Grief
Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz
Definition
A.Grief is defined as the normal, appropriate emotional response caused by a loss. This feeling of loss is a response that has been caused by a particular event in one’s life. It is unique to the individual experiencing it, and there is no general timetable for completing it. Grief is commonly seen following the death of a loved one, but grief also follows other losses (e.g., loss of independence, loss of affection, or loss of body parts, pain, and distress). Mourning is defined as the process by which grief is resolved. Mourning is individual and helps in reaching acceptance of a loss.
B.The process through which one resolves grief usually follows a typical course that can be viewed in five stages:
1.Denial: Denial occurs when one refuses to accept the circumstance that has occurred. It is a natural defense mechanism that occurs to protect the body.
2.Anger: Pain, tears, anxiousness, anger, and feelings of guilt may be seen.
3.Bargaining: In this stage the person tries to negotiate alternatives that will make him or her feel better.
4.Depression: One begins to understand what has happened and may show feelings of sadness and fear.
5.Acceptance: One begins to rebuild life and think about the past with pleasure. In this phase one regains interest in activities and forms new relationships.
C.It is important to distinguish between the normal grief reaction to pathologic grief and major depression. Often, depressive symptoms are a pervasive part of the grief response, and a clear delineation of grief versus depression is not always possible. (Based on the Grief Cycle model first published in On Death and Dying, Elisabeth Kübler-Ross, 1969, Interpretation by Alan Chapman 2006–2009.) Retrieved from www.ekrfoundation.org/5-stages-of-grief.
Incidence
A.Grief is a universal emotional response. Approximately 5% to 9% of the population will lose a close family member or friend each year. Grief is a normal emotional response that will follow this loss for an individual.
Pathogenesis
A.Grief is a normal emotional response to the loss of a loved one, pain, and/or distress. Abnormal, pathologic grief can occur if the mourner is not encouraged to grieve losses. Normal grief resolution begins to subside at approximately 6 months but may sometimes take longer.
Predisposing Factors
A.Sudden or terrible deaths.
B.Excessive dependency on the deceased and feelings of ambivalence.
C.Traumatic losses earlier in life.
D.Social isolation.
E.Actual or imagined responsibility for causing
the death.
F.Avoidance of grief and denial of loss.
G.Survived a traumatic experience that killed the deceased.
Common Complaints
A.Angry feelings at God or medical personnel for not doing more, anger at oneself for not seeing the warning signs, anger at the deceased for not taking better care of himself or herself. Common feelings of being left alone and not making proper financial/legal preparations may also occur.
B.Sleeping all the time or inability to sleep without medication.
C.Change in eating habits with significant weight loss or gain.
D.Fatigue, lethargy, or lack of motivation.
E.Decreased concentration and memory, forgetfulness.
F.Increased irritability.
G.Unpredictable bouts of crying.
H.Fears:
1.Of being alone or with people.
2.Of leaving the house.
3.Of staying in the house.
Other Signs and Symptoms
A.Normal grief:
1.Protest, disbelief, shock, and denial.
2.Profound sadness and survivor guilt.
3.Multiple somatic symptoms without actual organic disease.
4.Sense of unreality and withdrawal from others.
5.Disruption of normal patterns of conduct, with restlessness and aimlessness.
6.Preoccupation with memories of the deceased, dreams of the deceased, hallucinations, fear of going crazy, and transient psychotic symptoms.
7.Response to support and ventilation improves over time.
B.Complicated or prolonged grief:
1.Persistence of denial with delayed or absent grief.
2.Depression with impaired self-esteem, suicidal thoughts, and impulses with self-destructive behavior
3.Actual organic disease and medical illness.
4.Progressive social isolation.
5.Persistent anger and hostility, leading to paranoid reactions, especially against those involved in medical care of the deceased, or suppression of any expression of anger and hostility.
6.Continued disruption of normal patterns of conduct, often with a persistent hyperactivity unaccompanied by a sense of loss or grieving.
7.Continued preoccupation with memories of the deceased to the point of searching for reunion (sustained depressive delusions).
8.Conversion symptoms similar to the symptoms of the deceased.
9.Self-blame.
10.Prolonged grief longer than 6 months is commonly linked to complications and impairment for the next 1 to 2 years.
Subjective Data
A.Review onset, duration, and course of presenting symptoms. Review the mourner’s grief symptoms.
B.Obtain an in-depth personal history of the mourner and his or her relationship to the identified loss or with the deceased.
Understanding the bereaved’s history is critical to understanding the individual’s loss.
C.Identify anniversary dates pertinent to the mourner’s relationship with the deceased/loss.
D.Determine whether the mourner has suicidal ideation (especially with a plan). Be sure to ask: Have you ever thought of hurting yourself or others?
E.Assess whether the mourner experiences self-blame.
F.Review the mourner’s appetite.
G.Establish usual weight, review weight gain/loss, and in what time span.
