Also called: Bereavement
Grief is a healthy and natural reaction to a major loss, often characterized by extreme mental anguish. Though grief is important and leads to emotional healing, it can be a prolonged and intensely painful experience, and can result in significant emotional distress. The grief reaction may last for months or years. People who are grieving may never stop missing a deceased person or regretting a loss, but the pain will eventually lessen.
Any major loss can cause a grief reaction, especially the death of a loved one. Miscarriage and stillbirth, though not often recognized as major losses, can cause grief for the parents. A major lifestyle change, such as divorce, loss of a home, loss of a job, or loss of the ability to pursue a career (e.g., a physical injury ending an athletic career), may also result in grief. Grief responses may also occur following reminders of the loss, such as on anniversaries, holidays or other special days throughout the year.
Grieving is generally easy to recognize, and symptoms of grief are both physical and emotional. Grieving people are often sad and may sigh, sob, cry out or yearn for what was lost. Shock, disbelief and denial are common, especially immediately following the discovery of the loss. People who are grieving may feel angry or guilty. They may tire easily or feel as though they are always tired. Disturbances in appetite and sleep often occur.
Most people who are grieving do not seek or require professional help. When help is needed, a mental health evaluation by a physician or a mental health professional may be used to rule out other conditions. Although grief may progress into major depression in some cases, it should not be confused with this serious mood disorder.
It is not healthy to avoid grief or to deny a major loss for a long period of time. Avoidance of grief may lead to serious physical or emotional problems later in life.
The most important aspect for grieving people is learning to cope with the loss. Individuals who are grieving need to speak with and explain their feelings to others. Most physical complications of grief can be eased by eating properly, exercising and getting plenty of rest.
When professional help is sought, interpersonal therapy (IPT) is among the most commonly used forms of psychotherapy to help people cope with grief. Group therapy can also be helpful.
Grief is a natural, emotional response to a major loss, such as the death of a loved one. It is often characterized by extreme mental anguish. Other losses, such as divorce, miscarriage or the loss of a home or job, are also sources of grief. Grief is an important and necessary reaction that eventually leads to emotional healing. However, it can be a prolonged and intensely painful experience, and can result in significant emotional distress. Social function and productivity at work or school may be impaired, although most people who are grieving continue to work and socialize.
People grieve for different periods of time. The grief reaction may last for months or years. Intense symptoms of emotional distress generally last between six and 12 months, with less intense grieving continuing for one to three years.
The grieving process may occur in several stages. Early stages may involve numbness or denial of the loss, followed by anger. Some people may then experience deep yearning followed by despair. The final stages include acceptance of the loss.
The stages of grief are not linear. Some people go through the stages quickly or even skip some stages entirely. Other people seem to linger or return to certain stages after a period of feeling better. For example, a person who has been widowed may experience anger at the loss of the spouse soon after the spouse’s death. The anger may diminish but return months later, when the surviving spouse is confronted with a chore formerly performed by the deceased person (e.g., handling finances).
People grieve differently at different ages. Children may not understand the concept of death and may take more time to grieve. Preschool-aged children typically view death as temporary and may need to have it explained repeatedly. Children between the ages of 5 and 9 years generally begin to understand death better. They comprehend that the dead person is not returning and may ask questions or invent games about dying. Adolescents understand death as adults do, but may grieve differently. They often seek help within their own peer groups and may engage in more impulsive or risk-taking behaviors, such as drug or alcohol use or impulsive sexual behavior.
Different types of grief include:
- Normal grief. Also called uncomplicated grief. The normal, healthy response to a major loss.
- Anticipatory grief. Grief that begins before (in anticipation of) the loss, such as the initiation of divorce proceedings or when a loved one is diagnosed with a terminal illness.
- Anniversary reactions. Grief responses that occur following reminders of the loss, such as on anniversaries, holidays or other special days throughout the year. These can last for days or weeks, and are not necessarily a setback in the grieving process.
- Complicated grief. Also called traumatic grief. Occurs when grief becomes chronic, disabling and more intense. This is often seen as a progression of grief into major depression, with some features of post-traumatic stress disorder, such as nightmares and flashbacks. Complicated grief is not recognized by the American Psychiatric Association. According to the National Institute of Mental Health (NIMH), about 10 percent to 20 percent of people grieving the loss of a loved one experience complicated grief.
