Is Grief a Disease?

A Challenge for Medical Research

GEORGE L. ENGEL, M.D.

1 HISIS PAPER has perhaps more thequalities of a philosophic than a scientificdiscourse, but for this I offer no apology. Ishall present no new data and shall speakof a quite familiar phenomenon, but Ishall invite you to view it from a perspec-tive perhaps somewhat different from thatto which you are accustomed. In keepingwith this philosophic approach I have writ-ten this in the form of a Socratic dialogue.I pose the question, "Is grief a disease?"

No doubt this seems a strange question,since grief has not usually been consideredin such terms and, on first glance, thereseems little reason to do so. Yet, a thought-ful consideration of the issues raised bysuch a question will, I believe, throw lighton some deficiencies in currently held con-cepts of disease. And the concept of diseaseheld by an investigator, whether or not con-sciously utilized, has an important influ-ence on the choice of material and the de-sign of clinical research.1-3

Grief is the characteristic response to theloss of a valued object, be it a loved person,a cherished possession, a job, status, home,country, an ideal, a part of the body, etc.Uncomplicated grief runs a consistent

From the Departments of Psychiatry and Medi-cine, University of Rochester Medical Center,Rochester, N. Y.

Presented at the Annual Meeting, American Psy-chosomatic Society, Mar. 27, 1960, held at Montreal,Canada.

Received for publication April 14, 1960.

course, modified mainly by the abruptnessof the loss, the nature of the preparationfor the event, and the significance for thesurvivor of the lost object. Generally it in-cludes an initial phase of shock and disbe-lief, in which the sufferer attempts to denythe loss and to insulate himself against theshock of the reality. This is followed by astage of developing awareness of the loss,marked by the painful effects of sadness,guilt, shame, helplessness, or hopelessness;by crying; by a sense of loss and emptiness;by anorexia, sleep disturbance, sometimessomatic symptoms of pain or other discom-fort, loss of interest in one's usual activitiesand associates, impairment of work per-formance, etc. Finally, there is a prolongedphase of restitution and recovery duringwhich the work of mourning is carried on,the trauma of the loss is overcome, and astate of health and well-being re-estab-lished.4' 5

In what respects does this correspond toother situations that we customarily regardas "disease?" Certainly it involves suffer-ing and an impairment of the capacity tofunction, which may last for days, weeks,and even months. We can identify a con-sistent etiologic factor, namely, real, threat-ened, or even fantasied object loss. It ful-fills all the criteria of a discrete syndrome,with relatively predictable symptomatologyand course. The grieving person is oftenmanifestly distressed and disabled to a de-gree quite evident to an observer.

PSYCHOSOMATIC MEDICINE

ENGELThe sceptic quickly raises some pointed

questions: Is not grief simply a natural re-action to a life experience? How can oneput it into the same category as the patho-logical states we call disease? To this weanswer that it is "natural" or "normal" inthe same sense that a wound or a burn arethe natural or normal responses to physicaltrauma. The designation "pathological"refers to the changed state and not to thefact of the response. That one responds tothermal radiation with a burn is natural ornormal. The burn itself constitutes apathological state and the concept is as ap-propriately applied to the state of grief asto a wound, burn, or infection.

Or it may be said: Everyone experiencesgrief—it's part of life. But that only em-phasizes the ubiquity in life of the signifi-cant etiologic factor and the universalvulnerability of human beings to this par-ticular stressful experience. The same maybe said of many other disease states towhich man is prone—measles, for example.Actually, the statement is not entirely cor-rect. With a short life or under exception-ally favorable circumstances, one mayescape both measles and grief.

Our sceptic resumes his argument: Griefis a self-limited process, requiring no medi-cal attention. But so too are a great num-ber of disease processes. Actually, many per-sons suffering primarily from grief do cometo physicians but, because of cultural ex-pectations and the role ascribed to or heldby the physician, they do not complain tohim of grief. Rather, they report someother, often somatic, symptom and thephysician may not even learn of the grief.If he does, he may regard it either as notrelated to the complaint or not his concern.Besides, whether a condition requires medi-cal attention is not relevant to the judg-ment as to whether it is to be regarded as adisease. The history of medicine providesinnumerable examples of conditions thathave come in time to be recognized as dis-ease states but which had not been so re-garded earlier. Epilepsy, alcoholism, andmental disease are examples. We must not

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forget that in the prescientific era the rolesof physician, magician, and priest wereoften embodied in the same person. It isthe obligation of the physician of today toclaim for scientific scrutiny all naturalphenomena involving deviations in the in-dividual's state of well-being, of which griefis one.

