Grief is the response to bereavement, which is the situation in which a loved one has died . Natural acute grief reactions are often painful and impairing with emotional and somatic distress, but should not be diagnosed as a mental disorder. However, bereavement is a stressor that can precipitate or worsen mental disorders (eg, unipolar major depression). In addition, complications (maladaptive thoughts, feelings, or behaviors) may occur, such that acute grief becomes intense, prolonged, and debilitating. This condition is called complicated grief, which is viewed as a unique and recognizable disorder that requires specific treatment. Ref -[UpToDate
The terms bereavement, grief (acute and integrated), complicated grief, and mourning describe different aspects of experiencing the death of a loved one [1-4]:
●Bereavement – The situation in which someone who is close dies (rather than the reaction to that loss). (See ‘Bereavement’ below.)
●Grief – Grief is the natural response (including thoughts, feelings, behaviors, and physiologic reactions) to bereavement. Although grief can occur in response to other meaningful (non-bereavement) losses, this topic focuses primarily upon grief in response to the death of a loved one.
The pattern and intensity of grief varies over time as bereaved individuals adapt to the loss. The experience of grief is influenced by cultural and religious rituals that vary widely, and is unique to each person and each loss. Acute grief can be intense and disruptive but is eventually integrated. Progress from acute to integrated grief is often erratic and hard to discern as it is happening. (See ‘Typical acute grief’ below.)
●Complicated grief – Complicated grief is a form of acute grief that is unusually prolonged, intense, and disabling; troubling thoughts, dysfunctional behaviors, dysregulated emotions, and/or serious psychosocial problems impede adaptation to the loss. The syndrome of complicated grief is a unique and recognizable condition that can be differentiated from other mental disorders. Other terms that have been used to describe complicated grief include chronic grief, complex grief, pathological grief, persistent complex bereavement disorder, prolonged grief disorder, traumatic grief, and unresolved grief. (See “Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis”.)
●Mourning – Mourning is the process of adapting to a loss and integrating grief. Adaptation entails accepting the finality and consequences of the loss, revising the internalized relationship with deceased, and re-envisioning the future such that there is a possibility for happiness in a world without the deceased. When mourning is successful, the painful and disruptive experience of acute grief is transformed into an experience of integrated grief that is bittersweet and in the background. Like grief, mourning is influenced by cultural and religious rituals that vary widely.
TYPICAL ACUTE GRIEF
The hallmark of acute grief is the intense focus on thoughts and memories of the deceased person, accompanied by sadness and yearning.
This topic focuses upon grief in response to the death of a loved one. Nevertheless, grief can occur in response to other meaningful (non-bereavement) losses, including an interpersonal loss (eg, separation from a loved one through divorce) or loss of a pet, job, property, or community. In a study of survivors of a natural disaster who showed signs of unusually prolonged, intense, and disabling grief (ie, complicated grief), the large majority of survivors suffered non-bereavement losses .
Presentation — Mourners focus their attention, emotions, thoughts, and behavior upon the deceased person and what has been lost. However, the painful feelings and memories are commonly intermingled with periods of respite and positive feelings, thoughts, and reminiscing [3,116]. These positive experiences during bereavement reflect resilience and foretell better outcomes [13,117].
Acute grief symptoms vary across individuals and differ in the same person after different losses. Symptoms also vary over time and are influenced by social, religious, and cultural norms [3,4,14]. The features, intensity, and duration of grief are also influenced by age, health, religious and ethnic identity, coping style, attachment style, available social support and material resources, situation and circumstances of the death (see ‘Type of loss’ above), and the experience of prior losses .
General approach — If possible, clinicians should summon families prior to an expected death. If this is not possible and the patient dies, the clinician should promptly call immediate family members who are not present at the bedside in order to inform them, express condolences, answer questions, and offer them the option of viewing the body.
