- Grief is the painful response to a loss.
- Grief is the ‘form love takes’ after someone we love dies (per Dr Kathy Shear)
- The response automatically guides the bereaved to how to cope with the death, it is nature’s way.
- Grief following bereavement is permanent, because the loss is permanent
- It is permanent, but usually evolves and changes with time to become more tolerable.
- The grief response is unique to the person that is bereaved (because only they had that unique relationship with the deceased).
- Each person grieves each separate bereavement differently (because no two relationships are the same).
- There are commonalities in the grief response.
- It is useful to consider three forms of grief. The first two are normal grief responses; the third can be considered to lie outside of an adaptive grief response (ie treatment is indicated).
- Acute grief – arises immediately after the death and is often all consuming
- Integrated grief – the pain of grief lessens as adaptation to the death, and it’s consequences, occurs with time. Integration occurs indefinitely, as the loss continues to be processed.
- Prolonged Grief Disorder (PGD) – a clinical disorder arises if adaptation does not occur with time (typically not diagnosed until at least 12 months after a death)
Acute Grief
- Has typical emotional, cognitive, behavioural, physiological, social, cultural and spiritual expressions
- Initially there is often shock, disbelief and numbness – it is hard to comprehend that the loved one has died (as there is an expectation that they are alive).
- Accompanied by negative emotions (yearning, sadness, anxiety, anger, guilt and blame)
- Causes social withdrawal, preoccupation with thoughts of the deceased and loss of interest in usual activities
- Often associated with insomnia, physiological features of stress and loss of appetite
- Is a time of social and cultural rituals that are important in facilitating the grieving process (such as a funeral)
- Grief typically comes in waves or pangs
- It usually lasts weeks to months, but with a difficult death, it can last longer.
Integrated grief
- With the passage of time, the finality and reality of the death are gradually accepted. The intensity of the grief lessens and becomes more of a background state, although memories of the loved on are readily available and experienced as comforting although bittersweet.
- Acute grief or pangs of grief may still be triggered by reminders or special dates, but is not impairing, for years after the death
- There is an ongoing bond with the deceased; their memory and ‘being’ are held close, but in the knowledge that they have died.
Prolonged Grief Disorder (PGD)
Classified in ICD11 (2018) & DSM5-TR (2022)
Previously known as Complicated Grief
- Occurs if the grief remains impairing and preoccupying, without seeming adaptation – it seems ‘stuck’ long after the death
- Certain bereavements have elevated risk of PGD (death of a child, a spouse or following a suicide, homicide or accident).
- It is diagnosed by clinical interview and screening instrument (such as 19 item self-report Inventory of Complicated Grief)
- The prevalence is approximately 7% – 10% of close bereavements (higher, ie 25-30% following particularly difficult deaths)
- The treatment is psychotherapy: Prolonged Grief Therapy (previously known as Complicated Grief Therapy) which is a brief condition specific psychotherapy, or similar
- Psychotropic medication is not indicated for grief (but maybe useful for co-morbid conditions)
- Patients need to be assessed for suicide risk and substance abuse (both elevated in this disorder)
- PGD is distinguishable from, but often co-morbid with, depression and PTSD
Remember!
Grief is not the same as depression
Grief is characterised by yearning and preoccupation with the deceased and the death.
Positive emotions can be present in grief (joy and amusement at memories; comfort from consolation).
Must assess for suicide risk (suicidal ideation is common in the bereaved).
Also assess for substance abuse, such as increased alcohol use (used as a maladaptive coping strategy).
Physiological dysregulation that occurs with grief places the bereaved at risk of medical co-morbidity (do not overlook); although pain or symptoms similar to that which the deceased experienced are not uncommon in the bereaved.
Many with PGD do not present for treatment – this maybe because they consider the only way to make them better would be to have their loved one back. Thus, it is important to screen for PGD (even decades after a difficult bereavement), as it has a good response to treatment and reduces the risks associated with co-morbidity.
Grief is just as painful and impairing for the elderly – don’t expect them to adapt more quickly because they have experienced prior losses.
Management of normal grief
Listen to their story and provide empathic support
Validate their grief response as normal and appropriate
Mobilise social, cultural and religious supports
Discuss adaptive versus maladaptive methods of coping
Viewing of the deceased is generally useful, although painful.