Grief is a purely subjective, psychologicalexperience that does not involve any so-matic changes. But, to my knowledge, noone has ever studied the bodily changes oc-curring during grief; hence, to begin with,there is no basis for such a statement. Buteven if it were true, one who holds such aview is, in essence, relegating to an extra-medical and extrascientific status any kindof psychological or behavioral disturbance.As a matter of fact, many illnesses are large-ly subjective—at least, until we as observersdiscover the parameters and frameworkwithin which we can also make objectiveobservations. Hyperparathyroidism, inmany of its manifestations, was a purelysubjective experience for many patients un-til we discovered what to look for andwhich instruments to use in the search.Again, the physician who is familiar withgrief will recognize its occurrence throughhis systematic and ordered observations,even if the patient withholds or denies thenecessary information.

No one ever dies of grief. Again, this isan irrelevant argument, even if true; but isit true? The newspapers repeatedly reportpersons collapsing and dying soon afterlearning of the death of a loved person.Have these cases been so carefully studiedthat we can say that the death representedpure coincidence, that the shock phase ofthe grief contributed in no way to this fataloutcome? I know of no such studies.Literature and folklore are replete with thenotion that people fall ill and die "ofgrief." (I would prefer to say "duringgrief.") And few of the older physicians,from Hippocrates through the clinicalgiants of the late nineteenth century, failedto allude to grief as a factor in the causa-tion of disease. While such views hardly

20 IS GRIEF A DISEASE?

constitute scientific evidence, the incidentsare so common and the views so widelyheld that the cautious scientist will not bewilling to say, without the benefit of sci-entific study, that it cannot be so. Actually,many recent investigations indicate that awide variety of illnesses, including somethat are fatal, may begin during a phase ofgrief. Schmale has recently surveyed amedical population and reviewed the mod-ern as well as some of the older literaturefrom this perspective.0

Perhaps one should speak of pathologicalgrief and normal grief and restrict to theformer the category of disease. This is awelcome concession, but it does not go farenough. At the outset I intentionally usedthe term "uncomplicated grief" rather thannormal grief. It is normal only in a statisti-cal sense, meaning that it is the common,usual, and predictable response, as is anecchymosis after a blow or measles after aninfection with the measles virus. But it isnot normal in the sense of total health.Predictable does not mean invariable and,in any situation, whether it be loss of anobject or an exposure to physical trauma ora microorganism, we observe and defineconditions under which the response maybe different in degree or kind or where itmay not occur at all. This is a widely ac-cepted and familiar notion as applied totraditional disease states, but equally ap-propriate in respect to grief. We are fa-miliar with such responses as the absence ofgrief, delayed grief, unresolved grief, de-pression, psychotic or neurotic reactions,pain or other conversion symptoms, andeven organic disease occurring in place ofor in addition to the usual pattern of grief.As is true of the complications of a woundor an infection, we must also expect thatother factors operate to account for thesedeviations from the usual course. Yet noneof these considerations refutes the fact thatthe experience of uncomplicated grief alsorepresents a manifest and gross departurefrom the dynamic state considered repre-sentative of health and well-being.

Is not grief really just a healthy, adap-

tive, and reparative process which correctsor overcomes a stress while the above-men-tioned responses are the abnormal statesthat should be called diseases? The elementof reparation is indeed to be found in grief,but so too is it found in every other disease;indeed, it always accounts for some of thesymptoms and signs of a disease. If theadaptive or reparative processes involved indisease are successful, recovery occurs andthe patient reachieves a state of health. Ifnot, continued, progressive, or increasedillness or death is the consequence.

Can it not be said that the person isreally healthy and that he simply had themisfortune to suffer a loss and is now re-sponding, naturally, with grief? This argu-ment implies that all systems and levels oforganization, actually and potentially, mustbe impaired by the stress before the condi-tion can be considered disease. Actually,not only are health and disease relative con-cepts, but also at any time parts of the bodyand person may be more or less healthy,while other parts may be more or less im-paired. Indeed, this is the usual situation.It is only in fatal disease, when the victimis near death, that we see total disorganiza-tion.

Perhaps by now the sceptic is ready toconcede that grief can be considered a dis-ease state. But what is gained by such aposition? What are the implications formedical research and practice? They are, inmy opinion, important and far reaching:

1. Grief, in all its forms and with all itsramifications, becomes a legitimate andproper subject for study by medical scien-tists. Research, utilizing the tools of thephysical, biological, and behavioral sci-ences, must be directed to these sufferers noless than to those with other disorders. Theoccurrence of grief among animals is sowell documented as t(5 free the investigatorfrom exclusive dependence on human sub-jects for such research.

