When Grief Becomes a Disorder

By Mary Lou Bernardo, Ph.D
May 1, 1998

The dictionary tells us that to bereave is to “deprive ruthlessly or by force; deprive by death.” Grief is “keen mental suffering over affliction or loss.” It is a synonym for “mourning, sorrow, or woe.”

Life tells us that bereavement and grief are inevitable, until we, too, become the object or source. So then why even consider bereavement or grief to be worthy of attention or treatment?

Biondi and Picardi give us a partial answer in Psychotherapy and Psychosomatic (1996). After reviewing the human and animal literature on the biological aspects of loss and stress, they noted that numerous disruptions occur in the neuroendocrine and the immune systems for several months following stress and loss. Such disruptions leave the individual vulnerable to illness. This vulnerability places the grieving individual at increased risk for physical and mental illness for approximately two years after the loss, with men more at risk than women. However, in cases where grief is unresolved or complicated, physical and mental vulnerabilities continue.

According to the authors, should grief remain unresolved, this vulnerability becomes part of the individual’s nervous system, hardwired, so to speak, in the neurochemical substrate. The stage has been set for the development of recurring major depression.

What is important, then, is differentiating between normal and complicated grief. Normal grief requires no treatment. Untreated complicated grief may lay the groundwork for lifelong depression.

Andrew Rosenzweig summarized current knowledge on the psychosocial and psychobiological sequelae of both bereavement related depression and pathological bereavement in the elderly (Annual Review of Medicine, 1997). He found that up to 15% of bereaved elders meet criteria for major depression 13 months after the loss.

Neurovegetative symptoms were especially notable in this group. Treatment with tricyclic antidepressants is often effective. Elders with pathological bereavement, however, do not respond to tricyclic antidepressants alone. Treatment, most likely, will require both psychotherapy and psychopharmacology over a fairly extensive period. Left untreated, both bereavement related depression and pathological bereavement leave the individual vulnerable to physical illness.

In 1995, Holly Prigerson and others attempted to distinguish between the depressive symptoms of “normal” bereavement and complicated grief (American Journal of Psychiatry). Sampling from an elderly population of bereaved spouses, the authors used various psychological measures to arrive at a determination of the principle elements of complicated grief.

They found that complicated grief contains the elements of separation distress (e.g., crying, searching), posttraumatic stress (e.g., disbelief, shock), and the generalized element of coping (acceptance). Subjects who showed elements of complicated grief at baseline had poorer global function, more depressive symptoms, lower self-esteem, and poorer sleep quality 18 months after the spouse’s death. Prigerson, et al, concluded that complicated grief comprises a discrete set of symptoms independent of the symptoms of bereavement-related depression and bereavement-related anxiety.

Replication of this study (1996) validated the original findings on a larger (N=150), non-clinical, mid to latelife sample. The results of this study also predicted different mental and physical outcomes for those with symptoms of complicated grief.

Extending their research further, the Prigerson group (1997) continued to follow the subjects from their replication study in order to validate their findings on the mental and physical outcomes of complicated grief. It was during the course of this study that the group changed the name of the symptoms under investigation “… from ‘complicated’ to ‘traumatic’ grief because … considered the latter to capture more precisely the two underlying dimensions of the syndrome (i.e., trauma and separation distress).” (p. 618) While advising that their results should be viewed with caution due to the relatively small sample size, the authors do come to several conclusions. Traumatic grief symptoms seldom diminish after the second half of the first year following loss. Symptoms may actually increase as time goes on. Subjects with traumatic grief are at increased risk of developing cancer, high blood pressure, and heart disease. Subjects with traumatic grief are also at increased risk for suicidal ideation. These individuals demonstrated the most suicidal ideation in spite of the fact that there were more subjects with symptoms of depression (36% at 13 months) than there were with symptoms of traumatic grief (6% at 13 months).

The authors conclude that bereavement in itself does not put individuals at risk for adverse health outcomes. It is the psychiatric sequelae of bereavement, specifically traumatic grief, which make the individual vulnerable to illness. Interest in accurately diagnosing complicated grief has been rising. In 1996, Samuel Marwit wrote in support of the notion of a separate DSM classification for complicated grief (The Journal of Consulting and Clinical Psychology). He reasoned that there are various forms of grief and the current DSM category (v62.82 Bereavement) does not adequately address them. Using categories of grief obtained from the thanatology literature, Marit devised a study designed to explore diagnostic possibilities. He asked 40 mental health providers to read four vignettes and make a diagnosis based upon DSM-III-R (in use at the time). The subjects were then asked to open a sealed envelope, reread the vignettes, and place the “patient” into one of the thanatological categories of grief. Marit found that there was greater agreement between subjects when diagnosis was based upon the grief categories. He views these findings as support for a separate diagnostic category for complicated grief.

Mardi Horowitz and others took the idea of a separate category for complicated grief and established diagnostic criteria for complicated grief disorder. The authors studied a volunteer sample of bereaved spouses between 21 and 55 years old and presented their findings in The American Journal of Psychiatry (1997).

They found similarities across severe grief reactions and presented them in DSM style, including an event/response criterion and signs and symptoms criteria. The event/response criterion is a time frame of bereavement occurring at least 14 months prior to diagnosis. Signs and symptoms are grouped into intrusive and avoidance categories.

Should there be a separate diagnostic category for severe, prolonged grief? The authors cited in this article certainly think so. However, what of age or developmental variations in grief? How are grief and bereavement different for parents or siblings? Would the criteria described here hold for adolescents? Some thoughts on these questions will be presented in the next issue of The National Psychologist.

Mary Lou Bernardo, Ph.D., R.N. is interested in reader reactions as well as ideas for future columns dealing with research. Send your thoughts to mlbernardo@iname.com or telephone her at 203/459-1065.

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