2009/06/01 by Sidney Zisook, Katherine Shear · 448 citations
Psychology · Medicine · #Grief, Bereavement, and Mental Health #Migration, Health and Trauma #Palliative Care and End-of-Life Issues #Grief #Medicine #Psychiatry #Complicated grief #Disenfranchised grief #Need to know #Traumatic grief #MEDLINE #Psychotherapist #Psychology
paper · pdf · doi:10.1002/j.2051-5545.2009.tb00217.x
published in World Psychiatry 8(2), 67-74 (Wiley)
openalex publication_date 2009/06/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/08/05
Unfortunately, grief is not a topic of in-depth discussion at most medical schools or general medical or psychiatry residency training programs. Thus, myth and innuendo substitute for evidence-based wisdom when it comes to understanding and dealing with this universal, sometimes debilitating human experience. When Engel 1 raised the question “Is grief a disease?” as the title of his now classic article on the subject, he argued convincingly that grief shares many characteristics of physical diseases, such as a known etiology (in this case, death of a loved one), distress, a relatively predictable symptomatology and course and functional impairment. And while healing usually occurs, it is not always complete. In some bereaved individuals with preexisting vulnerabilities, for example, the intense pain and distress festers, can go on interminably (as “complicated grief”), and the loss may provoke psychiatric complications, such as major depression. Engel's work, followed by several empirical studies on the phenomenology and course of grief, and its complication and treatment, has legitimized the study of grief for mental health practitioners. Yet, to this day, the bulk of what is known about grief and its biomedical complications has not been widely disseminated to clinicians. This review is meant to help fill that gap. In order to appreciate how grief can go awry and transition from a normal response to a disabling condition warranting medical attention, the clinician must first know the characteristics of normal grief and how to differentiate normal grief from complicated grief and/or grief-related major depression. Consequently, this review begins with a section on “normal” grief, followed by sections on the phenomenology, differential diagnosis, course and treatment of “complicated” grief, and grief-related major depression. Since psychiatrists themselves are not immune to the potential ravages of grief, a final section focuses on the personal and emotional consequences of one of our most disturbing occupational hazards, a patient's suicide. Some investigators have attempted to define discrete stages of grief, such as an initial period of numbness leading to depression and finally to reorganization and recovery. However, most modern grief specialists recognize the variations and fluidity of grief experiences, that differ considerably in intensity and length among cultural groups and from person to person 2,3. To date, no grief stage theory has been able to account for how people cope with loss, why they experience varying degrees and types of distress at different times, and how or when they adjust to a life without their loved one over time. The terms bereavement and grief are used inconsistently in the literature to refer to either the state of having lost someone to death, or the response to such a loss. Researchers have suggested that the term bereavement be used to refer to the fact of the loss; the term grief should then be used to describe the emotional, cognitive, functional and behavioral responses to the death. Also, grief is often used more broadly to refer to the response to other kinds of loss; people grieve the loss of their youth, of opportunities, and of functional abilities. Mourning is also sometimes used interchangeably with bereavement and grief, usually referring more specifically to the behavioral manifestations of grief, which are influenced by social and cultural rituals, such as funerals, visitations, or other customs. Complicated grief, sometimes referred to as unresolved or traumatic grief, is the current designation for a syndrome of prolonged and intense grief that is associated with substantial impairment in work, health, and social functioning. What constitutes “normal” grief? There is no simple answer. Grief is different for every person and every loss, and it can be damaging to judge or label a person's grief, especially during early bereavement. However, a clinician needs to make a judgment about whether a person's grief is progressing adaptively in order to make categorical decisions about whether or not to intervene. A clinician who does not understand the range of grief symptoms is at risk for intervening in a normal process and possibly derailing it. At the same time, knowledge about the boundaries of uncomplicated, adaptive grief can guard against failure to recognize complicated grief and/or depression occurring in the wake of a loved one's death. If complicated grief or major depression is mistakenly judged as “normal”, bereaved individuals may be at risk for inattention to, or ineffective treatment of, clinically important problems. For pragmatic reasons, we favor the term “uncomplicated” over “normal” grief, as it is easier to categorize complications of grief, such as the syndrome of complicated grief or bereavement-related depression, than to resolve the endless debate of what is, and is not, normal. How long does grief last? The intensity and duration of grief is highly variable, not only in the same individual over time or after different losses, but also in different people dealing with ostensibly similar losses. The intensity and duration is determined by mul-tiple forces, including, among others: the individual's