which one organized set of beliefs is not readily
accommodated to another related body of informa-
tion. Contradictory and nonintegrated relational
schemas would exist. The mourning process is one
of review of a relationship and would activate these
contradictory schemas. When very discrepant sche-
mas were activated, the mismatch would lead to
266
M. J. HOROWITZ et al.
especially powerful and distressing pangs of emo-
tion.
The representation of an ambivalent relationship,
then, should prove to be even less flexible in accom-
modating to the loss of the other. Consistent with
this hypothesis, ambivalent feelings toward the de-
ceased (psychological dependency, guilt, anger) have
been cited as a major factor in pathological grief
reactions (26, 28, 30). Yet, although ambivalent rep-
resentations will be perhaps more difficult to rec-
oncile, the presence of ambivalence alone would not
necessarily prohibit reassessment and revision of
schematic representations. As already mentioned,
we propose that the reconciliation of unresolved or
conflicted representations of the deceased will be
more difficult for individuals who habitually avoid
painful topics, and contrary thoughts and emotions
that feel alarming and difficult to control. Such
individuals would be less able to identify contradic-
tory beliefs and, consequently, less able to adjust
their expectations of life, explore new behaviors, or
to find new meanings.
Anxiety and Cognitive Avoidance
Consider the experience of excessive anxiety, a
common feature of bereavement, particularly in the
early months following the loss. The death of a
spouse or important family member can often instill
in the survivor a profound sense of "aloneness"
accompanied by marked insecurities as well as re-
alistic fears, such as those related to financial hard-
ship (39). A portion of any bereaved sample, how-
ever, will tend to exhibit more severe anxiety states.
These individuals also tend to evidence a previous
history of anxious states of mind (25, 40). Thus,
individuals prone to the chronic experience of anx-
iety are mostly likely to exhibit excessive anxiety
during bereavement.
Chronically anxious individuals in a variety of
populations have been associated with "cognitive
avoidance" (41)—the avoidance of extended or pro-
longed processing of threatening information (42,
43). The individuals prone to experience excessive
anxiety during grief, then, could also be expected to
avoid contemplation of the emotional implications
of the loss to the self. They should be less able to
process the meaning of the loss and, as we are
proposing, should tend to exhibit more severe grief
reactions. A number of studies have demonstrated
the concordance of excessive anxiety with severe
(31, 32) or prolonged (44, 45) grief responses. In
addition, consistent with our proposal, the data from
Psychosomatic Medicine 55:260-273 (1993)
PATHOLOGICAL GRIEF
several studies has shown a relationship between
excessive anxiety, severe grief, and the inability to
reconcile and review the representations of the de-
ceased (45, 46).
Avoidant Personality Styles
Avoidant information processing has also been
assessed as a habitual "coping" style in a variety of
normal personality dimensions. While personality is
often cited as a likely predictor of grief outcome,
these dimensions have not been investigated in be-
reavement research. One such group that might
have difficulty adjusting to a loss are individuals
identified by questionnaire as "information blun-
ters" (47, 48). In one study blunters and their coun-
terparts, information monitors, were confronted
with low probability electric shocks and given the
choice of listening to an information channel about
the shocks of distracting themselves with music.
Blunters spent more time listening to the music
channel (48). In a study of combat-related PTSD (49),
blunters responded in a manner similar to chroni-
cally anxious individuals. They self-reported more
symptoms and greater problems in social function-
