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SIDNEY ZISOOK, M.D.

STEPHEN SHUCHTER, M.D.

MARC SCHUCKIT, M.D.

Factors in the persistenceof unresolved grief amongpsychiatric outpatientsABSTRACf: Seventeen percent of patients entering an outpatientpsychiatric facility had unresolved grief, according to self-report.Patients with unresolved grief proved to have a higher incidence ofmultiple losses, a history of difficulties in getting along with theirmothers, and present complaints of depression and physical distress.Clinicians should be alert for the presence of unresolved grief whenevaluating a new patient.

recognized, is readily diagnosablewhen looked for, and is treatable whenrecognized,' we decided to sample apopulation of new psychiatric outpa­tients for the presence of unresolvedgrief and to attempt to identify anyunique characteristics of that popula­tion.

Dr. Zisook is associate professor. Dr. Shuchler is associate clinical professor. and Dr.Schuckit is professor. all in the department ofpsychiatry. University ofCalifornia. SanDiego. School ofMedicine. Reprint requests to Dr. Zisook. UCSD Gifford Clinic. 3427FOUTthAve.• San Diego. CA 92103.

The universal experience of loss of aloved one through death carries with itrisk of medical and emotional morbid­ity. I The customary reaction to suchloss, grief, is generally considered anecessary but painful and self-limitedprocess that ultimately allows the be­reaved individual to continue with liv­ing. 2 The hallmark of the resolution ofgrief is the ability of the bereaved torecognize that they have grieved andcan now return to work, reexperiencepleasure, and respond to the compan­ionship and love ofothers.}

For many persons, however, totalresolution is not obtained. In fact

Parkes' suggested that chronic griefmay be the rule rather than the excep­tion, especially when the acute griefreaction is intense or there is difficultyaccepting the fact of the loss. In a pre­vious studt of symptoms of bereave­ment we found that even ten years ormore after the loss, many otherwisenormal individuals remain preoccu­pied with painful memories of the de­ceased. We also found" that at least14% of a bereaved population weresuffering from unresolved grief, asso­ciated with increased depression. Be­cause it has been suggested that unre­solved grief is often overlooked or un-

ProcedureAll new patients over a four-month pe­riod at the UCSD Gifford MentalHealth Clinic, which is the outpatientfacility for the department of psy­chiatry at the University ofCalifornia,San Diego, School of Medicine, wereasked to complete a 53-item question­naire. A research assistant was presentat the intake desk to help answer ques­tions and ensure maximum com­pliance. The questionnaire includeddemographic information; a four­point symptom checklist; a four-pointinventory assessing the quality ofpastand present relationships; a four-pointassessment of functioning at home,school, work, and leisure; and an as­sessment of medication, drug, and al­cohol intake.

Most germane to this report was aseries of further questions concerning

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Unresolved grief

Table-Mean SCores for Questionnaire Items Differing Significantlyfor Patients with Unresolved G:ief

deaths of relatives, how long ago thedeath occurred, and whether dealingwith the death was still difficult for thepatient. Forthe purposes ofthis paper,any patients who checked that theywere still having difficulty in dealingwith a death were considered to have"unresolved grief. " All patients wereassigned DSM-III diagnoses by the in­take clinician after three one-hour in­terviews and consultation with one ofthe full-time faculty experienced inuse of DSM-III.

Results

From the total of 245 new patientsseen during that period, 220 complet­ed questionnaires (90%) were re­turned. Fifty-three percent of the re­spondents were female; the mean agewas 33 years (range, 18 to 75 years);61 % of the sample were single, 9%married, and another 30% divorced,separated, or widowed. Twenty-twopercent had never before been to amental health facility. Most patientscame to the clinic requesting someform of individual talk therapy (74%),while one third wanted medicationwith or without psychotherapy and al-

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most 5% requested hospitalization.The major referral sources were non­psychiatric physicians (31 %), othermental health workers or clinics(29%), friends (12%), or self (12%).The reason for referral almost neverexplicitly related to grief. The mostcommon diagnostic categories wereadjustment disorders (27%), anxietydisorders (22%), affective disorders(18%), schizophrenic disorders(14%), and personality disorders(6%).

One hundred twenty-seven patients(58%) had not yet experienced thedeath of a first-degree relative (GroupI). Of the 93 patients who had experi­enced such a loss, 55 (25% ofthe totalpopulation) reported no present diffi­culties in dealing with the loss (Group2), while 38 (17% of the total popula­tion; 41 % of the bereaved population)felt that they were still experiencingdifficulty (Group 3). The majority ofthe deceased relatives were fathers(43%), followed by mothers (28%),siblings (17%), spouses (10%), andchildren (2%). The mean time sincethe death of parents was 16 years, ofsiblings 14 years, ofspouses six years,

and of children 11 years. The overallmean time since the deaths was 14years.