H.Review the mourner’s activities of daily living (ADLs). Does the mourner get up and dress daily and perform daily hygiene?
I.Review the mourner’s sleep quality.
J.Review the mourner’s daily routines; return to work, return to school, and exercise.
K.Review the mourner’s amount of crying per day, and note for what length of time (days, weeks).
L.Review the mourner’s drug and alcohol consumption since the loss.
Statements suggesting self-medication with alcohol to facilitate sleep could indicate a coexistent alcohol abuse dependence diagnosis.
M.Review the mourner’s usual medical problems and how the loss/grief has affected these problems.
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, weight.
B.Inspect:
1.Observe overall appearance. Note grooming habits, dress, appearance.
2.Note social interactions among family members.
3.Note social skills of the patient.
C.Auscultate:
1.Auscultate the heart and lungs.
Diagnostic Tests
A.As indicated to rule out other pathology.
B.Blood glucose.
C.Thyroid studies.
D.If depression is suspected, perform depression screening such as Beck’s Depression Inventory Scale questionnaire (see Depression
section of this chapter).
Differential Diagnoses
A.Grief.
B.Depressive disorder.
C.Posttraumatic stress disorder (PTSD).
D.Somatoform disorders (characterized by physical complaints lacking known medical basis or demonstrable physical findings in the presence of psychological factors).
E.Alcoholism and drug abuse/dependence.
Plan
A.General interventions:
1.Evaluate the nature of the grief and any accompanying psychiatric symptoms.
2.Treat physical/laboratory findings as indicated.
3.Encourage the patient to eat a healthy diet, exercise daily, maintain normal sleep habits and activities.
4.Encourage family and friend support.
5.Offer counseling with professional psychologist or group sessions.
6.Assess for depression at each office visit and treat accordingly.
B. 
See Section III: Patient Teaching Guide Grief.
C.Pharmaceutical therapy: Antidepressants should not be prescribed for acute grief, but reserved for a possible subsequent major depression. Clinical data suggests that selective serotonin reuptake inhibitors (SSRIs) may assist the patient with mobilizing the energy necessary to assist him or her through the grieving process.
Resist sedation of individuals suffering from acute grief because this tends to delay and prolong the mourning process. Refer to the Depression
section for pharmaceutical therapy.
1.Drug of choice: Sedative to help sleep:
a.Sedative anxiolytic hypnotics may be prescribed for no more than 2 weeks at a time.
b.Try initially for 1 week to establish a sleep pattern. If insomnia continues, refer the patient to a specialist.
c.Temazepam (Restoril) 7.5 to 30 mg at bedtime or flurazepam (Dalmane) 15 to 30 mg at bedtime.
d.Zolpidem (Ambien) 5 to 10 mg at bedtime (not to be used for more than 1 month).
2.Sedating antihistamines:
a.Hydroxyzine HCl (Atarax) 50 to 100 mg at bedtime.
b.Hydroxyzine pamoate (Vistaril) 50 to 100 mg at bedtime (not to be used for more than 4 months).
3.Antidepressant with sedating properties:
a.Trazodone HCl (Desyrel) 50 to 100 mg at bedtime.
b.Paroxetine (Paxil) 10 to 20 mg at bedtime.
c.Mirtazapine (Remeron) 15 mg every day at bedtime. Increase at 1 to 2 weeks: Usual range is 15 to 45 mg every day at bedtime.
Follow-Up
A.Follow up in 1 week to assess the patient’s status and symptoms.
B.Then follow up every 2 weeks to assess the patient’s progress.
C.Assess for depression and suicide at every office visit.
D.Once positive change is seen, the patient can be seen monthly.
Consultation/Referral
A.Provide immediate referral/consult for continuing psychotherapy for severe depression and/or suicidal threats.
B.Consult with a physician for evaluation of pharmacologic agents versus referral.
Individual Considerations
A.Pregnancy:
1.Miscarriage, stillbirth, and neonatal death should be considered a major loss and treated as a grief reaction.
2.Grief is also seen in pregnancy termination. The woman who terminates a pregnancy (regardless of gestational age and reason for termination) may exhibit a major response to this loss.
3.Hospitals often provide photographs, footprints, and identification bracelets and connect families with perinatal grief support groups.
4.Use the baby’s name when discussing feelings about the loss of a child.
5.Suggest that friends and family not put away the clothes and bedroom furniture. The baby couple should do this as part of closure.
B.Adults: Grief responses vary from among individuals. Look for behaviors outside the norm.
C.Geriatrics:
1.Grief in the elderly should be closely assessed to rule out medical diagnoses.
2.Grief can be a very complicated and prolonged process for individuals who have dementia.
3.Avoid use of sedating antihistamines and hypnotics in older adults because of potential for delirium, falls, fractures, and car accidents, as well as minimal improvement in sleep latency and duration.
D.Partners: Involvement in grief/loss psychotherapy groups is extremely helpful.