ing, and had higher levels of intrusions and avoid-
ance on the Impact of Event Scale (50).
A different group of individuals identified by
questionnaire and associated with avoidant infor-
mation processing have been labeled "repressors"
(51). Repressors comprise about 20 to 25% of a nor-
mal population and have been the object of consid-
erable study (52-54). They consistently exhibit the
behavioral signs of avoidance (51, 55) and demon-
strate poor memory for emotional events (56-58).
Yet, the repressor and information blunter measures
appear to assess different personality dimensions
(59, 60). Furthermore, repressors differ from chron-
ically anxious individuals in that they appear to
avoid the "experience" of anxiety (61). Individuals
suffering from anxiety disorders report elevated
anxiety and exhibit heightened physiological
arousal in response to stressful laboratory situations
(41, 62). Repressors also exhibit heightened arousal
in response to laboratory-induced threat but, in con-
trast to anxious individuals, they do not report a
corresponding increase in anxiety (51, 63, 64).
Attention and Control Processes
The difference between the cognitive avoidance
utilized by many anxious individuals and the re-
Psychosomatic Medicine 55:260-273 (1993)
duced conscious experience (or reports of) anxiety
demonstrated with repressors has been understood
in terms of each type of person's habitual style of
regulating attention and so the nature of their on-
going conscious awareness (61, 65, 66). The role
played by attention in self-regulation is sometimes
viewed on a continuum from an internal focus to-
ward the self to an external focus toward the envi-
ronment (61, 67, 68). The focus of attention inwardly
intensifies negative-affective states (e.g., 69, 70) and
leads to an increase in the activation of self-relevant
information derived from schemas of self (e.g., 71,
72). Although self-focused attention is considered an
essential element of normal self-regulatory proc-
esses (61, 68, 71), it is actively avoided when, for
example, it would lead to a negative emotional state
because the dominant current self schema is dis-
crepant from a desired self schema and a wished for
state (73), or when responsive emotions become ex-
cessive and intolerable (74). These conditions hold
an obvious similarity to the features of the mourning
process described on the preceding pages.
The experience of anxiety has long been associ-
ated with excessive self-focused attention (61, 68,
71, 75-77). Self-focused attention appears to mani-
fest in anxious individuals as a "priming" toward
the perception of anxiety-related information (78-
80). Such an anxiety-related "vigilance" seems to
further heighten arousal which, in turn, leads anx-
ious individuals to inhibit any further processing of
the threatening information (41, 81).
We propose that these same processes are opera-
tive in pathologically grieved individuals when they
experience excessive anxiety or other negative-sig-
nal affects. The characteristic "vigilance" to threat
has been observed in overly anxious, bereaved in-
dividuals (40). The resulting arousal-vigilance se-
quence should then minimize any prolonged self-
reflection and exacerbate symptoms. Accordingly, it
is not surprising that acute-anxiety states early in
bereavement predict prolonged anxiety at later
stages (39, 40).
Repressors, on the other hand, have been associ-
ated with the opposite of self-focused attention, what
Bonanno and Singer (61) have referred to as "percep-
tual cognition"—a lessened self-consciousness, ac-
companied by a global and superficial attention to
the external environment which is easily and fre-
quently shifted from one object to another. Such a
minimization or absence of self-focused attention
should result in a lessened experience of negative
affect and less accessible self-schema. Consistent
with this line of theory, it is not surprising that
repressors do not show the selective vigilance to
267
 M. J. HOROWITZ et al.

