Grief refers to the response to loss, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed.
Grief is focused on the emotional response to loss, but has physical, cognitive, behavioral, social, cultural, spiritual and philosophical effects.
Grief is a universal response to loss, but there is no universal way to grieve or come to terms with the loss.
Most bereaved persons find a way to accept the new reality and move forward.
Individuals usually oscillate between confronting emotional pain and setting it aside as they slowly accommodate to the changes of their life.
As this occurs, the intensity of grief subsides.
Grief can escalate intermittently and sometimes intensely, especially at anniversaries or in other situations, in which reminders of the deceased person are manifest.
Bereavement refers to the state of loss, while grief is the reaction to that loss.
Grief is associated with death and with a variety of losses throughout one’s life , such as unemployment, ill health or the end of a relationship.
Loss associated with grief can be categorized as either physical or abstract.
Physical loss: related to something that the individual can touch or measure, such as losing a spouse through death, while other types of loss are more abstract, possibly relating to aspects of a person’s social interactions.
The grief response is considered a natural way of dealing with loss.
Prolonged, highly intense grief may at times become debilitating enough to be considered a disorder.
Crying is a normal and natural part of grieving.
Crying and talking about a loss are not the only healthy responses.
Crying and talking, if forced or excessive, can be harmful.
Responses or actions can seem counter-intuitive or even appear dysfunctional: celebratory responses, laughter, or self-serving bias in interpreting events.
The lack of crying can be a healthy reaction, potentially protective and may also be seen as a sign of resilience.
Some healthy people who are grieving do not spontaneously talk about the loss.
Individuals being pressed to cry or retell the experience of a loss can be negative and damaging.
Genuine laughter is healthy grieving response.
27% of bereaved report that they have seen or heard the person they have lost.
Grief can be caused by the loss of one’s home and possessions.
There is a natural resilience that is the main component of grief and trauma reactions.
The absence of grief or trauma symptoms is a healthy outcome, rather than something to be feared as has been the thought and practice previously.
The four responses to grief:
Resilience:The ability of one exposed to an isolated and potentially highly disruptive event, to maintain relatively stable, healthy levels of psychological and physical functioning and to have capacity for generative experiences and positive emotions.
Recovery: When normal functioning temporarily gives way to threshold or sub-threshold psychopathology- symptoms of depression or post-traumatic stress disorder, or PTSD, usually for a period of at least several months, and then gradually returns to pre-event levels.
Chronic dysfunction: Prolonged suffering and inability to function.
It may last several years or longer.
Delayed grief or trauma:
The distress and symptoms may increase months later.
The Kübler-Ross model of the five stages of grief/impending death.
The five stages are:
denial
anger
bargaining
depression
acceptance
It suggests a framework that helps people learn to live without what they have lost.
The stages model has been debunked because studies show that the vast majority of people who have experienced a loss are resilient and that there are multiple trajectories following loss.
Refers to the response of the death of a close friend or relative.
Acute grief is associated with a array of emotions including shock, disbelief, separation distress, longing, and sadness.
Bereaved individuals may become preoccupied with thoughts, memories, and images of the lost person, and focus on the loss decreasing other activities.
The process leads to the initial symptoms of traumatic stress, separation distress, caregiver self blame and decreased involvement in activities of life.
Most individuals successfully negotiate the process of grief without intervention, and return to a meaningful life without the deceased individual people.
Initial reactions that may last days to months, after a loss, vary in intensity due to personal, cultural and religious factors .
Grief is associated with a wide range of experiences in response to a loss and is associated with a mixture of positive and negative emotions, which oscillate over time.
Most individuals move through a natural mourning process to a less intense form of grief in 6-12 months.
This less intense form of grief is referred to integrated grief, in which the process of death is assimilated and a return to ongoing life occurs.
Grief produces a local inflammation response as measured by salivary concentrations of pro-inflammatory cytokines.
This response is correlated with activation in the anterior cingulate cortex and orbitofrontal cortex, which activation is correlated with the free recall of grief-related word stimuli:
grief causes stress, and that this reaction is linked to the emotional processing parts of the frontal lobe.
Similarly, activation of the anterior cingulate cortex and vagus nerve are implicated in the experience of heartbreak.
Bereaving people, in the first three months have intrusive thoughts of reminders to their loss, about the deceased, and show ventral amygdala and rostral anterior cingulate cortex hyperactivity.
The amygdala activity is linked to sadness intensity.
fMRI scans have concluded that there is a high functional connectivity between the dorsolateral prefrontal cortex and amygdala activity, suggesting that the former regulates activity in the latter.
Grief is a painful cost of human’s capacity to form commitments.
Grief is a kind of psychological pain that leads the sufferer to a new existence without the deceased and creates a painful but instructive memory.
Grief is an indicator of an individual’s propensity for forming strong, committed relationships, and forming strong social commitments.
Severe grief reactions affect approximately 10% to 15% of people.
