Topic: Grief, Bereavement, and mourning
Author: Udi Alkhazaleh
Editor: Ihda Bani Khalaf
Reviewer: Ethar Hazaimeh 

Keywords: Grief, Mourning, Bereavement, Anticipatory grief, Prolonged  grief disorder, Major Depressive disorder

Overview

Death and birth, gaining and losing, joy and sorrow are life norms that we encounter on a daily base. As healthcare providers, we are always facing bereaved individuals throughout our personal or professional lives.¹ The loss of a close and loved person through death is considered one of life’s most stressful events. Most people are nevertheless able to handle the pain inflicted by this loss and adapt to a new life without the deceased. While some developmental afflictions as a result of their loss, that possibly may lead to mental health issues.² Bereavement is defined as the objective situation a human faces after having lost an important person via death. Grief is defined as the primarily emotional (Internal Experience) process of reacting to the loss of a loved one through death, and it’s expressed publicly through different aspects influenced by many factors.¹ It’s human primitiveness to express grief and gripe about his loss, but prolonged and persistent emotions piling up could cause persistent complex bereavement disorder in many different types. Persistent complex bereavement disorder, a syndrome that occurs in about 10% of bereaved people, due to the failure to transition from acute to integrated grief. As a result, acute grief is prolonged, perhaps indefinitely.³

Classification and Clinical presentation

Normal grief

To begin with, we must know what is normal to differentiate ourselves from what is abnormal. The literature uses the terms bereavement and grief interchangeably to describe the state in which one has experienced a death or the reaction to one’s loss.² According to research, the word “grief” should be used to characterize the behavioral, emotional, cognitive, and functional reactions to death, while “bereavement” should be used to speak to the actual fact of the loss. Additionally, the term “grief” is sometimes used more widely to describe how people react to other types of loss; for example, they grieve the loss of their youth, possibilities, and functional abilities.² Normal or common grief appears to occur in 50% to 85% of people after they have experienced a loss.⁴ Most importantly in defining Grief that it is not a state, but rather a process that has the following characteristics: ²

• Occurs in waves, unlike in MDD where it is persistent.
• Varies in duration.
• Intense sorrow, yearning and longing for the deceased, emotional distress.
• No persistent or long-term functional impairment, unlike MDD.
• Preoccupation with thoughts and memories of the deceased and circumstances surrounding the manner of death.

Many bereaved individuals will go through extremely severe, brief (e.g., 20–30 minute) episodes of distress, which are sometimes referred to as grieving waves or bursts. Occasionally, these pains are a response to things that serve as memories of the departed, such as significant social or cultural holidays, the anniversary of the patient’s passing, or giving away personal belongings. On the other hand, the pains could come on suddenly at other times. While the exact length of time required for healing is unknown, most bereaved individuals going through typical sorrow may notice a decrease in symptoms after roughly six months.⁵

Anticipatory grief

The word “anticipatory grief” was first used in 1944 by Erich Lindemann.⁸ Lindemann defined anticipatory grief as a response to the threat of death, rather than to death itself. It is widely recognized currently that anticipatory grief occurs before an imminent death.⁹ Both loved ones and those facing their imminent death face it. It differs from grief that happens after death, despite certain similarities. Anticipatory grieving is distinct from normal grief (post-loss) since it considers both past and present losses in addition to future losses.⁶ Debilitating anticipatory grieving can affect the dying person or even their loved ones. It can cause medical symptoms like insomnia as well as mental ones like bewilderment, hypervigilance, trouble focusing, making decisions, or appetite disruptions producing exhaustion.⁶

Prolonged Grief Disorder

Prolonged grief disorder simply known as pathological grief,¹⁰ is characterized by intense and persistent mental distress following the loss that impairs the individual’s capabilities to function in their daily life. Factors that may contribute to prolonged grief reactions are maladaptive thoughts (e.g., blame), avoidance behaviors, inability to manage painful emotions, differences in health and social status, and lack of Social support that impedes the ability to adjust to loss.^{11 12} It is been associated with negative outcomes that result in a higher risk of all-cause mortality and suicidal ideation and behaviors.^{13 11} In addition, prolonged grief reactions are uniquely associated with general health impairments,¹¹ including cancer and health problems,¹⁴ as well as increased substance use.¹⁵ The etiologies and determinants of these varied consequences are still poorly understood, even though a great deal of research is advancing our knowledge of grieving and related psychopathology.

Differentiating Normal Grief Reaction from Major Depressive Disorder

 The behavioral expressions linked to the grieving process and depressive symptoms include sleeplessness, guilt, ruminating, and lack of motivation often overlap. Clinicians were encouraged by the Diagnostic and Statistical Manual of Mental Disorders’ fourth revised edition (DSM-IV-TR) not to diagnose significant depression in patients within the first two months of their diagnosis.

following the death of a loved one in what was referred to as the “bereavement exclusion.” The fifth edition of the DSM (DSM-5) eliminated bereavement exclusion in the diagnosis of major depression. This change was added to recognize that in vulnerable individuals, grief can precipitate major depression within a short time and can be potentially lethal.

