duelo, grief and bereavement, setiembre 2009

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INTRODUCTION Over 2,500,000 deaths occur annually in the United States and between 5

and 9 percent of the population sustains the loss of a close family member each year [1,2]. Loss

of a close relationship often causes profound suffering and can have important effects on health

status.

The vast majority of bereaved individuals (80 to 90 percent) cope with their losses without

requiring professional intervention [3]. However, bereavement can have serious and long-term

adverse health effects, and patients often consult clinicians for help in managing distress

associated with bereavement. By understanding both normal and dysfunctional grieving processes

the clinician can appropriately reassure individuals with normal grief responses and intervene to

help those experiencing dysfunctional reactions to loss.

NORMAL BEREAVEMENT Death is the most powerful stressor in everyday life, causing both

somatic and emotional distress in virtually everyone closely tied with the person who has died [4].

The effects may be intense and long lasting.

Our culture uses three discrete terms to talk about the loss of a close relationship:

Bereavement is the reaction to the loss of a close relationship.

Grief is the emotional response caused by a loss including pain, distress, and physical and

emotional suffering.

Mourning refers to the psychological process through which the bereaved person undoes his or

her bonds to the deceased.

Anticipatory grief Grieving is thought to begin when an individual is forewarned of an

impending death. Anticipatory grieving may take the form of sadness, anxiety, attempts to

reconcile unresolved relationship issues, and efforts to reconstitute or strengthen family bonds.

Caretaking behavior may be a form of anticipatory grieving, as the caretaker expresses affection,

respect, and attachment through the physical acts of providing care. Anticipation and an

opportunity to prepare psychologically for death is thought to ease the adaptation of the grieving

individual after death.

Normal grief reaction Immediately following death, whether or not it has been anticipated,

Grief and bereavement

Last literature review for version 17.3: September 30, 2009 | This topic last updated:

February 23, 2009

Author

Susan D Block, MD

Section Editors

Thomas L Schwenk, MDKenneth E Schmader, MD

Deputy Editor

H Nancy Sokol, MD

Page 1 of 9Grief and bereavement

2/16/2010http://www.uptodateonline.com/online/content/topic.do?topicKey=psychiat/4519&view=p ...


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survivors often experience feelings of numbness, shock, and disbelief. They "go through the

motions," taking care of funeral arrangements, greeting relatives and friends, and tending to

financial matters. However, the reality of the death has not been fully comprehended. Shock and

numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future,

disorganization, and emptiness commonly arise in the weeks after the death.

"Searching behaviors," including visual and auditory hallucinations of the deceased person, are

common and may lead the bereaved person to fear that he or she is "going crazy." Despair and

sadness are common as it becomes clear that the deceased will not return. Sleeplessness,

appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic

complaints (especially those similar to the symptoms of the deceased) are common [5].

The survivor often replays and remembers the relationship with the deceased, particularly the

events of the terminal illness and death, and commonly ruminates over regrets and missed

opportunities. Anger at the person for dying, at God, and at professional caregivers may occur.

The individual may withdraw from family and friends. Being with others and being alone are both

difficult.

Grief comes in waves that are often precipitated by reminders of the deceased; the bereaved may

feel fine one moment, and be overcome with sadness and grief the next moment. Feelings of

pleasure are often experienced as a betrayal of the relationship with the person who has died.

Normal grief resolution Distressing feelings gradually diminish in intensity for most bereaved

persons, usually over months; the grieving individual slowly comes to accept the reality of the

loss, reestablishing mental and physical balance. Similar to stages of grief in dying described by

Kubler Ross [6], resolution of grief, to some degree, occurs in stages [7]. In the early phases after

a loss, the intensity and symptomatology of grief can overlap with signs and symptoms of

complicated grief (see 'Complicated or prolonged grief' below.

These signs and symptoms, and their intensity, subside slowly over time for patients experiencing

normal grief. Usually, these impairments are beginning to resolve by six months [3,7].

