32. Grief and Mourning

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    32 GRIEF A N D MOURNINGStephen R. S h u c h t e r M.D., and Sidney Zisook, M.D

    All psychiatrists encounter patients who have experienced the death of a loved one. Such lossesoften are quite traumatic and painful and can precipitate both psychological and medical sequelaewhich may require intervention. Appreciating the effects o death on survivors can be a crucial ele-ment in assessing the putient.

    1. What is grief?Grief comprises the myriad psychological, physiologic, and behavioral responses which accom-

    pany the human awareness of an irrevocableloss such as a pending or actualloss of a close friend or

    relative. It is an extraordinarily powerful emotion.Manifestations o Normal Grief

    Psychological PhysiologicNum bness or dissociationSense of lossAnguish InsomniaYearning Agitation

    Autonomic discharge: gastrointestinal,cardiovascu lar, respiratory, neuromuscular

    AngerGuiltApathy

    Anxiety and fearIntrusive imagesCognitive disorganizationDistractibilityHallucinatory experiencesRegression

    Anorexia

    2 What are the psychological aftereffects?The psychological se quelae may include experiences of intense anguish and em otional pain ac-

    companied by crying, feelings ofloss, and yearning for the one who has died; feelings of anger or

    guilt; transient periods of numbness, shock, or disbelief, when theloss does not register emotionally;a sense of apathy or lack of direction; anxiety and fearfulnes s; intrusion of painful im ages and m em-ories, especially if the nature o r courseof death was traumaticto the survivor; and cognitive disorga-nization. Behaviorally, survivors frequently search for evidence that their loved oneis still alive.They may exp erience multiple sensory hallucinations of the d eceased,most often in the for m ofsensing their presence but also including auditory, visual, haptic, and olfactory hallucinations.

    Many grieving persons attempt to isolate themselves from social contacts, which are too painfulbecause of the mem ories they evoke. They may avoid discussing theirloss or even confronting m un-dane experiences of life or possessions of the deceased which can trigger their anguish. The agg re-gation of these powerful emotional and cognitive forces often leads to aregression: an emotionalstate in which the grieving person feels overwhelm ed, out of control, helpless, and child-like inheightened dependency.

    3. What forms of physiologic responses are common?Physiologic responses occur frequently, often in reaction to reminders of theloss. They take the

    form of sudden autonomic discharge with acute symptoms reflecting the pangs of grief: chest pain

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    heartache), gastrointestinal distress a knife in the belly), dyspn ea, paresthesias, pa lpitations,dizziness, nausea, tremulousness, and others. Acutely grieving survivors may dem onstrate hypercor-tisolism, sleep and appetite disturbances, and continuously heightened autonomic arousal.

    4 Are all losses the same?No. Althoug h the word grief generally is reserved for the feelings and behavior associated with

    death e.g., bereavem ent), the same sort of reaction is seen after anyloss considered important by theindividual. Exam ples are stillbirth and miscam age, loss of a job, failing health, disability, amputation,loss of home, or divorce. Indeed, divorce, especially when dependent children are involved, can leadto som e of the most tumultuous and persistent grief reactions. Som etimesa loss that seems trivial tothe outside observer, such as the death ofa pet or a favorite celebrity, or losing an ob ject of sentimen-tal value, is followed by a severe grief reaction because the loss hasa disproportionate significance.The grief also can occur when the lossis intangible, suchas after a stroke or cataract, when the loss isafunction of a part of the body. In each of these examples, the individual loses someone or somethingthat is emotionally or physically partof themselves. Th e m eaning of such losses, the intensity of thegrief, and the way people u ltimately cope with the changes in their lives vary from person to person.

    5. What is mourning?Mourning isan important aspect of the total grief reaction. It refers toa prescribed set of experi-

    ences-which may includea time-frame anda series of behaviors, rituals, and observances-that re-flect a given cultures or religions v iews abou t the meaning s of life and death an d the role of theindividual survivor within this context. Mo urning customs m ay be strictly defined: the w idow shouldwear black and avoid pleasantries for a year; the funeral and m emorial services should contain cer-tain elements; prayers for the dead are said on particular occasions. S om e grief experiences, suchashallucinations, may be more acceptable or even desirable in certain cultures.

