What are the signs, symptoms, and stages of grief?
Perhaps the most well-known model for understanding grief was developed by Elisabeth Kübler-Ross, MD, in her 1969 book titled On Death and Dying. The five stages of the grief cycle that she outlined are
These stages also apply to the stages of dying, the grief associated with one's own death. She described the stage of denial as the bereaved having difficulty believing what has happened, the anger phase as the survivor questioning the fairness of the loss, the bargaining stage as wishing to make a deal with fate to gain more time with the one who was or will be lost, the depression stage as the period when the bereaved person gets in touch with how very sad they are about losing their loved one, and acceptance as feeling some resolution to their grief and more ability to go on with their own life.
Kübler-Ross apparently felt these phases can be applied to any significant personal loss (for example, of a job, relationship, one's own health, anticipating one's own death), as well as the death of a loved one. It also seems that she believed these stages don't all have to occur, can take place in different order, and can reoccur many times as part of an individual's specific grief process. Other grief experts describe seven stages of grieving, specifically
- shock or disbelief,
The shock or disbelief stage is understood as the numbness often associated with initially receiving the news of the death of a loved one. The guilt stage of grief refers to feelings of regret about difficult aspects of the relationship with the deceased.
In addition to the emotional pain already discussed, symptoms of grief can be physical, social, cultural, or religious in nature. Physical symptoms can range from mild sleep or appetite problems to heart attack. Social symptoms of bereavement include isolation from other loved ones and difficulty functioning at home, school, and/or at work.
For children and adolescents, reactions to the death of a parent or other loved one tend to be consistent with their reaction to any severe stress. Such reactions usually reflect the particular developmental stage of the child or adolescent. For example, since infants up to about 2 years of age cannot yet talk, their reaction to the loss of a loved one tends to involve crying and being more irritable or clingy. They further show physical symptoms of sleep or appetite problems, changes in activity level, and being more watchful of (vigilant toward) their surroundings.
Since preschoolers from 3 to 5 years of age begin to be able to remember the one who died but have not yet developed the ability to understand the permanence of death, they may believe they somehow magically caused the death and can make the person come back. In addition to showing signs of grief that are similar to infants, they may have more difficulty separating from caregivers.
Early school-aged children, from 6 to 8 years of age, more likely understand that death is permanent compared to younger children, often feel guilt about the death of the loved one, become preoccupied with memories about the departed, and try to master the loss they have suffered by talking about it frequently. While symptoms of grief in school-aged children from 9 to 11 years of age are quite similar to those of early school-aged children, this older group is more vulnerable to a decrease in self-esteem because they feel different from their peers if they have experienced the loss of a loved one. They are also more prone to defend against their feelings of loss by becoming engrossed in school, social, and/or extracurricular activities.
In keeping with their budding need for independence, young adolescents 12 to 14 years of age may experience mixed feelings about the deceased individual and exhibit a wide range of emotions. They may avoid talking about the loss. Older teens usually experience grief similarly to adults, enduring sadness, anxiety, and anger. They tend to deny their feelings of loss to parents but discuss them in detail with peers. For children, adolescents, and adults, as with any major stress, grief may cause a person to regress emotionally, in that they go back to former, often less mature ways of thinking, behaving, and coping.
Symptoms of complicated grief include intense emotion and longings for the deceased, severely intrusive thoughts about the lost loved one, extreme feelings of isolation and emptiness, avoiding doing things that bring back memories of the departed, new or worsened sleeping problems, and having no interest in activities that the sufferer used to enjoy. Teens tend to react to the loss of a loved one that died through suicide similarly to the ways in which adults experience complicated grief but it is noteworthy that their lack of life experience to draw strength from and high level of involvement with their peers may make teens more vulnerable to contemplating suicide themselves when a loved one commits suicide. Mental health professionals often refer to this type of vulnerability as contagion.
Regardless of age, individuals who lose a loved one from suicide are more at risk for becoming preoccupied with the reason for the suicide while wanting to deny or hide the cause of death, wondering if they could have prevented it, feeling blamed for the problems that preceded the suicide, feeling rejected by their loved one, and stigmatized by others.
Doctors are well acquainted with loss and grief. Of 200 consultations with general practitioners, a third were thought to be psychological in origin; of these, 55—a quarter of consultations overall—were identified as resulting from types of loss.1 In order of frequency the types of loss included separations from loved others, incapacitation, bereavement, migration, relocation, job losses, birth of a baby, retirement, and professional loss.