Severe reactions mainly occur in people with depression present before the loss event.
There are increased risks for stress-related illnesses with grief: increased doctor visits, with symptoms such as abdominal pain, breathing difficulties, in the first six months following a death.
There is a five times greater risk of suicide in teens following the death of a parent.
Bereavement also increases the risk of heart attack.
Prolonged grief disorder (PGD), is a pathological reaction to loss representing symptoms that have been associated with long-term physical and psycho-social dysfunctions.
PGD maladaptive state lasts for at least six months and are stuck in a maladaptive state.
PGD is not synonymous with grief, as it is complicated grief with an extended grieving period and other criteria, including mental and physical impairments.
PGD may present with severe loss related emotional pain and difficulty envisioning a meaningful future without the deceased person.
PGD may be associated with difficulties in the function of daily life, and suicidal ideation in behavior may be present.
PGD symptoms include: intense,yearning, longing, or preoccupation with the deceased person along with persistent, intense and pervasive manifestations of grief.
PGD symptoms of prolong grief disorder persist for a minimum period of greater than six months to greater than 12 months and cause significant distress or impaired functioning that exceeds expectations for grief in the context of a patient’s cultural religious or social community.
PGD symptoms include: emotional pain, sadness, guilt, anger, inability to feel positive emotions, denial, or difficulty excepting the death, feeling that a part of oneself has been lost, and reduced engagements in social or other activities.
Patients with PGD may present with a severe loss related emotional pain and difficulty envisioning a meaningful future without the deceased.
P7atients with PGD may have difficulty with functions of daily life, behavioral problems, or suicidal ideation.
An average of 3 to 10% of individuals bereaved by natural causes have prolonged grief disorder.
The rates of PGD are several times higher among individuals who lose loved ones due to suicide, homicide, accidents, natural, disasters, or other sudden unexpected causes of death.
Complicated grief has an extreme focus on the loss and reminders of the loved one, intense longing or pining for the deceased, problems accepting the death, numbness or detachment, bitterness about the loss, inability to enjoy life, depression or deep sadness, trouble carrying out normal routines, withdrawing from social activities, feeling that life holds no meaning or purpose, irritability or agitation, and lack of trust in others.
Complicated grief symptoms seem to be a combination of the symptoms found in separation as well as traumatic distress.
Unlike normal grief, complicated grief symptoms continue regardless of the amount of time that has passed and despite treatment.
Patients may experience successive avoidance of reminders of the permanence of the loss and imagine alternative scenarios are common, 7as is self blame and anger, difficulty regulating emotions and ongoing stress.
Patients with complicated grief symptoms are likely to have other mental disorders such as PTSD, depression, and anxiety.
Complicated grief is more severe and prolonged version of acute grief than a completely different type of grief.
Complicated grief is usually occurs when a loved one dies suddenly and in a violent way.
Complicated grief affects 2 to 3% of people in the world.
The symptoms of complicated grief in bereaved elderly are an alternative manifestation of post-traumatic stress.
Serotonin specific reuptake inhibitors
reduce intrusive thoughts, avoidant behaviors, and hyperarousal that are associated with complicated grief.
Disenfranchised grief is grief that is not acknowledged by society.
Death of a child can take the form of a loss in infancy such as miscarriage, stillbirth,neonatal death, SIDS, or the death of an older child.
Among adults over the age of 50, approximately 11% have been predeceased by at least one of their offspring.
In most cases, parents find the grief almost unbearably devastating, and it tends to hold greater risk factors than any other loss.
This loss also bears a lifelong process: one does not get over the death but instead must assimilate and live with it.
Rrisk factors are great and may include family breakup or suicide.
Feelings of guilt, whether legitimate or not, are pervasive.
Parents who suffer miscarriage or a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies.
Survivors of a spouse who died of an illness has a different experience of such loss than a survivor of a spouse who died by an act of violence.
Often, the spouse who is left behind may suffer from depression and loneliness.
Grieving siblings are often made to feel as if their grief is not as severe as their parents’ grief.
The sibling relationship is the longest significant relationship of the lifespan and siblings help form and sustain each other’s identities.
With the death of one sibling comes the loss of that part of the survivor’s identity because one’s identity is based on having their sibling present.
If siblings were not on good terms or close with each other, feelings of guilt may ensue on the part of the surviving sibling.
Guilt may also ensue for having survived, inability to prevent the death, or having argued with their sibling.
When an adult child loses a parent in later adulthood, it is not a normative event by any measure, but is a major life transition causing an evaluation of one’s own life or mortality.
Others may shut out friends and family in processing the loss of someone with whom they have had the longest relationship.
For a child, the death of a parent, without support to manage the effects of the grief, may result in long-term psychological harm, and is more likely if the adult carers are struggling with their own grief and are psychologically unavailable to the child.
There is a critical role of the surviving parent or caregiver in helping the children adapt to a parent’s death.
