Stephen R. Shuchter

Handbook of bereavement: The course of normal grief

Writing an essay on the course of normal grief is more difficult than immediately meets the eye. Grief is a natural phenomenon that occurs after the loss of a loved one. If grief is normal, what, then, is “normal” grief? In our experience, grief is such an individualized process - one that varies from person to person and moment to moment and encompasses simultaneously so many facets of the bereaveds being - that attempts to limit its scope or demarcate its boundaries by arbitrarily defining normal grief are bound to fail. With this in mind, the rest of this chapter should be read not so much as prescriptive of how the normal course of grief should run but, rather, descriptive of the many and varied ways people grieve the death of a significant other. We begin with a brief review of the stages of grief, its expected duration, and definitions and purported determinants of griefs resolution. Following a discussion of the limitations of the approach, we outline a multidimensional approach to understanding the phenomena and course of grief and supplement the discussion with data from our own work on the multidimensional assessment of widowhood. The stages of grief In a similar manner to Kubler-Rosss conceptualization of staging death and dying (1969), many investigators of the process of grief and bereavement have proposed stages of normal grief (Bowlby, 1980/1981; Glick, Weiss, & Parkes, 1974; Pollock, 1987).

PTSD Following Bereavement

Until quite recently, the only stressor considered consistent with the diagnosis of PTSD was a catastrophic, out of the ordinary, trauma that almost anyone could be expected to have a severe reaction to. Thus, PTSD was considered relatively rare among non-military populations. More recently, epidemiologic surveys have suggested that PTSD may be much more prevalent than heretofore recognized, and the DSM-IV has opened the door to a much larger variety of stressors (the “A” criterion). Yet, bereavement is not considered the type of stressor capable of producing PTSD. In this study, 350 newly bereaved widows and widowers were assessed for the prevalence of PTSD, its chronicity, comorbidity, and consequences. The diagnosis of PTSD was made on the basis of questionnaire items approximating the DSM-IV criteria for PTSD. At 2 months after the spouses death, 10% of those whose spouses died after a chronic illness met criteria for PTSD, 9% of those whose spouses died unexpectedly met criteria, and 36% of those whose spouses died from “unnatural” causes (suicide or accident) had PTSD. Symptoms tended to be chronic in at least 40% of the subjects, almost always were associated with comorbid depression, and created substantial morbidity. The results suggested that PTSD may occur after bereavement, and, by extension, other stressors not recognized by official diagnostic systems. The “A” criterion needs further examination.

The many faces of depression following spousal bereavement

While it is becoming increasingly clear that mood disorders tend to be chronic, intermittent and/or recurrent conditions with different manifestations over time, little is known of the variability or course of mood disorders that are associated with severe psychosocial stress. This paper reports on the prevalence and course of major, minor, and subsyndromal depressions in 328 widows and widowers followed prospectively from 2 to 25 months following one of the most disruptive of all naturally occurring stressors, spousal bereavement. The results are consistent with the following conclusions: (1) past major depression (prior to the death) predicts an increased risk for major depression following bereavement; (2) membership in any of the unipolar subgroups, in turn, predicts future depression throughout the unipolar depressive spectrum; (3) subsyndromal and minor depression stand between major depression, on the one hand, and no depression, on the other, in terms of their effects on overall adjustment to widowhood. Thus, the results support the validity of subsyndromal depression, and that the three subgroups (major, minor and subsyndromal depression) are pleiomorphic manifestations of the same unipolar depression disorder.

Bereavement, depression, and immune function

This study evaluates whether recently widowed women who fulfill criteria for a depressive syndrome differ in their immune responses from widows who do not. Twenty-one middle-aged widows who had lost their spouses 2 months before the initial evaluation and 21 demographically matched married women were evaluated at approximately 6-month intervals for 13 months. Evaluations consisted of diagnostic interviews using the Schedule for Affective Disorders and Schizophrenia, Hamilton Rating Scale for Depression, and Beck Depression Inventory. Immune function was measured by total lymphocyte counts, natural killer (NK) cell activity, mitogen responsiveness to concanavalin A, and T-cell subsets. There were no statistically significant differences on any of the immune measures between the entire cohort of widows and control subjects. However, the subset of widows who met DSM-III-R criteria for major depressive syndromes demonstrated impaired immune function (lower NK cell activity and lower mitogen stimulation) compared with those who did not meet criteria for major depression. This study suggests a relationship between impaired immune function and depression in women experiencing the stress of bereavement.