Individuals with acute grief may present seeking relief from symptoms such as intense sadness or disrupted sleep; assessment should rule out conditions that may be triggered or exacerbated by bereavement:
●Suicidal ideation and behavior
●Other mental disorders, such as major depression, posttraumatic stress disorder (PTSD), insomnia disorder, and anxiety disorders
Primary care clinicians who are not comfortable diagnosing and treating mental disorders should refer patients to mental health clinicians.
Information about mental disorders that may be precipitated by acute grief, and information about the differential diagnosis of acute grief, is discussed separately. (See “Grief and bereavement in adults: Clinical features”.)
Interventions — Acute grief typically does not require treatment . Most bereaved individuals are resilient and acute grief is transformed and integrated during a natural adaptive process that typically unfolds with the support and encouragement of close family and friends, as well as clergy . Grief work (confronting painful emotions) on its own does not appear to facilitate adjustment to bereavement [6,7], and bereaved individuals who experience little distress, even when they suppress their emotions, have been shown to have a benign course . In addition, embarking on an uncovering or personality-targeted psychotherapy may derail the natural healing process and is potentially harmful [1,4,5,9-12]. Guidelines from the World Health Organization for bereaved individuals who do not have mental disorders recommend that structured psychological interventions should not be routinely offered [13,14].
Bereavement is the situation in which a loved one has died, and grief is the distress that occurs in response to bereavement. Acute grief can be intense and disruptive, but usually is integrated over time. Complicated grief is a form of acute grief that is abnormally prolonged, intense, and disabling; as such, complicated grief is a unique and recognizable mental disorder. (See ‘Terminology’ above.)
●Reactions to bereavement can vary depending upon the type of lost relationship. The intensity of acute grief is generally greater in parents who lose a child than it is for bereaved spouses, which in turn is greater than the grief of adult children who lose a parent. The intensity and course of acute grief is also influenced by the circumstances of the death, including the age of the deceased, and whether the loss is sudden or violent, or the result of a chronic or terminal illness. (See ‘Type of loss’ above.)
●Bereavement is associated with an increased risk of mortality, general medical illnesses (eg, cardiovascular disease), and mental disorders (eg, unipolar or bipolar major depression, anxiety disorders, and posttraumatic stress disorder [PTSD]), as well as suicidal ideation and behavior that is independent of psychopathology. Some bereaved individuals develop complicated grief, which may account for most of the increased risk for each of these negative health outcomes. (See ‘Adverse general medical outcomes’ above and ‘Associated psychopathology’ above.)
●Although diagnosing major depression in the context of bereavement is controversial, bereavement does not preclude the diagnosis. The rationale for diagnosing major depression in bereaved individuals is based upon the best available evidence, which indicates that bereavement-related major depression and major depression not related to bereavement are comparable with regard to risk factors, symptoms, impaired functioning, comorbidities, course of illness, and response to treatment. (See ‘Major depression’ above.)
●There is no single way to grieve and adapt to a loss. The specific pattern of grief symptoms as well as the process of adaptation is unique to each specific loss situation, influenced by individual factors as well as social, religious, and cultural norms. Nevertheless, the symptoms of typical acute grief are usually related to either separation from the deceased (eg, yearning for and seeking proximity to the deceased, loneliness, and crying) or to stress and trauma (disbelief, shock and numbness). (See ‘Presentation’ above.)
●The course of typical acute grief does not follow a specific series of stages that occur in a fixed order; rather, the trajectory of adaptation is erratic and specific to each loss. However, grief is time-limited and integrated such that painful emotions and insistent thoughts diminish in frequency, intensity and duration. Adaptation to the loss is usually well underway within 6 to 12 months. Grief becomes more subdued but generally does not resolve completely; the deceased person is not forgotten and is still missed, and the intensity of grief may flare during anniversaries of the death, holidays, or periods of heightened stress. (See ‘Course’ above.)
●Typical acute grief is not a mental disorder and should not be diagnosed or treated as such. Nevertheless, grief includes symptoms that overlap with those of common mental disorders. The differential diagnosis of acute grief includes complicated grief, major depression, and PTSD. (See ‘Differential diagnosis’ above.)