- It allows final time together
- Aids the comprehension of the finality and reality of the death
- Is an act of respect and caring for the deceased
Assess for psychiatric or medical co-morbidity (risk of relapse of preceding illness with bereavement)
Monitor high risk bereavements over time (such as suicide bereavement, death of a child etc)
Encourage self-care and daily routine (nutrition, sleep, exercise, recreation, socialisation, health)
Advise of local support services or groups for the bereaved
Grief support counselling is indicated if there is a lack of social support or obvious risks
Bonus information ….
Grief is an instinctive response, triggered by acute disruption of the ‘attachment’ and ‘care-giver’ biobehavioural motivational systems that operate as neurophysiological regulatory systems within our nervous systems.
These systems operate unconsciously, but regulate our emotions, cognitions, physiology and behaviours.
Our self-identity, ie who we sense we are, is strongly influenced by those we love. Thus, grief is a complex manifestation of dysregulation of these systems and altered identity.
Grief is partly due to:
‘Separation distress’ – which causes anxiety, preoccupation, yearning and searching for the loved one; and partly due to
‘Traumatic distress’ – caused by the emotional shock, disbelief and trauma of the death and stresses that the death causes within the daily life of the bereaved.
A sense of confusion after someone dies is common. This is partly due to the shock and general dysregulation including insomnia; but also due on the one hand knowing the fact of the death, but on the other ‘expecting’ the person to be alive due to implicit memories. This is because of complex memory networks that link into multiple areas of the brain, known as the ‘Working Model’ or specific attachment system linked to our loved one. These neural circuits/memory systems are laid down over a prolonged period, each time there was interaction with the deceased before they died. This leads us to predict and expect what the loved one would/should be doing. This system needs to be updated, through repeated experience of the fact of the death after the death, to revise the working model to accurately reflect (or learn at an emotional or unconscious level) that the death has occurred.
Grief is essentially a complex learning process; this can be difficult if there is cognitive impairment.
Attachment biology is highly rewarding (think oxytocin, dopamine and opiates) making the importance of relationships and the pain of their loss unparalleled in human experience.
Relationships are based on love; thus grief can be considered the form love takes after someone dies (Dr Kathy Shear).
The role of our care-giving system is to look after and protect our loved one. Consciously we want the best for them; the unconscious component of this system is very powerful. If a loved one dies, although rationally we did all we could, unconsciously this is a biological failure of the worst kind. This can cause automatic feelings of failure and guilt; these can be problematic in PGD.
Disenfranchised grief refers to those that are grieving, often intensely, but are not recognised by others as having legitimate grief. Much grief falls into this category – doctors that have lost a patient, distant classmates impacted by a suicide at the school or siblings and grandparents when a child dies in a family. Remember – all grief is legitimate and beware of comparative suffering.
Avoidance of reminders of the death, whilst normal early in the grieving process, can become unhelpful to adaptation if they persist. Examples of things commonly avoided are difficulty looking at photos, looking or dealing with belongings, seeing people that are reminders or going to places that used to be frequented with the deceased. Ongoing avoidance causes failure to learn how to cope with the reality of the death; it inhibits learning and acceptance of the death, thus the memory systems are not updated. Once avoidance is overcome, the bereaved have a greater acceptance of the finality of the death, which makes it less distressing and less traumatising.
Grief interventions and assessment need to be ongoing (ie not just in the couple of weeks after a terrible loss). Whilst the majority of people are resilient and cope adaptively with usual supports, it is at six or twelve months (or more) after a bereavement that those that are going to struggle long term would be picked up.
The future: IMHO
Much research is needed into PGD, it’s risks and co-morbidity.
There is a great need for clinicians to be better trained in grief, it’s assessment and management.
It is possible that should grief be better understood and managed this could have an impact on reducing suicide rates, reducing substance misuse and improving parenting / outcomes for bereaved children (for bereaved parents/children).
Much improved services for the bereaved need to be developed. These need to include family support and counselling for families that have a difficult bereavement (due to the negative health consequences of poorly supported families that have such a bereavement).
- Guidelines and services to monitor and support ‘high-risk bereavements’ on an ongoing basis need to be developed, with ready access to specialised grief therapy if required.
- High risk bereavements should be monitored routinely, at least three monthly, for the first three or four years after such a loss.
- Additionally, all patients presenting (any length of time) after a high-risk bereavement, for any medical condition, should have a brief grief assessment.
Well done for getting all the way to the bottom!!! Go to the top of the class.