    In the United States, no standard traditions dictate the decisions and behavior of survivors.There are few tight-knit commu nities where widowed men and and w omen are scrutinized o r moni-tored. Individuals religious beliefs may dictate some traditions, but for the most part, mourning hasevolved toward a more individualized and relatively unstructured experience.

    6. What is pathologic grief?Patholog ic grief isa commonly used term w ith an elusive definition. It originally referred to those

    patients whose grief was absen t or excessive ly intense or prolonged . It also referred to situations wheregrieving patients developed medical or psychiatric illnesses. Although clinicians will likely continue toencoun ter references to pathologic grief, it is not a useful concept. First, the spectrum of n ormative re-sponses to loss is enorm ous. Som e peoples grief is brief and limited in terms o f their emotional re-sponses and sequelae; others grieve profoundly for a long time. Furthermore, particularly following thedeath of a spouse ora child, survivors are likely to continue to m anifest elements of grief intermittentlythroughout their lives. Responses at both ends of this continuum are norm al and no t pathologic.

    Second, som e individuals are vulnerable to the development of medical and psychiatric illnessesin the context of grief. These illnessesalso d o not con stitute pathologic grief,but idiosyncratic vul-nerability genetic and developm ental),as expressed at a point of an enormou s stressor.

    7 How long does grief last?There is great variability in the course of grief. The most important determinant of the length

    and intensity of grief is the closeness of the relationship between the deceased and survivor: howcentra l that person was to the survivors emo tional life.In the closest of relationships, an acuteperiod of grief may last froma few weeks to several months, and protracted grief m ay last for years.If you encounter such extended grief,or a persistent, intense grief a year or more after the death,consider the possibility of major depression.

    8. Does grief end?The most comm on and clinically norm al forms of protracted grief occur on an intermittent basis

    for several years, or forever.A person w ho has lost a child may exp erience elements of acute grief

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    every time he or she hears the name of the child, on special occasions birthdays, holidays, anniver-saries), or when seeing the childs picture. Such grief, often referred to as anniversary reactionsusually is short-lived and dissipates in minutes. Similarly, when a clinician makes an inquiry into theemotions of any patients loss, it should be recognized that in such a regressively oriented explo-

    ration, elements of grief are likely to appear and are normal. It is a mistake to think that grief re-solves in the sense that it disappears or goes away. In most people, grief is circumscribed andsuppressed, only to re-emerge in response to familiar triggers.

    9 What is the relationship between grief and depression?Acute grief represents one of the most powerful paradigms for the stress-diathesis model of

    medical illness, including psychiatric illness see figure). The death of a loved one is likely to be themost profound and intense stressor that most people will encounter. Studies repeatedly have demon-strated the association between grief and the development of numerous stress-related medical disor-ders, including heart disease, cancer, and the common cold. The bereaved are vulnerable, as well, topsychiatric syndromes, especially depression.

    25 theroscleroticcardiovascular disease

    Vulnerable Individual(genetic predisposition,past history, poor health,

    nd inadequate social

    Depression, panic,post-traumatics t r ss disorder

    Duodenal ulcer,ulcerative colitis

    Cancer

    Marrow

    Stress-diathesis model of medical illness

    Historically, bereaved individuals, their families, and physicians have taken the position thatgrief is depressing and that mourning and melancholia are inseparable phenomena. No one issurprised when a survivor is depressed; it seems normal and natural. Consequently, the physician ex-hibits less zeal in treating a disorder that otherwise would be the object of aggressive therapy.

    At some time during the first year after the death of a spouse, 30-50 of widows and widowersmeet the criteria for a major depressive episode. Recognizing the ubiquity of depressive symptomsin grief, the DSM-111 and DSM-111-R introduced the term Uncomplicated Bereavement to demarcatedepressive syndromes occurring shortly after the death of a close friend or relative from a major de-pressive disorder. Because uncomplicated bereavement is not considered an illness, the ciinical rule-

    of-thumb has been benign neglect rather than active trea