As the loss becomes more fully accepted the bereaved begins reorganizing his or her life and

reinvesting in living. The bereaved person slowly becomes able to remember the deceased without

being overwhelmed by grief, can work productively, can sustain a sense of self-esteem and

purpose, and can carry on with pleasure and enjoyment. Anniversaries and important events

continue to precipitate waves of sadness; the amplitude of these waves diminishes over time,

although the grief may never go away entirely.

There is considerable range in the duration and intensity of the bereavement process. Some

variables that may have an impact are:

Age of deceased The death of an elderly person after a full life will have a different impact

than the death of a child or a young adult.

Pregnancy and newborns Miscarriage or death of a newborn are often not recognized as

major losses but can precipitate prolonged grief.




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Suicide Bereavement due to suicide or other socially disapproved deaths may lead to more

isolation and to increased vulnerability to suicide among some survivors [8].

ABNORMAL BEREAVEMENT The primary care clinician is in an excellent position to prevent

both physical and psychological morbidity associated with bereavement, and to help the bereaved

individual adapt to his or her loss. Despite experiencing worse health, persons with abnormal

bereavement are less likely to use health services. Thus, outreach efforts are particularly

important in identifying individuals at risk and preventing the adverse effects of abnormal

bereavement.

Risk factors for poor bereavement outcomes A number of risk factors for the development

of poor bereavement outcomes have been identified, including the following:

Poor social supports

Past history of psychiatric problems, especially depression

Past history of childhood separation anxiety

High initial distress

Unanticipated death, lack of preparation for death

Other major concurrent stresses and losses

History of abuse or neglect in childhood

Lifestyle rigidity (aversiveness to lifestyle change)

Highly dependent relationship with the deceased

Death of a child

Psychological sequelae of abnormal bereavement Depression, suicide, anxiety, and

complicated grief are the most common adverse psychological sequelae of loss. Rates of

depression during the first year after the loss of a spouse, 15 to 35 percent, are four to nine times

higher than the rate in the general population [9]. Suicide rates after loss of a spouse areelevated, particularly in older men and in the first year [2,10].

Complicated or prolonged grief Complicated/prolonged grief is a discrete cluster of

symptoms that define a syndrome with characteristic symptoms and risk factors, a predictable

course, and outcomes. Complicated/prolonged grief represents a disturbance of attachment

associated with an unstable sense of self and insecurity [11,12].

Complicated/prolonged grief is defined as the persistence, for at least six months, of a

constellation of disruptive emotional reactions including yearning and four of the following eight

symptoms:

Difficulty moving on

Numbness/detachment

Bitterness

Feelings that life is empty without the deceased

Trouble accepting the death

A sense that the future holds no meaning without the deceased

Being on edge or agitated

Difficulty trusting others since the loss




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Other indicators of complicated grief include social withdrawal and difficulty reengaging with life.

Symptoms of complicated/prolonged grief at six months post-loss are highly predictive of

impairment and complications at 13 and 24 months post-loss [13,14].

Bereavement related depression While many patients with complicated/prolonged grief

also meet diagnostic criteria for major depression and/or generalized anxiety disorder [15], only a

small minority (


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in addressing family concerns. Hospice use by patients is associated with decreased bereavement

mortality among surviving spouses [22]. Caregivers of spouses with longer hospice enrollment

have a lower incidence of major depressive disorder [23]. Thus, family members should be

supported in their involvement in providing care and should be encouraged to be present at the

time of death.

Conflicts between the patient and family or among family members about the type of care desired

for the patient often pose particular difficulties for family members after the death. Similarly,

feelings of guilt and doubt may color the bereavement experience when family members are

required to assume responsibility for discontinuation of life support or other treatment withdrawal.

The clinician should provide family members with appropriate information and support to guide

decision making and help prevent negative sequelae in these situations. Clear recommendations

from the clinician about difficult treatment decisions are often helpful in situations where family

members are distraught by difficult choices.