• The characteristics of a typical grieving process in contrast to a major depressive episode are meticulously described by the DSM-5 as follows:

• In grief, painful feelings come in waves, lessen in intensity and frequency gradually over time, and are often intermixed with positive memories of the deceased; in depression, mood and ideation are constantly negative.
• In grief, the prevailing affect is one of emptiness; in major depression, it is a long, sustained, depressed mood and an inability to expect pleasure or happiness.
• In grief, self-esteem is usually preserved; in major depression, feelings of worthlessness and self-loathing are common.
• In grief, people’s functionality could be maintained to do basic functioning, and support from loved ones often helps while depression, often leads to significant impairment in daily functioning (e.g., work, and social life).
• In grief, while symptoms such as suicidal ideation can occur, they are generally focused on the deceased, such as a desire to die with the deceased or regret about shortcomings or voids in the relationship with the deceased
• In major depression, suicidal ideation is more likely directed at self only.

According to the DSM-5, significant depression should not be classified as part of a typical mourning process, even though depression is a common side effect of loss.

It also highlights that when depressive symptoms and characteristics are evident and easily differentiated from a typical grieving process, serious depression can and should be identified. To acknowledge the existence of a protracted and intricate grieving process in susceptible people, the DSM-5 also developed a candidate disorder called persistent complex bereavement disorder.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association, 2013.

Mourning

The external expression of [one’s] thoughts and feelings.⁶ The term “mourning” refers to the personal experience and psychosocial expression of sorrow or grief. The external social and emotional expressions of grief represent the notion of mourning. Weeping, religious and social performances in dirges and burial rites, melancholy conversations about a deceased person or thing connected to perceived loss, and austere behavior are some examples of the expressions. Mourning involves the visible personal and collective expressions of grief. On the other hand, mourning is a natural psychological, behavioral, social, and physical phenomenon.⁷

Bereavement

Bereavement is defined as the objective situation one faces after having lost an important person due to death, in other words, it’s the state of losing somebody and describing the experience of being deprived of a loved one. On the contrary, grief is an emotional process that focuses on the fact of the loss itself.¹

Risk factors

Factors that may increase the risk of developing prolonged grief include:

• Experiencing an unexpected or violent death, (e.g., death from an accident, murder, or suicide of a loved one)¹⁶
• Experiencing the death of a child¹⁶
• Close or dependent relationship to the deceased person¹⁶
• Social isolation, loss of a support system, or loss of friendships¹⁶
• History of depression, separation anxiety, or post-traumatic stress disorder (PTSD)¹⁶
• History of mood disorders (e.g., bipolar disorder)^{17 18}
• Traumatic childhood (e.g., child abuse, neglect, or violence)¹⁹
• Other major life aggravators, such as major financial or family hardships¹⁶
• Maladaptive thinking (e.g., blame), avoidance strategies, an inability to control unpleasant feelings, and a lack of social support that hinders loss adaptation are all factors that may lead to prolonged grief disorder reactions.^{11 12}
• Prolonged grief reactions are specifically linked to increased substance use,¹⁵ and general health impairments¹¹, including cancer and other health issues.¹⁴
• Older age, lower socioeconomic status, and female gender are demographic risk factors of prolonged grief disorder.²⁰

Diagnostic Criteria 

Proposed prolonged grief disorder criteria for DSM-5-TR

1. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago).
2. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree: intense yearning/longing for the deceased person, and preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death). In addition, the symptom(s) have occurred nearly every day for at least the last month.
3. Since the death, at least 3 of the following symptoms have been present most days to a clinically significant degree: identity disruption (e.g., feeling as though part of oneself has died) since the death; marked sense of disbelief about the death; avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders); intense emotional pain (e.g., anger, bitterness, sorrow) related to the death; difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future); emotional numbness (absence or marked reduction of emotional experience) as a result of the death; feeling that life is meaningless as a result of the death; intense loneliness as a result of the death. In addition, the symptoms have occurred nearly every day for at least the last month.
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. The duration and severity of the bereavement reaction clearly exceeds expected social, cultural or religious norms for the individual’s culture and context.
6. The symptoms are not better explained by major depressive disorder, posttraumatic stress disorder, or another mental disorder, or attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

The most highlighted difference is the timeframe criterion, as prolonged grief disorder in the DSM-5 needs the death to have occurred at least 12 months before diagnosis as opposed to 6 months prior. Both criteria set include gateway symptoms of yearning or preoccupation with thoughts or memories of the deceased. The DSM-5 criteria set requires at least three other symptoms occurring on a daily base for at least the past month. The DSM-5 diagnosis of prolonged grief disorder is likely to be included in the Trauma and Other Stressor-Related Disorders section, like the provisional persistent complex bereavement disorder diagnosis.²¹