EXTERNAL STRUCTURES CONSCIOUS

SITUATION AND PROCESSES EXPERIENCES

Internal working model- Well being

of external situation
matches schemas of
self and other(s)

i Emotional alarms
Internal working model

ii
of new external
situation does not
match schemas of self
and other(s) ]_

I Regulation
I
L
I
to
modulate emotion
nIi
I i
I
| Supports ) » Reassesses situation Emotional-relational
' '< to revise schemas efforts at restoration;
trial and practice of
new behaviors and
recognitions; possible
turbulence requiring
endurance and hope

Modified repertoire of Well being (completion

schemas of self and of normal grief)
other(s) matches new
external situation and
opportunities

Fig. 4. Successful mourning.

negative stimuli typically exhibited in anxiety states
(55, 82). Repressors also distract themselves more
readily than do other individuals (55) and appear to
more efficiently dissociate the experience of exces-
sive arousal or unpleasant feelings (63, 64).
Given these characteristics, bereaved repressors
would not be likely to exhibit anxiety-related symp-
toms during the initial phases of grief. It is possible
that they may be especially prone, however, to the
later development of symptoms, or "delayed grief"
(26, 28, 30, 46). Repressors could also be expected to
exhibit signs of strong grief reactions indirectly as,
for example, psychosomatic complaints or night-
mares, and to exhibit avoidant or escapist imagery.
To recapitulate, we have suggested that persons
may have many different types of person schemas
for organizing belief and behaviors in relation to the
deceased, and the self as related to the deceased.
People with many contradictions and discrepancies
within these person schemas or internalized object
relationships would be more likely to have strong
negative emotions while processing and reschema-
tizing all the implications surrounding the loss and
the life of the self after the loss. The more contra-
dictions, the more turbulent the emotionality during
such processing. There would be different types of
emotionality and different ideational preoccupa-
tions depending on the different aspects of contra-
dictions and qualities of ambivalence. At the same
time persons would vary in how they habitually
used processes of control to reduce emotionality.
There would be different styles of overcontrolling
emotionality, that is, different ways of reducing neg-
ative emotional states of mind to such an extent that
reschematization opportunities are impaired by ex-
cessive avoidance of processing the ideas and feel-
ings that would lead to the reschematization. Nei-
ther factor alone would lead to pathological grief,
but contradictions (of any kind) and overcontrol (of
any kind) in combination would yield such an un-
successful mourning process that pathological out-
comes and prolongations would occur.
This theory is given graphic form in Figures 4 and
5, and provides an explanatory basis for how path-
ological grief might contain different patterns of
ideational, emotional, and behavioral content, and

268 Psychosomatic Medicine 55:260-273 (1993)

PATHOLOGICAL GRIEF

EXTERNAL STRUCTURES CONSCIOUS

SITUATION AND PROCESSES EXPERIENCES

Internal working — Approach-avoid

models of external
situations are unstable
due to contradictory
schemes of serf and
other(s)
dilemmas, problems in
relating, and contusions
or contradictions in
feelings

Internal working model Emotional alarms,

of new external severe moods, frozen
situation does not states
match schemas of self
and others; activation
of latent contradictory
schemas I

Overcontrol
to avoid dreaded
emotional states

{ Inhibited or distorted — Compulsive repetitions

I information processing and negative emotional
• prevents reassessments recognition that
I of situations and behaviors are
modification of schemas inappropriate,
(and walls off support) excessive numbing or
flooding of emotion

Repertoire of schemas
remains contradictory -
and does not match
new external situation
and opportunities
More severe dilemmas,
symptoms, problems, or
extreme avoidances
(pathological grief)

Fig. 5. Unsuccessful mourning.

yet have a common enough form that a single diag-
nostic entity could be defined for nosological and
research purposes.
DIAGNOSIS OF PATHOLOGICAL GRIEF
The polythetic criteria of DSM-III-R makes it pos-
sible and reasonable to include different expressions
of psychopathology which share common features
within the same diagnostic entity. In addition, from
a research point of view, a single diagnostic catego-
rization of pathological grief offers methodological
advantages over any more complex set of typologies
such as acute, chronic, delayed, or stifled grief. Pop-
ulation samples can be smaller if there is one rather
than many entities to consider.
As in PTSD, the first criterion for such a diagnosis
is the evocative event—the loss of an object or a
function that for the person has had an enduring
importance as an "attachment" of the self. The loss
may be of a spouse, a child, or another significant
person. The loss may be of a body part, a bodily
function, or even one's personal status, position, or
possessions. Unlike the stressor in PTSD, such a loss
does not have to be out of the ordinary range of
experience. On the contrary, at some point in life,
losses of this kind are likely to happen to everyone.
Beyond the stressor event criterion, the criteria
for the diagnosis of pathological grief encompass
three categories of symptom-related features: intru-
sions, avoidance, and dysfunctional adaption. These
criteria are shown in Table 3. Intrusions include
recurring, unbidden, and uncontrollable conscious
experiences, such as haunting thoughts and hard to
dispel images, including memories, images, dreams,
and most especially nightmares.
A difference between traumatic reactions to ac-
cidents, disasters, or violence and pathological grief
may be found in the manner in which the intrusions
are experienced. Individuals suffering from PTSD
may feel out of control because they cannot avoid
images that repeat the traumatic perceptions; these
represent a kind of hypermnesia or an excessive
activity of memory. Similar intrusions may occur in