CARING FOR THE BEREAVED AFTER THE DEATH The clinician caring for the deceased can

facilitate acceptance of the death with attention to several follow-up recommendations:

The clinician should contact family members not present at the bedside immediately after the

death via telephone to inform them, express condolences, answer any immediate questions, and

offer them the option of viewing the body.

A letter of condolence is a core component of quality end-of-life care. Attending the funeral or

memorial service is usually deeply appreciated.

The United States Preventive Services Task Force (USPSTF) recommends that clinicians "be

alert" for suicidal ideation in people who have had a recent bereavement [24]. Reaching out to

bereaved persons, through a personal phone call or an offer of an appointment to "check in," is

recommended as the bereaved often find it difficult to initiate actions [25].

Patients should be encouraged to maintain regular patterns of activity, sleep, exercise, and

nutrition as much as possible, as these activities appear to enhance adaptation during

bereavement [26].

Most grieving persons do not want or need professional help in the grieving process; instead they

turn to family, friends, and religious institutions. At times, however, grieving persons who do not

have adequate social supports turn to the clinician as an outlet for their grief. Crying is an integral

part of the grieving process and should be encouraged. Short-term supportive counseling that

promotes ventilation of feelings is usually helpful.

Sleep disruption is a common symptom of grief. Short-term prescription of a sleep hypnotic may

be effective in promoting sleep. For individuals who experience high levels of anxiety, a time-

limited prescription of an anxiolytic can be useful as a crisis measure. However, these medications

generally should not be prescribed at high doses or for long periods since their use has the

potential to retard and inhibit the grieving process.

Support groups are a valuable resource for many bereaved individuals and have been shown to

facilitate grief resolution [27]. Some support groups target particular types of deaths, such as




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death of a spouse, suicide, death of a child, AIDS, violent crime. However, a randomized trial of

cognitive behavioral therapy for relatives of people who committed suicide did not reduce the risk

for complicated grief, though may have had other beneficial effects related to blame and

maladaptive grief reactions [28].

Local hospice organizations usually can identify community resources for bereavement support.

Chaplains, social workers, and grief counselors also provide services to bereaved individuals.

Treatment of complicated or prolonged grief Because complicated grief can lead to

prolonged dysfunction, and is often difficult to differentiate from major depression, patients with

complicated grief should be referred to a psychiatrist for evaluation. Treatment aims to facilitate

understanding of the loss and its impact on the survivor's sense of self and sense of the future.

Focus is also on mastering concrete tasks (eg, managing finances, learning how to cook) that

were carried out by the deceased and that can lead to a new sense of competence and

independence. Encouragement to develop new routines, new relationships, and to practice good

self-care (diet, exercise, sleep, etc) is also helpful. Support groups can be an important resource

for the bereaved by reducing the sense of isolation, supporting the development of new

relationships, and teaching concrete survival strategies.

Effective treatments for complicated grief are beginning to emerge. Complicated grief treatment

(CGT) is a psychotherapeutic approach that includes cognitive behavioral methods similar to those

used for post-traumatic stress disorder (ie, confronting the loss through exposure). (See

"Overview of post-traumatic stress disorder".) A randomized trial in 95 people with complicated

grief found a higher response with CGT than with interpersonal psychotherapy (51 versus 28

percent) [29]. Other studies have shown reductions in grief symptoms with crisis intervention,

brief dynamic psychotherapy, and support groups [25]. An open-label trial of

paroxetine demonstrated a 53 percent reduction in symptoms of complicated grief [30].

Treatment of bereavement-related depression Bereaved patients who have symptoms of

depression for at least two weeks, six to eight weeks after a major loss, should be considered

candidates for a therapeutic trial of antidepressants and psychotherapy. Major depression

following a loss responds to the same therapeutic approach as major depression in general. (See

"Initial treatment of depression in adults".) Treatment with antidepressants is associated with

improvement in symptoms of depression, but appears to be ineffective in ameliorating the

symptoms of grief [31,32]. One study, as an example, found that treatment of bereavement-

related depression in 13 patients resulted in a 68 percent decrease in the Hamilton rating score for

depression after a median treatment interval of 6.4 weeks; the intensity of grief did not change

[32].