preexisting personality, attachment style, genetic makeup and unique vulnerabilities; age and health; spirituality and cultural identity; supports and resources; the number of losses; the nature of the relationship (e.g., interdependent vs. distant, loving vs. ambivalent); the relation (parent vs. child vs. spouse vs. sibling vs. friend, etc.); type of loss (sudden and unanticipated vs. gradual and anticipated, or natural causes vs. suicide, accident or homicide) 4. Certainly, many of these factors also contribute to the proclivity for complicated grief, major depression, and other adverse consequences. Nonetheless, there are general guidelines to help the clinician determine the expected phenomenology, course, and duration of uncomplicated grief. First, grief is not a state, but rather a process. Second, the grief process typically proceeds in fits and starts, with attention oscillating to and from the painful reality of the death. Third, the spectrum of emotional, cognitive, social and behavioral disruptions of grief is broad, ranging from barely noticeable alterations to profound anguish and dysfunction. Sometimes, clinicians mistakenly label the lack of observable grief or mourning as pathological, suggesting vulnerability to delayed intense grief or medical complications. However, there is little empirical validation of this assumption and significant data to refute it 5,6. On the other side of the spectrum, be-reavement can be one of the most gutwrenching and painful experiences an individual ever faces. Shock, anguish, loss, anger, guilt, regret, anxiety, fear, loneliness, unhappiness, depression, intrusive images, depersonalization, and the feeling of being overwhelmed are but a few of the sentient states grieving individuals often describe. At first, these acute feelings of anguish and despair may seem omnipresent, but soon they evolve into waves or bursts, initially unprovoked, and later brought on by specific reminders of the deceased. Healthy, generally adaptive people likely have not experienced such an emotional roller coaster, and typically find the intense, uncontrollable emotionality of acute grief disconcerting or even shameful or frightening. If these reactions are prominent, a person may attempt to avoid reminders or over-control stimuli which can interfere with the normal grief progression. Yet, grief is not only about pain. In an uncomplicated grief process, painful experiences are intermingled with positive feelings, such as relief, joy, peace, and happiness that emerge after the loss of an important person. Frequently, these positive feelings elicit negative emotions of disloyalty and guilt in the bereaved. Of note, at least one investigator has found that positive feelings at 6 months following a death are a sign of resilience and associated with good long-term outcomes 7. Fourth, for most people grief is never fully completed. However, there are two easily distinguishable forms of grief 8. First, the acute grief that occurs in the early aftermath of a death can be intensely painful and is often characterized by behaviors and emotions that would be considered unusual in normal everyday life. These include intense sadness and crying, other unfamiliar dysphoric emotions, preoccupation with thoughts and memories of the deceased person, disturbed neurovegetative functions, difficulty concentrating, and relative disinterest in other people and in activities of daily life (apart from their role in mourning the deceased). This form of grief is distinguished from a later form of grief, integrated or abiding grief, in which the deceased is easily called to mind, often with associated sadness and longing. During the transition from acute to integrated grief, usually beginning within the first few months of the death, the wounds begin to heal, and the bereaved person finds his or her way back to a fulfilling life. The reality and meaning of the death are assimilated and the bereaved are able to engage once again in pleasurable and satisfying relationships and activities. Even though the grief has been integrated, they do not forget the people they lost, relinquish their sadness nor do they stop missing their loved ones. The loss becomes integrated into autobiographical memory and the thoughts and memories of the deceased are no longer preoccupying or disabling. Unlike acute grief, integrated grief does not persistently preoccupy the mind or disrupt other activities. However, there may be periods when the acute grief reawakens. This can occur around the time of significant events, such as holidays, birthdays, anniversaries, another loss, or a particularly stressful time. Fifth, grief is not only about separation from the person who died, but about finding new and meaningful ways of continuing the relationship with the deceased 9,10. Faced with the dilemma of balancing inner and outer realities, the bereaved gradually learn to accept the loved one back into their lives as deceased. What occurs for survivors is the transformation of a relationship that had heretofore operated on several levels of actual, symbolic, internalized, and imagined relatedness to one in which the actual (living and breathing) relationship has been lost. However, other forms of the relationship remain, and continue to evolve and change. Thus, it is not unusual for bereaved individuals to dream of their deceased loved ones, to half look for them in crowds, to sense their presence, feel them watching out for or protecting them, to rehearse discussions or “speak” to them. Auditory or visual hallucinations of the deceased person are often seen during acute grief. Sometimes people maintain a sense of connection through objects such as clothing, writings, favorite possessions, and rings, which may be kept