Psychosomatic Medicine 55:260-273 (1993) 269


TABLE 3. Diagnostic Criteria for Pathological Grief
Criteria Description
A. Stressor Loss of a significant other
B. Intrusion 1. Occurrence of distressing, intrusive images,
ideas, memories, recurrent dreams, or night-
mares; the mind is flooded with emotions
without a sense of reduction in intensity.
2. Illusions or pseudohallucinations. The mind
is "haunted" by a sense of presence of the
deceased without a sense of reduction in
intensity.
C. Denial 1. Maladaptive reduction in or avoidance of
contemplation in thought, communication,
or actions of some important topics related
to the loss.
2. Having an implicit relationship for more than
6 months with the deceased as if alive; keep-
ing the belongings of the deceased exactly
or completely as before.
D. Failure to adapt 1. Inability to resume work or responsibilities
at home beyond 1 month after the loss.
2. Barriers to forming new relationships be-
yond 13 months after the loss.
3. Exhaustion, excessive fatigue, or somatic
symptoms having a direct temporal relation
to the loss event and persisting beyond 1
month after the loss.
* General rule for the diagnosis of pathological grief: The person
must meet criterion A, and in addition needs to display at least one
manifestation within all of the classes from B to D. It also is possible
to diagnose pathological grief if only one of the criteria from B to
D is present to a highly maladaptive degree.
pathological grief response. Yet a considerable por-
tion, of the intrusions may arise in relation to mem-
ories or images that serve as essentially positive and
temporarily comforting portrayals of the deceased
as still alive. Such ephemeral comforts result, how-
ever, in a repeated intrusive realization of the void
or absence of the lost object and constitute a painful
reminder of the present that is devoid of the lost
object. There is a 'trauma of contrast' between what
was and what is. The survivor is tormented by
exposure to the present now schematized to consist
of an excruciating emptiness and in sharp contrast
with the absorptions in 'good' memories of the past.
A further distinction of pathological grief reac-
tions from the experience of shock-induced PTSD is
that some pathologically grieving individuals prefer
by choice to indulge tenaciously in the 'good' mem-
ories or images of the past over such an extended
period of time that it becomes an obstacle to their
reorientation in life. Despite the untoward conse-
quences, such an avoidant dwelling on the past may
be experienced as an appealing relief and a comfort
and as a solitary source of gratification.
Positive memories of the deceased are often in-
270
M. J. HOROWITZ et al.
flated by idealized fantasies or selective forgetting
of negative features. In such instances the giving up
of the lost object usually is associated with strong
and overwhelming emotions, and may for this rea-
son be avoided. Such manifestations would appear
to reflect the combination of contradictory sche-
matic representations and the overcontrol of emo-
tional experience discussed earlier.
The maladaptive component of this phenomenon
is manifest in the inability to make decisions in
accord with the here-and-now reality. Pangs of fear,
sorrow, rage, shame, or guilt may emerge. The per-
son constantly feels close to loss of control; intense
motoric emotional responses and startle reactions
are easily triggered by any factual or symbolic re-
minder of the deceased.
A variety of escape-from-death images, illusions
and pseudohallucinations, may be entrenched in
socially accepted and promoted systems related to
death issues. These include ideas of reincarnation,
communication with the spirit world, and the prom-
ise of life after death. When and if these notions are
spiritual beliefs and acts of faith, they are beyond
the scope of diagnosis. No established belief system,
irrational as it appears, can be a criterion of a dis-
order. In order to assess the avoidant criterion for a
pathological grief diagnosis, functional impairment
must be assessed in relation to shared beliefs held
by a surrounding group of affiliated individuals or
social network. For a diagnosis to be made there
must be functional impairment in addition to irra-
tional beliefs or intrusive images.
Cultural schemas and social belief systems for
how a person is to behave in bereavement will relate
to the question of whether or not a functional im-
pairment is present. In some cultural contexts, for
example, widows or widowers may be expected to
remain celibate and to avoid the experience of a
new love. In most western cultures, by contrast,
mourning is viewed as a relatively brief, finite phase
of experience with a completion. After the mourning
period, the person is expected to resume relating to
others in a normal manner. If a bereaved person's
experience is dominated by rigid social beliefs about
the mourning process, there may be a failure to
adequately comprehend the personal meaning of the
loss and to revise the schematized representations
of self with intimate others.
A premature attempt to replace the lost person
may lead to perplexed and awkward states of mind.
If the person has not yet revised their role-relation-
ship models to accommodate anyone other than the
deceased, they may experience uneasiness, intense
guilt, or even panic (15, 21). The confusion engen-
Psychosomatic Medicine 55:260-273 (1993)
PATHOLOGICAL GRIEF

