Grief – UpToDate

  • Bereavement is the reaction to the loss of a close relationship.
  • Grief is the emotional response  (subjective feeling) caused by a loss including pain, distress, and physical and emotional suffering.
  • Mourning refers to the psychological process through which the bereaved person undoes his or her bonds to the deceased.
    • Process by which grief is resolved
  • Death is the most powerful stressor in everyday life.

 1 In patients who have undergone a loss, prepare them for the types of reactions (e.g., emotional, physical) that they may experience.

  • Prepare pt for emotional & physical responses when experiencing the loss of a loved one
  • Anticipatory grief —Grieving is thought to begin when an individual is forewarned of an impending death. Anticipatory grieving may take the form of sadness, anxiety, attempts to reconcile unresolved relationship issues, and efforts to reconstitute or strengthen family bonds.
    • Caretaking behavior may be a form of anticipatory grieving, as the caretaker expresses affection, respect, and attachment through the physical acts of providing care.
    • Anticipation and an opportunity to prepare psychologically for death is thought to ease the adaptation of the grieving individual after death.
  • Normal grief reaction —
    • Stage One – Shock — Immediately following death – few weeks
      • Whether or not it has been anticipated, survivors often experience feelings of numbness, shock, and disbelief.
      • They “go through the motions,” taking care of funeral arrangements, greeting relatives and friends, and tending to financial matters.
      • However, the reality of the death has not been fully comprehended.
    • Stage two – Preoccupation with the diseased –
      • intense grief resolves by 1-2 months & most symptoms resolved by 6mo but may last for years in attenuated form
      • Shock and numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness commonly arise in the weeks after the death.
      • “Searching behaviors,” including visual and auditory hallucinations of the deceased person, are common and may lead the bereaved person to fear that he or she is “going crazy.”
      • Despair and sadness are common as it becomes clear that the deceased will not return. Sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic complaints (especially those similar to the symptoms of the deceased) are common.
      • The survivor often replays and remembers the relationship with the deceased, particularly the events of the terminal illness and death, and commonly ruminates over regrets and missed opportunities.
      • Anger at the person for dying, at God, and at professional caregivers may occur. The individual may withdraw from family and friends. Being with others and being alone are both difficult.
      • Grief comes in waves that are often precipitated by reminders of the deceased; the bereaved may feel fine one moment, and be overcome with sadness and grief the next moment.
      • Feelings of pleasure are often experienced as a betrayal of the relationship with the person who has died.
    • Stage three – Resolution — around 6mo to 1 yr after the death
      • As the loss becomes more fully accepted the bereaved begins reorganizing his or her life and reinvesting in living. The bereaved person slowly becomes able to remember the deceased without being overwhelmed by grief, can work productively, can sustain a sense of self-esteem and purpose, and can carry on with pleasure and enjoyment.
      • Anniversaries and important events continue to precipitate waves of sadness; the amplitude of these waves diminishes over time, although the grief may never go away entirely.


  • Resembles separation process: protest, despair, and detachment.
    • Protest – desire for caregiver, crying.
    • Despair – child loses hope about caregiver’s return, intermittent crying, withdrawal, apathy.
    • Detachment – child relinquishes some emotional attachment and exhibits interest in surroundings.

Child needs to find a substitute for the lost parent and they may transfer attachment to several adults. If there is no consistent person available, severe psychological damage may occur, so that the child no longer looks for, or expects, intimacy in any relationship. There is evidence that depression and suicide attempts are more common in adults who experience the death of a parent as a child.

It is probably best for children to attend the funeral to prevent the ritual becoming a frightening mystery, unless the child is reluctant or refuses.

Assess what stage of grief the pt is in

  • These stages can occur in any order or simultaneously“SDABDA”
  • S: Shock
  • D: Denial
    A: Anger
    B: Bargaining
    D: Depression
    A: Acceptance
  •  Ameliorate grief reactions in relatives of their dying patients.