indefinitely. Some people continue a relationship with the deceased through living legacies, such as identification phenomena, carrying out the deceased's mission, memorial donations, or seeing them live on in others through genetic endowments. For others, periodically visiting the grave or lighting candles may help keep memories alive. Bereaved individuals may take some comfort in learning that the relationship does not need to be totally severed, but that it is perfectly acceptable and even normal for the relationship to endure indefinitely. There is no evidence that uncomplicated grief requires formal treatment or professional For most bereaved the through grief in an acceptable of to a life without their loved Thus, most bereaved individuals do without Certainly, someone with grief they should have to and that that their response is after a loss. When and generally by is not or groups may help fill the gap. groups can be particularly after traumatic losses, such as the death of a a death after or from other causes Complicated grief, a syndrome that occurs in about of bereaved from the failure to transition from acute to integrated grief. a acute grief is indefinitely. include separation distress of painful emotions, with intense and for the and preoccupation with thoughts of the loved and traumatic distress of the death, and intrusive thoughts to the death, and of reminders of the painful individuals complicated grief have difficulty the death, and the intense separation and traumatic distress may months Bereaved individuals with complicated grief find themselves in a of intense and that becomes the major of their by and Complicated may their grief as and may that their life is over and that the intense pain they endure never there are who do not the grief to as they feel it is that is of the relationship with their loved Sometimes, people by their they are their lost loved behaviors of in activities to the on the one and on the with the deceased may include at the or At the same time, the bereaved person may avoid activities and that them that the loved one is or of the good they with the deceased. Frequently, people with complicated grief feel from others, people that used to be factors for complicated grief have not been However, individuals who have a of early relationships and a person with they had a satisfying relationship seem to be at with a of or who have experienced important losses, have a of adverse life and health, lack of social or life have overwhelmed their to may be at risk for complicated grief question is why one person complicated grief, while another from major depression or in the wake of a loss. Complicated grief can be the of Complicated Grief is by a on the at least months after the death. is associated with significant distress, and negative health consequences have and in daily with complicated grief have been found to be at risk for and bereaved over the age of of with complicated grief had to the who not of with complicated grief more likely to for depression, than who not have complicated grief In studies of complicated grief associated with a of a of and not by major depression and with of in complicated grief to be and complicated grief must be and and to have little on this a complicated grief treatment has outcomes than in this syndrome behavioral with of and The treatment a on to terms with the loss and on finding a to a on the time of the death as as gradual in activities and that have been are and A to that the to the on that had been for more than months they for complicated grief. to not individuals to from the of and to be more likely to a course of these and the of and in individuals with complicated grief, it likely that treatment, and may be the most treatment the role of for the treatment of complicated grief with and without are There have been studies of the bereaved. The of studies have on the there are studies of who have lost a and of who have lost a studies have found similar a of symptoms that in and intensity over time, but that may continue to occur at than in for after the death In classic studies a of the experienced and beginning loss; and some and loss of in their not the people around and while thoughts and and hallucinations not When most and that they had or had been by their had their seen them, or their The of their in a the of the first the symptoms of depression had associated with specific or and The studies that symptoms the following and a death, good and and and one most bereaved able to the person with These in study with an that loneliness, and the symptoms of with the In studies for major depression at one and after one had major depression at some during the to of and for the These are similar to by and who found that of their at two at at months and at In of these the of major depression at months depression at one or two to the and a of major depression also major depression at one In bereaved are not only at risk for major depression, but they are also at risk for even in the of may be associated with prolonged personal role and clinicians are by the relationship grief and depression and find depression to in the of bereavement. is a major and has been found to of major depression, in a that may have profound there are grief can be distinguished from a bereaved individuals experience intense but only a for major depression. The of is the of and social in bereavement and major depression. However, there are also the two Grief is a experience in which positive emotions are experienced negative ones. time the intense, emotions that typically in waves are these waves of grief are to and reminders of the deceased. grief is a state with individual in which and behavioral are the bereaved can the deceased in a in his or her