Treatment

Many bereaved individuals may eventually see a natural decrease in their grief-related symptoms and won’t need any kind of official intervention. Additionally, the existence of certain grief-related symptoms that do not significantly disrupt functioning or cause distress, and that may fluctuate throughout the year, with periods of escalation on significant anniversary dates (such as the date of death), does not by itself signify pathology or necessitate intervention. Nonetheless, there are evidence-based, brief therapies that can help reduce the symptoms of prolonged grief disorder in the minority of individuals who acquire the illness.²²

Prolonged Grief Treatment (PGT)

Several randomized controlled trials (RCTs) have shown that prolonged grief treatment, a manualized 16-session intervention, is effective in lowering symptoms of extended mourning disorder.^{23 24 25} Cognitive-behavioral therapy (CBT), attachment theory, and other methods are used in PGT to support the body’s natural adaptive responses to loss. According to the dual process paradigm of grief, PGT promotes adaptation by emphasizing both loss and restoration.²⁶ Providing information to help patients understand and accept grief, managing emotional pain and keeping an eye on symptoms, thinking ahead, reestablishing relationships, sharing the death story, learning to live with reminders, and connecting with memories are the seven main themes that PGT incorporates to achieve the adaptation goal.²⁷

Cognitive-behavioral therapy (CBT)

Patients with prolonged grief disorder may also benefit from cognitive behavioral therapy (CBT), including exposure therapies. For instance, patients who were randomized to receive group cognitive behavioral therapy (CBT) for grief and four individual sessions of exposure interventions (exposure to the death story) showed better functioning, fewer negative appraisals, and larger decreases in depressive and grief symptoms than those who received group CBT plus four individual supportive counseling sessions.²⁸

Additionally, CBT might be useful in addressing symptoms that frequently accompany prolonged grief disorder. Most patients with prolonged grief disorder, for instance, experience severe sleep disturbances, which may not necessarily get better with grief-focused therapy.²⁹ A short, sleep-focused intervention, like cognitive behavioral therapy for insomnia (CBT-I), might be helpful for these patients. It has been shown that CBT-I is effective in reducing the symptoms of insomnia.³⁰

Supportive Groups

Bereavement or support groups might be useful in decreasing the symptoms of grief. Support groups might not be efficient for prolonged grief disorder, although they might help lessen the severity of acute grief.³¹ Since a lack of social support is a risk factor for the development of prolonged grief, support groups may, given the circumstances, be a helpful source of social support following a loss.^{32 33}

Comorbidities

It has been demonstrated that sleep abnormalities and disturbances are aggravated due to emotional and stress-related conditions. Sleep difficulties have been linked to both complicated grief (CG) and grief ³⁴, and they frequently continue following effective CG treatment. Insomnia is more prevalent in bereaved individuals than in non-bereaved individuals.³⁴ For example, Hardison et al.³⁵ demonstrated that insomnia affected 17% of non-bereaved individuals and 22% of a heterogeneous sample of bereaved individuals. Research on the prevalence of nightmares revealed that 45–88% of children and teenagers had frequent or severe nightmares after a traumatic loss. ^{36 37} Frequent nightmares were more common in children who had experienced traumatic loss than in those who had not ³⁷. Moreover, it was found that more frequent or severe sleep disruptions were linked to increased grieving intensity.³⁸ When put together, the findings offer compelling proof of a positive correlation between the severity of sorrow and grief to sleep disturbance.

One of the seven main emotions required for human survival, according to the discipline of affective neuroscience, is grief. Maladaptive grieving, on the other hand, can seriously harm an individual’s life and result in psychopathologies such as major depressive disorder (MDD).³⁹ Grief co-occurs with many mental health disorders/symptoms. One risk factor for the development of depression is the death of an emotionally significant individual. Individuals who are suffering from grief are more likely to develop depression symptoms (e.g., isolation, loss of appetite, and sadness). According to a study on perinatal death, mothers had both mourning and depression symptoms in the first month following a loss.⁴⁰ According to another study, following an unexpected or violent death, 35.5% of individuals experienced indications of MDD and prolonged grief disorder (PGD).⁴¹ However, the loss could also be studied through the loss of social support. Complicated grief and poor bereavement outcomes have been linked to lower social support levels.⁴² Perceived absence of social support has been linked to MDD following a loss, which is aligned with these findings.⁴³ For instance, a study of college students who had experienced major loss revealed that those who felt less supported by others had more signs of depression, sadness, and prolonged grief disorder.⁴⁴ These findings emphasize how crucial social ties are. Undoubtedly, social support is protective against the symptoms of depression.^{45 46 47 48}

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