Be alert to risk factors for abnormal grieving.

    • Poor social supports
    • Past history of psychiatric problems, especially depression
    • Past history of childhood separation anxiety, abuse or neglect in childhood
    • High initial distress
    • Unanticipated death, lack of preparation for death
    • Other major concurrent stresses and losses
    • Lifestyle rigidity (aversiveness to lifestyle change)
    • Highly dependent relationship with the deceased
    • Death of a child – Pregnancy and newborns — Miscarriage or death of a newborn are often not recognized as major losses but can precipitate prolonged grief.
      • Parental reaction to death of child or birth of very sick infant goes through the five stages of terminal illness: shock, denial, anger, bargaining, depression and acceptance.
    • Age of deceased — The death of an elderly person after a full life will have a different impact than the death of a child or a young adult.
    • Suicide — Bereavement due to suicide or other socially disapproved deaths may lead to more isolation and to increased vulnerability to suicide among some survivors


Before the death

  • Ensure a “good death” (means different things for different families).
  • Pay attention to family members, be available to them before the death. Consider referring relatives with poor coping skills for psychosocial supports before the death. Provide guidance, clear information and reassurance to family regarding difficult decisions e.g. discontinuing life support.

After the death

  • Contact family members not present at the bedside immediately after the death via telephone to inform them, express condolences, answer any immediate questions, and offer them the option of viewing the body.
  • Follow-up by phone or appointment within two weeks can be helpful. A letter of condolence is a core component of quality end-of-life care. Attending the funeral or memorial service is usually deeply appreciated.
  • Encourage bereaved to maintain normal patterns of activity, sleep, exercise and meals, as these routines enhance adaptation during bereavement.
  • If sleep disruption is a problem, can offer a mild, short-term anxiolytic or hypnotic. Anxiolytics can retard and inhibit grieving process, which the person has to go through to come to a resolution.
  • Complicate grief can lead to prolonged dysfunction – need psychiatry referral for complicated grief therapy (CGT).
  • Some evidence the Paroxetine may reduce some symptoms (by 53%).
  • Bereavement related depression is treated with psychotherapy and antidepressants.

2 In all grieving patients, especially those with a prolonged or abnormal grief reaction, inquire about depression or suicidal ideation.

  • Normal bereavement can manifest as intense symptoms that subside slowly but usually cause little impairment by 6 months
  • Dx of MDE  in the grieving individual is difficult, is usually withheld until >2mo after a loss
    • symptoms of bereavement-related depression for at least two weeks, six to eight weeks after a major loss, should be treated for depression
  • No concrete definition as to how long a normal grief reaction can last
  • Mood disturbance: constant in MDD, fluctuating in grief (“waves” of grief), able to have moments of lightheartedness, happy memories, dysphoria triggered by thoughts of deceased.
  • Shame and guilt: in depression due to distorted belief that one is wicked or worthless, in grief related to not having done enough for deceased etc.
  • Hope: absent for many with MDD (will never feel better), bereaved realise grief is time limited.
  • Suicide: in MDD threaten to suicide more often, unusual in grief except in physically dependent older persons.
  • Timing: MDD can start at any time and can be chronic, in bereavement mood disturbances start within 2 months of death and last less than 2 months.

3 Recognize atypical grief reactions in the very young or the elderly (eg behavioral changes).

Complicated/prolonged grief is >6mo of yearning associated with of 8 symptoms:
  1. difficulty moving on,
  2. detachment,
  3. bitterness,
  4. feeling that life is empty,
  5. trouble accepting the death,
  6. feeling of meaningless with future,
  7. agitation,
  8. difficulty trusting others.

Psychiatric referral for these patients!

4 In patients with a presentation suggestive of a grief reaction without an obvious trigger, look for triggers that may be unique to the patient (e.g., death of a pet, loss of a job).

  • TN 2014
  • UpToDate
Posted in 43 Grief, 99 Priority Topics, FM 99 priority topics, Psych

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