memory and a satisfying life can be In major depression to be more and is characterized by significant difficulty in and positive depression is of a and of debilitating by a to be and associated with and social and other This is as of major depression after the death of a loved one as in individuals with major depression major depression after bereavement the of the pain and associated with grief. The characteristics and course of bereavement major depression are similar to of major depression. adverse consequences of bereavement major depression with a number of and symptoms of and of bereavement major depression are usually and long In bereavement major depression also has characteristics that with other such as immune and about bereavement major depression is on death of a considered one of the most and of life to there is an in general medical by in the first after the loss. In there is an of especially and of and it is likely that and major depression for at least a of the seen in bereaved The causes of have in different but always include and When a major syndrome occurs soon after the death of a loved to the it should be as major depression. The same is not major depression to the but rather it is with the mental of is the syndrome an likely treatment, or is it a normal at The states most bereavement within two months of the death the of major depression, but that major depression should be considered when there is guilt about to at the time of the death, feelings of or prolonged and functional impairment. However, these are also likely to be in bereavement major depression as in other of major depression and several studies have found that bereavement major depression is more similar to, than different other forms of major depression and that it to treatment in the same way as major depression. Thus, we feel the of the of major depression within two months of bereavement no longer fits the evidence and may have the of people with life such as major depression, from the The to treatment is the that bereavement major depression is similar to major depression. However, clinicians how to with bereavement major depression and sometimes question whether to at as as the to and bereavement grieving individuals to the of depression and the stressful of with their loss. Thus, we bereavement major depression as and as when depression to other life events, or with major depression, factors used to determine whether to are and the and of the such as when there is a of major depression, treatment to the of a new in the of this period should be On the there is no or of major depression and the syndrome is relatively in terms of and treatment may be delayed for at least the first two not but the should be The clinician may then treatment with the same general guidelines as one would for major depression. If the depression does not fully to this of should be used At there are no studies specifically on bereavement major depression which there are no to that would not be as in bereavement major depression as in major depression. in to determine the potential of for depression in the of grief, we for an integrated treatment that there are studies on bereavement depression the and of a of In of these grief intensity with of in grief not as as of depression. is the treatment for bereavement-related depression. about and personal or with can help a in If the is relatively and not associated with risk or and be an initial On the other the more and the the more should the treatment For or highly or has been treatment with in to may be unique to complicated grief may a specific form of In treatment should be the individual's specific needs and as as the of treatment in the A treatment that a and form of and the of a positive is one of the most risk factors for suicide, occurring in of is an occupational for psychiatrists the most and that are not have found that of psychiatrists have lost at least one to suicide, and many have lost more than one Thus, it is no that has been as one of the most and stressful experienced by health around the When a psychiatrists should the and potential in for the of the deceased. survivors with the clinician as they to make sense of the death and process their grief clinicians should to with after a suicide, there are to not do The can help to the reactions of to within the of a on the that may in their guilt, or about the death. at and are an individual but often the and the find this Even when the does not know the and are usually When a a to suicide, personal reactions are as as in other and for example, have been studies have found of grief experiences in such as intense guilt or feelings of for the death, a need to or make sense of the death, feelings of and at the complicated grief, and about the of death are not immune to these reactions when survivors In of and from the psychiatric can the response should be and should from and For some individuals and in healing may be by and who a to should from a and experienced who can as a and of emotional while also on the most response to the survivors by the death. their and formal psychiatrists may not be fully to some of the most they in and complicated grief and bereavement major depression on the of such with symptoms found in uncomplicated grief, and often are as “normal” with the assumption that time, of and the natural is important to while individual grief process is there is a form of grief that is with and of life. This complicated grief response to be and in the of and may be life Complicated grief usually to a specific when in with In with being a occupational risk for it is for them to recognize their to the personal that often such losses, not only for their mental health and but also to the most and to their