INFORMATION FOR PATIENTS Educational materials on this topic are available for patients.

(See "Patient information: Depression in adults".) We encourage you to print or e-mail this topic

review, or to refer patients to our public web site, www.uptodate.com/patients, which includes this

and other topics.

SUMMARY AND RECOMMENDATIONS

Normal bereavement can manifest as intense symptoms that subside slowly but usually cause




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little impairment by six months (see 'Normal bereavement' above.

Complicated/prolonged grief is the persistence for at least six months of yearning associated

with four of eight symptoms: difficulty moving on, detachment, bitterness, feeling that life is

empty, trouble accepting the death, feeling of meaningless with future, agitation, difficulty

trusting others. We recommend psychiatric referral for these patients (see 'Complicated or

prolonged grief' above and 'Treatment of complicated or prolonged grief' above.

The diagnosis of major depression in the grieving individual is difficult. Patients with

symptoms of bereavement-related depression for at least two weeks, six to eight weeks after a

major loss, should be treated for depression (see 'Bereavement related depression' above and

'Treatment of bereavement-related depression' above.

Clinicians can help ameliorate grief reactions in relatives of their dying patients. They should

be alert to risk factors for abnormal grieving. Immediate communication, expression of condolence

after death, and follow-up by phone or appointment within two weeks can be helpful. Clinicians

should encourage the bereaved to maintain regular patterns of activity, sleep, exercise, and

nutrition. (See 'Risk factors for poor bereavement outcomes' above and 'Caring for the bereaved

after the death' above.)

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2. Osterweis, M, et al. Bereavement: Reactions, Consequences, and Care. National AcademyPress, Washington, DC 1984.

3. Prigerson, HG. Complicated grief: when the path of adjustment leads to a dead end.Bereavement Care 2004; 23:38.

4. Holmes, TH, Rahe, RH. The Social Readjustment Rating Scale. J Psychosom Res 1967;11:213.

5. Lindemann, E. Symptomatology and management of acute grief. Am J Psychiatry 1944;101:141.

6. Kubler Ross, E. On Death and Dying. Macmillan Publishing Company, New York 1969.

7. Maciejewski, PK, Zhang, B, Block, SD, Prigerson, HG. An empirical examination of the stagetheory of grief. JAMA 2007; 297:716.

8. Ness, DE, Pfeffer, CR. Sequelae of bereavement resulting from suicide. Am J Psychiatry1990; 147:279.

9. Zisook, S, Shuchter, SR. Depression through the first year after the death of a spouse. Am JPsychiatry 1991; 148:1346.

10. Stroebe, M, Schut, H, Stroebe, W. Health outcomes of bereavement. Lancet 2007;370:1960.

11. Prigerson, HG, Shear, MK, Frank, E, et al. Traumatic grief: a case of loss-induced trauma.Am J Psychiatry 1997; 154:1003.




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14. Prigerson, HG, Bierhals, AJ, Kasl, SV, et al. Traumatic grief as a risk factor for mental andphysical morbidity. Am J Psychiatry 1997; 154:616.

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17. Helsing, KJ, Szklo, M. Mortality after bereavement. Am J Epidemiol 1981; 114:41.

18. Parkes, CM. The first year of bereavement. A longitudinal study of the reaction of Londonwidows to the death of their husbands. Psychiatry 1970; 33:444.

19. Parkes, CM, Brown, RJ. Health after bereavement. A controlled study of young Bostonwidows and widowers. Psychosom Med 1972; 34:449.

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22. Christakis, NA, Iwashyna, TJ. The health impact of health care on families: a matchedcohort study of hospice use by decedents and mortality outcomes in surviving, widowedspouses. Soc Sci Med 2003; 57:465.

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