dered by a "new" social obligation to a new other
may also motivate avoidant or escapist coping mech-
anisms.
In pathological grief, avoidance may also manifest
behaviorally in the form of staying away from places
or people that are reminders of the deceased. An
enduring dissociated state of mind, with elements of
depersonalization or derealization may be observed.
Avoidance may also be expressed through indulg-
ence in excessive activity, or hypomania.
Prolonged dysfunctional or maladaptive behavior
will be evident in an individual's relationship to
work, in the general manner in which responsibili-
ties are carried out, and in social relationships. In
the work sphere the person may have a curtailed
ability to complete projects, to concentrate, or main-
tain a daily routine. Like PTSD patients, pathological
grief cases occasionally have a dismaying sense of a
foreshortened future. More common is the feeling of
being on hold. In the social realm, pathologically
grieving individuals appear to be unable to give as
much as before to children, relatives, or close
friends. More clearly pronounced are the problems
reflected in the ability to approach to a new intimate
relationship.
Once formed, the person may encounter substan-
tial problems in maintaining or deepening the new
relationship out of guilt toward the deceased. Guilt
is sometimes especially prominent when the person
discovers new qualities or joys in a relationship
compared with the previous relationship with the
deceased.
Differential Diagnosis
Pathological grief can be diagnosed by a set of
separate and distinct criteria that are independent
of those used for a diagnosis of Major Depressive
Disorder. In a study now underway, analysis of some
of the early subjects has shown a high level of
interrater reliability for the diagnosis of pathological
grief by criterion as shown in Table 3. Preliminary
diagnosis of this sample shows that there are persons
who, after a spousal bereavement, have signs and
symptoms that warrant the diagnosis of major de-
pressive disorder without other Axis I diagnoses,
other subjects who warrant the diagnosis of both
major depressive disorder and pathological grief,
and subjects who do not have the symptoms that
would warrant a diagnosis of major depressive dis-
order but who do warrant the diagnosis of patholog-
ical grief. The proportion of subjects found in all
three categories indicates the need for an additional
diagnosis.
Because of the criteria in the diagnosis of posttrau-
matic stress disorder, many persons who have per-
sisting intrusive and denial-numbing-type symp-
toms without the signs and symptoms of major de-
pressive disorder after a loss are given a diagnosis of
adjustment disorder, possibly only within the time
frame of 6 months. Unfortunately adjustment dis-
order is a time-limited and diffuse entity, inadequate
to problems of either research or clinical work. One
alternative possibility to our suggestion of a patho-
logical grief diagnosis would be to modify the stres-
sor event criterion of the posttraumatic stress dis-
orders to continue emphasizing the intrusive and
denial-type symptoms as found in DSM-III-R as well
as to add some proposed diagnostic criterion for
pathological grief in Table 3.
This paper is based on research supported by the
John D. and Catherine T. MacArthur Foundation's
Health Program through funding of its Program on
Conscious and Unconscious Mental Processes.

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