Use of analysis of variance and theLeast Significant Difference MultipleRange Test showed that the threegroups did not differ significantly inregard to demography, diagnosis,time since death, relative who haddied, impairment of the patient on ad­mission, drug- or alcohol-taking be­havior, and functioning at home,work, school, and leisure. However,Group 3 (those still having difficultywith the loss) proved to differ signifi­cantly (P< .05) from the other twogroups in regard to self-perceived dif­ficulty with depression, physicalsymptoms, and past relationships withthe mother (Table).

These three characteristics, ratedon the simple four-point scales, de­rived from the questionnaire items:"How much difficulty are you havingwith feeling depressed or sad?";"How much difficulty are you havingwith physical symptoms (ie, sleeping,eating, headaches, etc)?"; and "Ratethe quality of your relationship withyour mother when growing up."

PSYCHOSOMATICS

None of the other items on thesymptom checklist (ie, anxiety, self­esteem, substance use, etc) or itemspertaining to the quality of other pastrelationships (ie, with fathers, teach­ers, siblings, or friends) differedamong the three groups. Although"difficulty in past relationships withthe mother" related to self-perceivedpresent difficulties in dealing withloss through death, such present diffi­culties did not correlate significantlywith death of the mother per se; rather,past relational difficulties with themother were associated with laterproblems in dealing with lossesthrough death of any first-degree rela­tive, not just with the deaths ofmothers. Finally, patients who hadexperienced multiple prior lossesthrough death were more apt to behaving difficulty than patients whohad experienced only one loss(X 2 =4.07; P< .05).

DiscussionThe rather simple but clinically usefulindex of unresolved grief used here re­vealed an incidence of unresolvedgrief of 17%, a finding remarkably si­milar to that found' in other outpatientpsychiatric populations. There is nouniversally accepted definition of un­resolved grief, which may refer to anunusual duration or intensity of grief,'to clinical syndromes associated withgrief,9 to incomplete resolution ofoneof the stages ofgrief,' or to other oper­ational definitions."

In the present study we simplifiedthe concept to include only those be­reaved individuals who themselvesfelt that they were having difficultiesin dealing with their loss. Of course,we recognize that this concept leavesout those individuals who deny or oth­erwise do not recognize their difficul­ties, and it includes some individualswho would not, by other clinical mea­sures, be experiencing unresolved

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grief. Further, its validity as an indexofunresolved grief is buttressed by thefollowing facts. Asking a bereaved in­dividual if he or she is having diffi­culty dealing with the death is one ofthe key questions used clinically tohelp identify unresolved grief. ',9Moreover, self-perceived difficultiesapproximate an operational definitionof unresolved grief previously used toidentify subgroups of bereaved indi­viduals at high risk for depression."The concept identifies approximatelythe same percentage of individuals as

Unresolved grief is notuncommon and can bequite disabling.

having unresolved grief as do otherclinical markers used in outpatientclinics,7 consultation liaison ser­vices,',lo and nonpatient populations."Lastly, the concept identifies a groupof individuals who differ in certainkey respects (by having depressiveand physical symptoms) from personswho do not feel that they have had dif­ficulties in dealing with a death.

Another problem with these data isthat they derive primarily from a self­report questionnaire. While no at­tempt was made to validate the self-re­port of grief difficulties by systematicinquiry during the patient interviews,we think that this would be a fruitfulfuture subject. Although 18% of thepopulation was diagnosed as having amajor affective disorder on admis­sion, there was no statistically signifi­cant correlation between this or anyother diagnostic category and any ofthe three groups studied. Self-per­ceived difficulties in dealing withdeath were not associated with depres­sive or physical illnesses, but ratherwith self-perceived symptoms ofdepression or physical distress.

Despite the statistical associationbetween self-perceived difficulties indealing with death and present depres­sive and physical symptomatology,the data offer no cause-and-effect re­lationship, since this study did not en­able us to control for cognitive distor­tions or past history ofdepression. It ispossible, for example, that unresolvedgrief predisposes to physical and psy­chosocial morbidity-the conclusionwe are most disposed to accept. It isequally possible that the causal rela­tionship may be in the opposite direc­tion. For example, those individualswho are depressed or ill before thedeath of a close relative may havemore difficulty in dealing with a vari­ety of stresses, including bereave­ment. Or, alternatively, presently de­pressed persons may tend to See them­selves as having difficulty with manyfacets of their lives, including the pastdeaths of loved ones.