The loss of a parent at a young age also has some positive effects: increased maturity, better coping skills and improved communication.
Adolescents who lost a parent valued other people more than those who have not experienced such a close loss.
At a time when trust and dependency are formed, loss at around critical periods of 8–12 months, when attachment and separation are at their height can cause distress.
As a child grows older, death is still difficult to fathom and affects how a child responds.
Young children see death more as a separation, and may believe death is curable or temporary.
Reactions can manifest as acting out behaviors, and a return to earlier behaviors.
As children enter pre-teen and teen years, there is a more mature understanding of loss.
Adolescents may respond by delinquency, or oppositely become over-achievers.
Adolescents may respond by repetitive actions or taking up repetitive tasks to avoid the grief.
Childhood loss can predispose a child to physical illness, and to emotional problems and an increased risk for suicide, especially in the adolescent period.
Grief can be experienced as a result of losses due to causes other than death: damage to or the loss of their ability to trust.
With child sexual abuse, it may represent for many children multiple forms of loss: not only of trust but also loss of control over their bodies, loss of innocence and indeed loss of their very childhoods.
Relocations can cause children significant grief.
Survivor guilt is a mental condition that occurs when a person perceives themselves to have done wrong by surviving a traumatic event when others did not.
Survivor guilt may be found among survivors of combat, natural disasters, epidemics, among the friends and family of those who have died by suicide, and in non-mortal situations such as among those whose colleagues are laid off.
Other losses associated with grief: loss of a jobs, loss of children through means other than death, for example through loss of custody in divorce proceedings; legal termination of parental rights by the government, such as in cases of child abuse; through kidnapping; child voluntarily leaving home, or because an adult refuses or is unable to have contact with a parent, the loss of a romantic relationship, empty nest syndrome, loss of a pet, loss of a home, siblings leaving home, loss of a friend, loss of faith in a religion, retirement, loss of job by retirement, injury or loss of certification, and loss of trust.
The loss of a child, other than by death has a grief process that is prolonged or denied because of hope that the relationship will be restored.
Living veteran soldiers often experience grief.
Bereavement often happens abruptly, but there are also cases of being gradually bereft of something or someone: the gradual loss of a loved one by Alzheimer’s produces a gradual grief.
Some suggest that every degree of death, every death of a person’s characteristics, every death of a person’s abilities, is a bereavement.
Bereaved people often report experiences of sensory and quasi-sensory experiences of the deceased which correlate with pathology like grief complications.
Resources available to the bereaved may include grief counseling, professional support-groups or educational classes, and peer-led support groups.
Grief can result in depression or alcohol- and drug-abuse and, if left untreated, it can impact daily living.
Each culture specifies manners such as rituals, styles of dress, or other habits, as well as attitudes, in which the bereaved are encouraged or expected to take part.
In non-Western cultures beliefs about continuing ties with the deceased varies: in Japan, maintenance of ties with the deceased is accepted and carried out through religious rituals, Hopi of Arizona, the women go into self-induced hallucinations where they conjure images of the deceased loved one to mourn and process their grief.
Different cultures grieve in different ways, but all have ways that are vital in healthy coping with the death of a loved one.
In individuals with intellectual disability, are able to process grief in a similar manner to those without cognitive impairment.
Differences between those with an intellectual disability and those without is typically the ability to verbalize their feelings about loss: non-verbal cues and changes in behavior become important, because these are usually signs of distress and expression of grief among this population.
Treatmentm goals, are to help the patient to accept the performance of the loss and restore capacity to have a meaningful life without the deceased person, so that the preoccupation with the deceased person subsides.
Randomized trials have shown that active intervention with targeted psychotherapy is efficacious and strongly recommended.
Such therapy is more efficacious than treatment for depression with interpersonal therapy or with medications.
Treatment for prolonged grief disorder typically includes therapy and, in some cases, medication.
Cognitive-Behavioral Therapy (CBT): This is often used to help individuals process their loss and develop coping strategies.
It may involve cognitive restructuring, exposure therapy, and learning to adapt to life without the deceased.
Complicated Grief Therapy (CGT): A specialized form of CBT tailored specifically for prolonged grief.
It focuses on resolving grief complications and promoting adaptation to the loss.
Grief Counseling: Provides a supportive environment to express feelings, process the loss, and find meaning in life after the death of a loved one.
Pharmacotherapy: In some cases, antidepressants or other medications might be prescribed to help manage symptoms, especially if the individual is also experiencing depression or anxiety.
Mindfulness and Acceptance-Based Therapies These can help individuals accept their feelings and reduce avoidance, which is often a component of prolonged grief.
Support Groups: These provide a space for sharing experiences with others who are going through similar struggles, which can foster connection and understanding.
Psychoeducation: Educating individuals about the nature of grief and differences between normal and prolonged grief can empower them to understand their experiences better and seek appropriate support.