After a major loss, such as the death of a spouse or child, up to a third of the people most directly affected will suffer detrimental effects on their physical or mental health, or both.2 Such bereavements increase the risk of death from heart disease and suicide as well as causing or contributing to a variety of psychosomatic and psychiatric disorders. About a quarter of widows and widowers will experience clinical depression and anxiety during the first year of bereavement; the risk drops to about 17% by the end of the first year and continues to decline thereafter.2 Clegg found that 31% of 71 patients admitted to a psychiatric unit for the elderly had recently been bereaved.3
Despite this there is also evidence that losses can foster maturity and personal growth. Losses are not necessarily harmful.
Yet the consequences of loss are so far reaching that the topic should occupy a large place in the training of health care providers—but this is not the case. One explanation for this omission is the assumption that loss is irreversible and untreatable: there is nothing we can do about it, and the best way of dealing with it is to ignore it. This attitude may help us to live with the fact that, despite modern science, 100% of our patients still die and that before they die many will suffer lasting losses in their lives. Sadly, it means that, just when they need us most, our patients and their grieving relatives find that we back away.
Losses are a common cause of illness; they often go unrecognised
Conflicting urges lead to a variety of expressions of grief; even so there is a pattern to the process of grieving
A knowledge of the factors that predict problems in bereavement enables these to be anticipated and prevented
Grief may be avoided or it may be exaggerated and prolonged
Doctors can help to prepare people for the losses that are to come
People may need permission and encouragement to grieve and to stop grieving
Recent approaches to loss
A 1944 study of bereaved survivors of a night club fire focused attention on the psychology of bereavement, and led to the development of services for the bereaved and to other types of crisis intervention services.4 It established grief as a distinct syndrome with recognisable symptoms and course, amenable to positive or negative influences. This, in turn, fuelled interest in the new fields of preventive psychiatry and community mental health. Elizabeth Kubler Ross’s studies extended this understanding to dying people,5 and helped to provide a conceptual framework for the humanitarian work of Dame Cicely Saunders and the other pioneers of the hospice movement.
More recently the improvements in palliative care have led to improvements in home care for the dying. Home care nurses have bridged the gap and general practitioners have had a central role, not only in caring for dying patients and their families but also in supporting people through many other losses. This is the main theme of this series, which draws together authorities with special knowledge of the losses which afflict our patients and their families and looks at the practical implications for doctors.
The components of grief
Three main components affect the process of grieving. They include the urge to look back, cry, and search for what is lost, and the conflicting urge to look forward, explore the world that now emerges, and discover what can be carried forward from the past. Overlying these are the social and cultural pressures that influence how the urges are expressed or inhibited. The strength of these urges varies greatly and changes over time, giving rise to constantly changing reactions.
Most adults do not wander the streets crying aloud for a dead person. Bereaved people often try to avoid reminders of the loss and to suppress the expression of grief. What emerges is a compromise, a partial expression of feelings that are experienced as arising compellingly and illogically from within.
Much empirical evidence supports the claims of the psychoanalytic school that excessive repression of grief is harmful and can give rise to delayed and distorted grief—but there is also evidence that obsessive grieving, to the exclusion of all else, can lead to chronic grief and depression. The ideal is to achieve a balance between avoidance and confrontation which enables the person gradually to come to terms with the loss. Until people have gone through the painful process of searching they cannot “let go” of their attachment to the lost person and move on to review and revise their basic assumptions about the world. This process, which has been termed psychosocial transition, is similar to the relearning that takes place when a person becomes disabled or loses a body part.
The course of grief
Disorganisation and despair
The normal course of grief
Human beings can anticipate their own death and the deaths of others. Unlike the grief that follows loss, anticipatory grief increases the intensity of the tie to the person whose life is threatened and evokes a strong tendency to stay close to them.
Although the moment of death is usually a time of great distress, this is usually quickly repressed and, in Western society, the impact is soon followed by a period of numbness which lasts for hours or days. This is sometimes referred to as the first phase of grieving.6 It is soon followed by the second phase, intense feelings of pining for the lost person accompanied by intense anxiety. These “pangs of grief” are transient episodes of separation distress between which the bereaved person continues to engage in the normal functions of eating, sleeping, and carrying out essential responsibilities in an apathetic and anxious way.
All appetites are diminished, weight is lost, concentration and short term memory are diminished, and the bereaved person often becomes irritable and depressed. This eventually gives place to the third phase of grieving, disorganisation and despair. Many find themselves going over the events which led up to the loss again and again as if, even now, they could find out what went wrong and put it right. The memory of the dead person is never far away and about a half of widows report hypnagogic hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead person near at hand. These hallucinations are distinguished from the hallucinations of psychosis by the circumstances in which they arise and by their transience—they disappear as soon as the bereaved arouse themselves. A sense of the dead person near at hand is also common and may persist.