It is interesting, but not particularlysurprising, that self-perceived griefdifficulties did not relate significantlyto time since death. Others' havefound chronic grief to be relativelycommon and we have previously as­certained that grief-related symptomsoften remain present years after thedeath ofa close relative"" and that un­resolved grief, once present, tends toremain."

It is striking that 41 % of patientswho had lost a close relative (oftenyears earlier) still found difficulty indealing with their losses. The data alsosupport previous reports that unre­solved grief may be associated with anincreased risk of depression" and ofphysical symptoms. 1,10 In this study itwas not the loss itself, but ratherdiffi­culty in dealing with the loss that wasassociated with depression and physi­cal symptoms.

Some of the factors that could ac­count for multiple deaths being asso­ciated with greater difficulty in resolv­

(continued)

499

ing grief are increased sensitivity to10ss,12 physical and emotional exhaus­tion, lingering depression, loss of thesupport network through death, or re­awakening of conflicts surroundingold losses. 7 On the other hand,Parkes" found that previous experi­ences with death were not related tooutcome, and Bornstein and asso­ciates ,. discovered 13 months after be­reavement that more "well" than de­pressed persons had previous bereave­ments. Indeed, for some individuals,coping with prior bereavement mayfacilitate adjustment to futuredeaths."

REFERENCES1. Klerman GL, lzen JE: The eHects of bereave­

ment and grief on physical health and welt­being. Adv Psychosom Med9:66-104, 1977.

2. Lindemann E: The symptomatology and man­agement of acute grief. Am J Psychiatry101:141-148,1944.

3. DeVaul RA, Zisook S, Faschinbauer TA: Clini­cal aspects of grief and bereavement. Pri­mary Care 6:291,1979.

4. Parkes CM: Bereavement and mental illness.Part 2. A clarification of bereavement reac­tions. BrJ Med Psychol 38: 13-26, 1965.

5. Zisook'S, DeVaul RA, Click MA: Measuringsymptoms of grief and bereavement. Am JPsychiatry 139:1590-1593,1982.

6. Zisook S, DeVaul RA: Grief, unresolved grief,and depression. Psychosomatics 24:247-

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While we are not aware of any pre­vious reports documenting a specificrelationship between past difficultiesin getting along with mothers and laterunresolved grief, we believe that ourfinding of such a relationship reso­nates well with analytic concepts ofthe critical role that mother/child rela­tionships play in preparing one for in­timacyas well as for separation. '6 Ear­ly difficulties with mothers have beenfound 17 to result in many later prob­lems in tolerating affects such as anx­iety. sadness, and grief.

Although often overlooked in clini­cal settings, unresolved grief is not un-

256,1983.7. Lazare A: Unresolved grief, in Outpatient Psy­

chiatry, Diagnosis and Treatment. Baltimore,Williams & Wilkins, 1979, pp 498-512.

8. Parkes CM: Bereavement: Studies ot Griet inAdult ute. New York, International Universi­ties Press, 1972.

9, DeVaul RA, Zisook S: Unresolved grief: Clini­cal considerations. Postgrad Med 59:267,1976.

10. Zisook S, DeVaul RA: Grief-related facsimileillness. tnt J Psychiatry Med 7:329-336, 1977.

11 . Zisook S, Shuchter SA: Time course of spou­sal bereavement. Gen Hosp Psychiatry, to bepublished.

12. Volkan V, Showalter CR: Known object loss,disturbance in reality testing, and 're-griefwork' as a method of brief psychotherapy.

Unresolved grief

common, can be quite disabling, andmay be amenable to therapeutic inter­vention.6 Clinicians should maintain ahigh degree of suspicion for the pres­ence of unresolved grief when eval­uating any new patient and at the leastshould inquire whether anyone closehas died and whether coping with thedeath is presently posing any diffi­culty. 0

This work was done at the UCSD GiffordMental Health Clinic in San Diego.The authors would like to acknowledgeElizabeth Kasdonfor her statistical assis­tance.

Psychiatr Q 42:358-374, 1968.13. Parkes CM: Determinants of outcome follow­

ing bereavement. Omega 6:303-322, 1975.14. Bornstein PE, Claylon PJ, Halikas JA, et al:

The depression of widowhood after thirteenmonths. BrJ Psychiatry 122:561-566, 1973.

15. Vachon VD: A stUdy of a patient's re-griefwork through dreams, psychological testsand psychoanalysis, Psychiatr Q 44:231-250,1970.

16. Bowlby J: The making and breaking of affec­tional bonds: Aetiologyand psychopathologyin the light of attachment lheory. Br J Psy­chiatry 130:201-210, 1977.

17. Zetzel EA: Depression and the incapacity tobear it, in Schur M (ed): Drives, Affects, Be­havior. New York, International UniversitiesPress, 1965, vol 2.

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