Grief is a psychological, emotional, and physiological (biopsychosocial)response to the loss orsignificantinterruption (as when a loved one in the military is deployed to a distant location) of an important relationship.
A grieved loss can be personal, as in death; occupational, as in job loss; or social, as in divorce or relationship termination. It is experienced as a deep, painful, and sometimes prolonged sense of loss that gradually diminishes over a period of months or years. Mourning, the outward expression of grief, is experienced worldwide and is behaviorally evidenced according to local cultural norms and practices.
Richard Friedman (in the New England Journal of Medicine, 2012) describes grief as “an entirely normal and expected emotional response to loss. Clinicians and researchers have long known that, for the vast majority of people, grief typically runs its course within 2 to 6 months and requires no treatment.”
The late thanatologist Elisabeth Kubler-Ross (1926–2004) categorized five stages of loss and grief in response to death in her 1969 book, On Death and Dying. The stages are considered universal, but the pace, intensity, length, and order of progression through them vary individually. The stages are: denial, anger, bargaining, depression, and acceptance. Kubler-Ross’ work focused on the death (completed or impending) of self or of a loved one, whether human or animal.
The denial phase involves refusal to accept the truth of the completed or impending death. Sigmund Freud (1856–1939) would consider the denial phase a form of defense as it serves to protect the individual from potentially overwhelming emotion.
In the second phase, the shock has begun to recede and is replaced by anger, which may be directed at the medical team for not being able to cure the dying one, at the person who is dying, at the perceived unfairness of the loss for causing pain to those remaining, or at virtually anyone or anything else. The individual is typically aware that the anger is not rational, causing feelings of guilt that may then intensify the anger.
Bargaining is a means of trying to re-establish control in a perceived untenable situation, attempting to make a deal with the Universe to prevent or reverse the loss. In the bargaining phase, people often make extravagant promises regarding positive life changes in exchange for avoiding the loss.
The depression phase occurs when individuals recognize that denial, anger, and bargaining were ineffective. They recognize the loss as real, inevitable, and unalterable and may experience intense feelings of sadness, appetite and sleep disturbances, and/or social isolation, and may begin to internally process the loss. This phase is not to be confused with clinical depression.
In acceptance, individuals are actively processing grief and bereavement, have accepted the permanency of loss, and are beginning to resume their normal lives.
Complicated grief is a bereavement process that exceeds, either in duration or intensity, the typical grief experience. Individuals with complicated grief reactions often report a heightened version of the typical grief symptoms, sometimes lasting for many years. Some individuals, as a result of underlying mental health issues, lack of social supports, physical illness, or other sensitizing factors, are at increased risk for complicated grief. In addition to internal factors predisposing a heightened grief experience, a history of clinical depression or anxiety, codependent relationships or substance abuse may be contributing factors. When the grief is in response to a death that is violent, unexpected, traumatic, sudden, or involves the loss of a child, the likelihood of a complicated grief response is significantly increased. Complicated grief is often treated with psychotherapy, support groups, and medications such as antidepressant drugs.
See also Affect ; Abnormal psychology ; Antidepressant drugs ; Depression ; Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ; Emotion ; Maslow's hierarchy of needs.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. Washington, DC: Author, 2013.
Kubler-Ross, Elisabeth. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families.. New York: Scribner, 1969.
Sherman, Deborah Witt. Final Moments: Nurses' Stories about Death and Dying. New York: Kaplan, 2009.
Friedman, R. A. “Grief, Depression, and the DSM-5.” New England Journal of Medicine 366 (May 17, 2012): 1855–57.
Iglewicz, A., et al. “The Removal of the Bereavement Exclusion in the DSM-5: Exploring the Evidence.” Current Psychiatry Reports 15, no. 11 (November 2013): 413.
Parker, G. “Opening Pandora's Box: How DSM-5 Is Coming to Grief.” Acta Psychiatrica Scandinavica 128, no. 1 (2013): 88–91.
Shear, M. K., et al. “Complicated Grief and Related Bereavement Issues for DSM-5.” Depression and Anxiety 28, no. 2 (February 2011): 103–17.
Sung, S. C., et al. “Complicated Grief Among Individuals with Major Depression: Prevalence, Comorbidity and Associated Features.” Journal of Affective Disorders 134, no. 1–(November 2011): 453–58.
Wakefield, J. “The DSM-5 Debate over the Bereavement Exclusion: Psychiatric Diagnosis and the Future of Empirically Supported Treatment.” Clinical Psychology Review 33, no. 7 (2013): 825–45.
Zisook, S., et al. “Grief, Depression and the DSM-5.” Jour-nal of Psychiatric Practice 19, no. 5 (September 2013): 386–96.
National Institutes of Health. “Bereavement.” http://health.nih.gov/topic/Bereavement (accessed September 19, 2015).
National Institute of Mental Health. “Director's Blog: Transforming Diagnosis. By Thomas Insel on April 29, 2013” http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml (accessed September 19, 2015).