Potential causes of grief
Any major loss can cause a grief reaction. Common losses that cause grief include:
- Death of a loved one. Grieving for the death of a loved one is a natural reaction, even when the death was anticipated (e.g., elderly parent or grandparent). The death of a child may instill a sense of injustice due to lost potential and the concept that children are not supposed to die. The death of a spouse is traumatic due to the loss of a life partner. This can be even worse in the elderly, whose grief may be complicated by the death of close friends. However, this is not always the case as many elderly individuals report accepting death as a normal part of life and finding comfort in the memories of their loved one.
Death by suicide can be particularly difficult. Guilt, anger and shame may be much worse and the stigma of suicide may lead to isolation and suicidal ideation (thoughts of suicide) among some survivors. Other traumatic deaths, such as by homicide or natural disaster, can also worsen grief.
- Miscarriage, stillbirth and infertility. Though not often recognized as major losses, miscarriages and stillbirth can elicit a full grief reaction among the parents. Couples undergoing treatment for infertility may experience grief after failed attempts to achieve a pregnancy.
- Pet loss. Many people have their first experience of grief with the death of a beloved pet.
- Major lifestyle change. Major life changes, such as divorce, the loss of a home or possessions, or loss of a career or ability to pursue a career (e.g., a physical injury putting an end to an athletic career) may cause grief.
- Anticipation of a loss, such as the diagnosis of a terminal illness in a loved one, can also cause grief.
Signs and symptoms of grief
Grieving is a personal process. Different people may grieve in different ways, and these may vary by families and culture. Some people may express their sorrow openly by crying, whereas others believe certain aspects of grieving should remain private.
The emotional and psychological symptoms of grief include:
- Sadness and low mood. Sorrow, regret and a sense of mental discomfort are common in grief. The grieving person may sigh, sob, cry out or yearn for what was lost. There may be a feeling of having a lump in the throat.
- Shock, disbelief and confusion. The first response to a major loss is often the denial that the loss has occurred. Individuals may not be able, or may refuse, to grasp the truth of the loss. When the actuality of the loss sets in, the grieving person may be confused and unable to comprehend how or why it has happened.
- Anger and irritability. After denial, anger may set in. Grieving people may be angry at themselves or others for allowing the loss to occur. They may lash out and seem enraged at the world.
- Guilt. Guilt generally follows anger in the grieving process. People who are grieving may feel as though they failed to prevent the loss. They may also experience a mild reduction in their feelings of self-worth, but any severe decline in self-esteem may be a warning sign that major depression is developing.
- Anhedonia. Loss of interest or pleasure in activities. Many people who are grieving lose interest in daily activities.
- Passive wish to “join the loved one.” This should not be confused with actual suicidal ideation (thoughts of suicide) and does result in suicidal behavior or attempts. Actual suicidal behavior is a serious warning sign that grief has progressed into major depression and requires immediate treatment.
- Obsession with what was lost.
Grief can negatively impact on physical health, as well. Existing medical conditions may worsen and new conditions may develop. Other physical symptoms of grief include:
- Numbness and emptiness. People who are grieving may experience emotional and physical numbness and hollow or empty feelings in the chest and abdomen.
- Fatigue. Grieving people may tire easily or feel as though they are always tired.
- Appetite and sleep disturbances. People who have experienced a major loss may eat too much or lose their appetite. They may sleep too little (insomnia) or too much (hypersomnia) and may have nightmares.
- Substance abuse. Grieving people may use alcohol or drugs in an attempt to deal with their grief.
- Aches and pains. Vague physical complaints such as stomachaches and headaches are common among grieving individuals.
- Trouble concentrating. Grief can often impair a person’s concentration.