As time passes the intensity and frequency of the pangs of grief tend to diminish, although they often return with renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind. Consequently the phases of grief should not be regarded as a rigid sequence that is passed through only once. The bereaved person must pass back and forth between pining and despair many times before coming to the final phase of reorganisation.
After a major loss such as the death of a loved spouse or partner, the appetite for food is often the first appetite to return. By the third or fourth month of bereavement the weight that was lost initially has usually returned, and by the sixth month many people have put on too much weight. It may be many more months before people begin to care about their appearance, and for sexual and social appetites to return. Most people will recognise that they are recovering at some time in the course of the second year.
Assessing the risk
Much research, in recent years, has enabled us to identify people at special risk after bereavement either because the circumstances of the bereavement are unusually traumatic or because they are themselves already vulnerable (box). These risk factors can give rise to complicated forms of grief that can culminate in mental illness. A clear understanding of these factors will often enable us to prevent psychiatric disorder in bereaved patients.
Factors increasing risk after bereavement
Traumatic circumstances Death of a spouse or child Death of a parent (particularly in early childhood or adolescence)
Sudden, unexpected, and untimely deaths (particularly if associated with horrific circumstances)
Multiple deaths (particularly disasters)
Deaths by suicide
Deaths by murder or manslaughter
Vulnerable people General: Low self esteem
Low trust in others
Previous psychiatric disorder
Previous suicidal threats or attempts
Absent or unhelpful family
Ambivalent attachment to deceased person
Dependent or inter-dependent attachment to deceased person
Insecure attachment to parents in childhood (particularly learned fear and learned helplessness)
Bereavement has physiological as well as emotional effects (lower box). It also affects physical health: after bereavement, the immune response system is temporarily impaired7,8 and there are endocrine changes such as increased adrenocortical activity and increases in serum prolactin and growth hormone,2 as in other situations that evoke depression and distress.
A variety of psychiatric disorders can also be caused by bereavement, the commonest being clinical depression, anxiety states, panic syndromes, and post-traumatic stress disorder. These often coexist and overlap with each other, as they do with the more specific morbid grief reactions. These last disorders are of special interest for the light that they shed on why some people come through bereavement unscathed or strengthened by the experience while others “break down.”
It is a paradox that people who cope with bereavement by repressing the expression of grief are more likely to break down later than are people who burst into tears and get on with the work of grieving. The former are more liable to sleep disorders, depression, and hypochondriacal symptoms resembling the symptoms of the illness that caused the bereavement (“identification symptoms”). Not all psychogenic symptoms, however, are a consequence of repressed or avoided grief. Some reflect the loss of security which often follows a major loss and causes people to misinterpret as sinister the normal symptoms of anxiety and tension.
At the other end of the spectrum of morbid grief are people who express intense distress before and after bereavement. Subsequently they cannot stop grieving and go on to suffer from chronic grief. This may reflect a dependent relationship with the dead person, or it may follow the loss of someone who was ambivalently loved. In the former case the bereaved person cannot believe that he or she can survive without the support of the person on whom they had depended. In the latter, their grief is complicated by mixed feelings of anger and guilt that make it difficult for them to stop punishing themselves (“Why should I be happy now that my partner is dead?”).
Some degree of ambivalence is present in all relationships. To some degree its effects can be assuaged by conscientious care during the last illness, and many people will recall “We were never closer.” If members the family have been encouraged and supported so that they have been able to care, and the death has been peaceful, anger and guilt are much less likely to complicate the course of grieving.
These two patterns of grieving often seem to occur in “avoiders” (people with a tendency to avoidance) and “sensitisers” (those with a tendency to obsessive preoccupation), respectively.9
Complications of bereavement
Impairment of immune response system
Increased adrenocortical activity
Increased serum prolactin
Increased growth hormone
Increased mortality from heart disease (especially in elderly widowers)
Depression (with or without suicide risk)
Anxiety or panic disorders
Other psychiatric disorders
Post-traumatic stress disorder
Delayed or inhibited grief
Preventing and treating complicated grief
Doctors are in a unique position to help people through the turning points in their lives which arise at times of loss. In order to fulfil this role we need information and skills. One of our problems as caregivers is our ignorance of our patients’ view of the world. Not only do we seldom know what they know or think they know about the situation they face, we do not even know how that situation is going to change their lives. It follows that we need to find out these things and, where possible, add to their knowledge or correct any misperceptions, taking care to use language that they can understand. (This is easier said than done when words like “cancer” and “death” mean different things to doctors than they do to most patients.) Above all, we should spend time helping them to talk through and to make sense of the implications of the information we have given. If need be, we should see them several times to facilitate this process of growth and change. General practitioners, because they are likely to know the person, are often well placed to provide this “trickle” of care. For most bereaved people the natural and most effective form of help will come from their own families, and only about a third will need extra help from outside the family.