Major Depression Associated With Widowhood

The authors look at the frequency of depressive symptoms and syndromes associated with spousal bereavement in late life and assess both the course and associated morbidity of those syndromes over a 2-year period. The prevalence of major depressive syndromes ranges from 24% 2 months after the spouses death to 14% at 25 months. Major depression was associated with poor role functioning, interpersonal difficulties, poor medical health, and increased medical treatment. Risk factors for continuing major depression 25 months after the death of a spouse include, in descending order of importance, early post-bereavement depressive syndromes, intensity of early depressive symptoms, family history of depression, alcohol consumption, medical health, and suddenness of the death.

Early Psychological Reaction to the Stress of Widowhood

As part of an ongoing panel study, we evaluated 350 widows and widowers at 2 and 7 months following the loss of their spouses. In general, no consistent progression of grief resolution was noted. At 7 months, grief-specific feeling states remain remarkably similar to what they were at 2 months. Anxiety levels remain high and change little from 2 to 7 months. When changes do occur, they are not unidirectional. For example, subjects are about as likely to increase as to decrease their drinking or smoking. Furthermore, depression scores at month 2 correlate well with depression and anxiety scores at month 7. Over 50% of the subjects were depressed at some time during the study period, but the depression could initially manifest itself at any time during this period. Despite the presence of psychological distress in a significant minority, most bereaved individuals report good health, satisfactory work performance and good adjustment to widowhood.

Treatment of the Depressions of Bereavement

Although the onset, exacerbation, or persistence of major depressive episodes are among the most frequently encountered complications of bereavement, there is scant empirically based literature on the treatment of bereavement-associated depressions. Whereas uncomplicated bereavement rarely requires formal treatment, for bereavement that is complicated by a major depressive episode, treatment can greatly diminish suffering and promote well-being. When establishing a treatment plan for major depressive episodes following the death of a loved one, clinicians must keep in mind that they are dealing with both grief and depression; thus, an ideal intervention targets both components, often simultaneously. The authors present an integrative model of treatment that incorporates basic principles of grief therapy along with the same combinations of psychoeducation, psychotherapy, and pharmacotherapy generally applied to the treatment of nonbereavement-related major depressive episodes. The authors emphasize that treatment must be individualized and focused to address specific needs and resources of each unique patient.

The Psychological and Physical Health of Hospice Caregivers

This study explores the psychological distress of caring for a dying family member and examines the differences in depression, anxiety, health, social and occupational functioning, and social support among hospice caregivers and community controls. It compares psychological functioning of spousal and adult child hospice caregivers. Caregivers of terminally ill hospice patients were assessed prior to death as a part of a longitudinal bereavement study. Caregivers reported experiencing higher levels of depression, anxiety, anger, and health problems than controls. Hospice caregiving was associated with deterioration in physical health and in social and occupational functioning. The comparisons between adult children and spouse caregivers revealed that levels of psychological and physical morbidity were very similar for the two generations of caregivers. An awareness of distress symptoms among hospice caregivers could lead to timely proactive clinical intervention that may prevent bereavement complications.

Reported suicidal behavior and current suicidal ideation in a psychiatric outpatient clinic

One thousand consecutive intakes at an outpatient psychiatric clinic were screened for past suicide attempts and present suicidal ideation and diagnosed using DSM-III-R criteria. A full range of thoughts about death and suicide were prevalent in all diagnostic groups. Over one-third of patients with major depression and borderline personality disorder had actual plans to kill themselves, and over two-thirds of patients with borderline personality disorder had made one or more suicide attempts.

Aging and bereavement.

This paper compares the grief responses of widows and widowers of different age groups over the 1st year of bereavement. The results strongly suggest that older widows and widowers perceive themselves as adjusting better to their loss and suffering from less depression and fewer anxiety symptoms than their younger counterparts. Furthermore, the oldest widows/widowers demonstrate the most consistent improvement in their levels of distress over time. Thus, when it comes to coping, older persons are not at the disadvantage that certain stereotypes and “clinical wisdoms” have previously suggested. Seniors are every bit as adaptive and able to cope with the severest forms of stress as anyone else, and they are, if anything, less prone to depression than are younger individuals.