Children and adolescents may exhibit different signs and symptoms while grieving. Signs that a child may be grieving include:
- Withdrawal from friends
- Unrestrained, aggressive play
- Decline in school performance or refusal to attend school
- Asking questions about or imitating what was lost
- Playing games about dying
- Acting much younger or reverting to earlier behaviors (e.g., bedwetting, baby talk, thumb sucking)
Grieving adolescents may show signs of shock or anger for an extended period of time. Some teenagers may respond to grief by turning to alcohol, drugs or sexual activity. Some adolescents may have thoughts of suicide while grieving. In such cases, professional help should be sought immediately for the person.
When to seek help
Grieving may follow any major loss and is generally easy to recognize. Most people who are grieving do not seek or require professional help. When help is needed, an evaluation by a physician or mental health professional may be used to rule out other conditions.
According to the American Psychiatric Association, about 25 percent to 35 percent of people develop major depression after a major loss. Although grief may progress into major depression, it should not be confused with this serious mood disorder. Grief is a healthy, adaptive process, whereas major depression is a pathological condition that needs to be treated. Depressed people tend to focus on themselves and their role in the loss. Grieving people tend to focus more on what was lost.
There are several symptoms of depression that do not typically occur in normal grief. When these are noted in people who have experienced a major loss, a psychiatric evaluation may be recommended. These include:
- Suicidality. Grieving people may have a passive wish to “join” the deceased loved one, but do not normally dwell on the concept of their own death or exhibit suicidal behavior.
- Psychosis. People who are grieving may see reminders of their loss in many places, but do not normally develop hallucinations or delusions involving the loss.
- Severe loss of self-esteem or functionality. Grief is often accompanied by some degree of functional impairment or feelings of reduced self-worth, but these are not normally severe.
- Psychomotor retardation. Significant slowing down of thought processes or physical activity do not tend to occur in normal grief.
Coping with grief
Grief is a healthy and necessary process. It is not healthy to avoid grief or to deny a loss for a long period of the time. Avoidance of grief may lead to serious physical or emotional problems later in life.
Most grieving people do not need psychological or psychiatric treatment. Typically, medications, such as antidepressants, are required only when grief has progressed into major depression. When professional help is sought for grief, interpersonal therapy is among the most commonly used forms of psychotherapy. This therapy focuses on grief, assessment of the relationship with the deceased, identifying and reviewing symptoms, and encouraging satisfying relationships and activities. Group therapy can also be helpful. It allows grieving people to meet and discuss their feelings with others who are grieving. Support groups, both in-person and on the Internet, can help grieving people, especially those who wish to receive more specialized support, such as parents who have lost a child.
The most important aspect for grieving people is learning to cope with their loss. People who are grieving may need to keep certain coping tips in mind, including:
- Avoid isolation. It is important for grieving people to talk to others and explain how they are feeling. They must not be afraid to ask for support.
- Take care of physical health. People who are grieving still need to see a physician when feeling unwell. Most physical complications of grief can be eased by eating properly, exercising and getting plenty of rest.
- Postpone major decisions when possible. Grief may interfere with judgment. Major decisions may need to be postponed.
Individuals can take certain steps to help others cope with grief, including:
- Listen. People who are grieving need to share their thoughts and feelings with others.
- Do not offer false comfort. Comments such as “He’s in a better place now” or “At least she’s not suffering anymore” often do not help and may make the grieving person feel even worse.
- Offer practical help. Grieving individuals may benefit from assistance with household chores or errands.
Tips to help children cope with grief include:
- Answer questions simply and honestly. Children’s questions should be answered truthfully in terms the children can understand. Adults who try to protect children from the truth about death may actually do more harm.
- Maintain regular routines as often as possible. Children need structure and routine. Though a loss may necessitate a change in structure, maintaining routines as much as possible can help children come to terms with the loss.
Parents and caregivers may also enroll children in programs, such as special day camps, which are designed to teach children about grief and help them learn to accept and cope with their loss.
Questions for your doctor regarding grief
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following grief-related questions:
- Are my physical symptoms related to grief or another condition?
- What type of grief am I experiencing?
- Do I need medication or other type of therapy?
- Do you know of any support groups in the area that may be helpful to me?
- Does my grief seem to be progressing towards major depression?
- My feelings and symptoms are different from other times I have been bereaved. Is this normal?
- For how long can I expect my grief to last?
- How can I talk to my child about death?
- How can I help my children cope with their grief?