Members of health care teams can often prepare people for the losses that are to come. People need time to achieve a balance between avoidance and confrontation with painful realities, and we need to take this into account when we impart information that is likely to prove traumatic. One way is to divide the information that needs to be confronted into “bite sized chunks.” Doctors do this when we break bad news a little at a time, telling a patient as much as we think he or she is able to take in. Patients seldom ask questions unless they are ready for the answers, and they will usually ask precisely what they want to know and no more. It follows that we should invite questions and listen carefully to what is asked rather than assuming that we know what the patient is ready to know. By monitoring the input of information, a person can control the speed with which they process that information.
Although a little anxiety increases the rate and efficiency with which we process information, too much anxiety slows us down and impairs our ability to cope, our thought processes become disorganised and we “go to pieces.” Anything that enables us to keep anxiety within tolerable limits will help us to cope better with the process of change. If we are breaking bad news (box) it helps to do so in pleasant, home-like surroundings and to invite the recipient to bring someone who can provide emotional support. A few minutes spent putting people at their ease and establishing a relationship of trust will not only make the whole experience less traumatic for them but it will increase their chance of taking in and making sense of the information which we then provide.
Breaking bad news
Consider social support (who to ask to be present)
Consider setting (where to meet)
Try to establish a relationship of mutual respect and trust
Discover what the patient or the family knows or think they know already
Give information at a speed and in a language that will be understood
Monitor what has been understood
Recognise that it takes time to hear and understand bad news
Give the patient or the family time to react emotionally
Give verbal and non-verbal reassurance of the normality of their reaction
Stay with the patient or the family until they are ready to leave
Offer further opportunities for clarification, information, or support
Supporting bereaved people
A visit from the general practitioner to the family home on the day after a death has occurred enables us to give emotional support and to answer any questions about the death and its causes that may be troubling the family. Newly bereaved people often feel and behave, for a while, like frightened and helpless children and will respond best to the kind of support that is normally given by a parent. A touch or a hug will often do more to facilitate grieving than any words.
During the next few weeks bereaved people need the support of those they can trust. We can often reassure them of the normality of grief, explain its symptoms, and show by our own behaviour and attitudes that it is permissible to express grief. If we feel moved to tears at such times there is no harm in showing it. Bereaved people may need reassurance that they are not going mad if they break down, that the frightening symptoms of anxiety and tension are not signs of mortal illness, and that they are not letting the side down if they withdraw, for a while, from their accustomed tasks.
As time passes people may also need permission to take a break from grieving. They cannot grieve all the time and may need permission to return to work or do other things that enable them to escape, even briefly, from grief. It is only if they get the balance between confrontation and avoidance wrong that difficulties are likely to ensue.
The first anniversary is often a time of renewed grieving, but thereafter the need to stop grieving and move forward in life may create a new set of problems. People may need reassurance that their duty to the dead is done, as well as encouragement to face the world that is now open to them. The most important thing we have to offer is our confidence in their personal worth and strength. We should beware of becoming the “strong” doctor who will look after the “weak” patient for ever, but this does not mean that we become angry and dismissive, reprimanding the patient for becoming “dependent.” In the end, most bereaved people come through the experience stronger and wiser than they went into it. It is rewarding to see them through.
In the acute stages it is usually best to give support by personal contact, preferably in the client’s home. Later the help of a group in which bereaved people can learn from each other, as well as a counsellor, may be helpful. Organisations such as Cruse Bereavement Care and the member organisations of the National Association of Bereavement Services may be able to provide either of these types of help. The Compassionate Friends (for bereaved parents), Lesbian and Gay Bereavement, Support after Murder and Manslaughter (SAMM), and the Widow-to-Widow programmes that exist in the United States and other parts of the world provide mutual help by bereaved people for others with the same types of bereavement.
Markus AC, Parkes CM, Tomson P, Johnstone M. Psychological problems in general practice. Oxford: Oxford University Press, 1989.
Parkes CM. Bereavement: studies of grief in adult life. 3rd ed. Harmondsworth: Pelican, 1998.
Funding: No additional funding.
Conflict of interest: None.
The articles in this series are adapted from Coping with Loss, edited by Colin Murray Parkes and Andrew Markus, which will be published in July.
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