Grief

Original article by Tom Leach | Last updated on 19/5/2014
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Important facts

  • Risk of suicide is 2.5x greater in the first year of bereavement
  • Particularly high risk at the anniversary of the death
  • Death from physical illness is also increased in the first year after bereavement – particularly death from cardiovascular disease
 

Normal Grief reaction

After the death of a close relative, patients will experience grief. Elizabeth Kubler-Ross described the Stages of grief model in the 1960’s. Interestingly, this model has been applied to many other areas of psychology, where people are said to suffer a grief reaction – which can be any life even that involves a big change (e.g. losing your job, moving house, break up of a relationship etc)
 
Contrary to many popular references to her work, people do not necessarily exhibit all 5 stages, neither do they progress through them in any order. Indeed, an individual may experience one of the stages several times. There is also no timeframe during which these stages can occur – some people may initially appear to be accepting, but many years down the line, they may progress to further stages.
 
The 5 stages of the model are:
 

Denial

Sometimes described by patients as a feeling of numbness. this is often the first stage and may be short-term (<2 weeks). Prolonged denial does not necessarily cause more stress for the patient. In fact, it may even be beneficial to the patient as it forms a protective facade, whilst allowing the patient time to inwardly analyse the situation.
  • The patient may be pre-occupied with thoughts of their deceased relative. The thoughts may at first be distressing, but later, may be comforting. They may dream of their relative. They may concentrate of physical objects that remind them of the deceased.
  • Illusions – the patient may think they hear or see the deceased (pseudohallucinations), and may interpret unusual noises at home as their relative moving around the house. They may feel as though the deceased is still nearby or present, and may talk to them, and even prepare meals for them.
 

Anger

Many patients exhibit anger after the response of denial – they may feel it is unfair that they are in this position and others are not. The anger can cause problems for the care of the patient. Doctors and relatives of the patient may feel that the anger is directed at them, even though the original cause of the anger is totally unrelated to them. Anger can be directed at other family members, medical practitioners, and God.

Bargaining

(E.g. trying to justify it, or seeking to change behaviours in an attempt to reverse / alleviate the event) - in this stage the patient makes a ‘promise’ either with themselves, or others (or perhaps God), that if they are allowed to carry out a favourite task, ritual or experience ‘one more time’, then after this event, they may be more willing to accept the truth. However, often after the event itself, the patient is not satisfied, and may make further attempts at bargaining.

 

Depression

There is usually a triad of low mood, poor sleeping pattern and weeping. This is seen in >50% of grieving relatives. There are usually also other features of depression, that in many cases are enough to satisfy the diagnostic criteria, and thus be treated. There can also be:

  • Suicidal thoughts – the individual may feel they could have done more to prevent the death of the loved one, and may feel guilt, and may want to join them
  • Somatic symptoms –often similar to those felt by the deceased before they passed away
  • Generalised anxietythe individual may be very restless, they may pace about the house, they may visit public places, or the cemetery looking for the deceased.
 

Acceptance

This is frequently the final stage that the patient will experience. They will often have been on an emotional journey through several other stages before they reach this state.

In the majority of cases, symptoms will resolve within 6 months. It is true that with time, feelings subside, although most people will still feel some sense of loss many years later.
 

Atypical grief reaction

  • More common in women
  • Different types of atypical grief reaction, most commonly:
  • Often very prolonged
    • Denial may last >2 weeks
    • Total grief reaction may last >1 year
  • Symptoms include:
    • Social withdrawal
    • Inability to work
    • Suicidal thoughts and acts
    • Sever guilt
    • Sever feeling of hostility to others
    • Extreme somatisation and hypochondrial symptoms, similar to those of the deceased
  • Other types:
    • Delayed grief reaction – the individual functions normally for up to several months after the event, before entering a state of grief.
    • Denial – the patient spends a very long time in the denial stage of the grief reaction.
 
An atypical grief reaction is more likely to occur when:
  • The death is sudden and unexpected
  • Circumstances have prevented normal grief at an early stage (e.g. Unable to see the body)
  • The relationship before the deceased died was hostile / there were unresolved problems
  • The loss involves a child of the affected (even if ‘child’ is now adult)
  • The patient has a small social circle, and/or few relatives
 

Management

Patients experiencing both typical and atypical grief reactions will often be involved with medical services. It is important to try to establish which stage of grief the patient is in (nad if atypical reaction, are they stuck in this stage?). you are then able to help them move onto the next stage. In atypical reactions, the patient may receive special psychological therapies to help them out of the ‘stuck’ stage.
 
Antidepressants are recommended if there is diagnosabledepression, regardless of the cause.
In some cases, anti-psychotic medications may be indicated, but psychotic symptoms can be difficult to distinguish from some of the signs of a normal grief reaction described above, e.g. pseudohallucinations.