2. The occurrence of grief, preceding orin the course of other illness, somatic andpsychologic, as is so often reported by pa-tients or their families, can no longer be

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ENGEL

passed off as irrelevant or coincidental untilsuch data have been subjected to the samekind of rigorous and systematic explorationand examination that has been applied toother phenomena of disease. That grief inits various forms so often precedes the de-velopment of other disease states in itselfconstitutes no proof of a relationship. Butthe medical scientist is remiss if he does notsubject all antecedent circumstances to ex-amination as to whether they constitutecontributing, necessary, or sufficient condi-tions for the development of a disease state.The obvious derangements in the function-ing of the indidivual suffering from objectloss and consequent grief make such in-quiry all the more relevant. It is well to bebe reminded in this era of crash-programapplied research that many fundamentaldiscoveries elucidating the pathogenesis andmechanisms of disease states came aboutthrough the investigation of just such basicphenomena, often with grounds for antici-pating a relationship far less than is the casewith grief. One is reminded of the contro-versies concerning the role of miasmas inthe pathogenesis of malaria. The investi-gation of the climatic and geographic con-ditions under which malaria occurred even-tually provided the basis for elucidation ofthe disease even though the original theo-ries concerning the miasmas were erroneous.

3. If the actual or threatened loss of anobject so consistently disturbs the total ad-justment of the organism, then we haveidentified an etiologic factor of such gen-eral importance as to put it in the sameclass as other major rtbxa, e.g., physicalagents, microorganisms, eftc. Until—and notuntil—much more is known about the bio-chemical, physiological, and psychologicalconsequences of such losses, no one is justi-fied in passing judgment as to how impor-tant this factor is in the genesis of thedisease states that seem so often to followclose upon an episode of grief. To dismisssuch inquiry as unnecessary or irrelevant atthis stage of our knowledge is an expressionof prejudice (in its literal sense, a prejudg-ment, or forming a judgment without due

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knowledge or examination). Who nowwould be so rash as to dismiss the possi-bilities that biochemical or physiologicalprocesses occurring during the grief reac-tion may not constitute conditions condu-cive to other somatic changes of more seri-ous consequence?

4. As a corollary of the above, we iden-tify a ubiquitous psychological stress, mean-ing that the concept of objects and of ob-ject loss is only meaningful in terms of theexistence and operation of the mental ap-paratus. This means that whatever the con-sequences of object loss and grief may be,whether manifest ultimately in biochemical,physiological, psychological, or socialterms, they must first be initiated in thecentral nervous system. This imposes uponthe medical scientist the necessity to paymore attention to the role of the centralnervous system in the maintenance of thefunctional integrity of the organism as awhole as well as of its various parts. Inspite of much lip service to the contrary,most physicians and clinical investigatorsthink and work as if the central nervoussystem is the seat only of reflexes and ofpurely intellectual processes and reallyneeds not be considered when studying dis-ease manifest elsewhere in the body. Thereluctance and/or inability to consider psy-chological components of man and hisillnesses actually has come to include thenervous system as well. But new knowledgeof central integrating and regulating proc-esses, as has been brought forth by recentwork on the limbic and reticular activatingsystems, promises soon to dissipate thisbarrier.7

5. The concept of grief as a disease re-quires that we keep in view and in perspec-tive aspects of the external environmentother than what we have been accustomedto heretofore—namely, the environmentmade up of the significant psychic objects.This becomes one reason why the persons,job, home, goals, etc., in the life of ourpatients cannot be disregarded in our con-sideration of illness, at least not until it hasbeen proven that the vicissitudes of object

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relations, including grief, the disorder con-sequent to object loss, plays no role in thepathogenesis of disease.

6. If object loss is a potential stress, thenmaintenance of objects or replacement ofobjects must be considered as importantvariables in sustaining health and adjust-ment. The physician, the hospital, the clin-ical investigator, indeed, even the experi-ment, may come to fulfill the requirementsof a necessary and supporting psychic objectfor a patient. Everyone is aware of thetherapeutic influence of the physician onthe patient, but how many unwary clinicalinvestigators have been observing physiolo-gic or biochemical changes in their experi-mental subjects, believing these to be theinfluence of some drug or other procedurewhen in fact these changes were secondaryto the varying effects of the experimenter'sunwitting role as a psychic object for thepatient. For many varieties of clinical in-vestigation it is necessary to regard the ex-perimenter as part of the experiment.8

This does not exhaust the Pandora's boxopened by such a perspective. Once opened,we cannot easily refute the real, yet un-known influences that must now come un-der our scrutiny. Yet the human mind, thatwonderful instrument of discovery, has adisconcerting capacity to use denial, to turnaway from that which is not easily com-prehended or which has awesome implica-tions, as I believe is true of this concept.The first response when confronted withnews of a grievous loss is, "No, it can't be.I don't believe it; I won't believe it." I

IS GRIEF A DISEASE?

would call your attention to the fact thatcherished ideas, even if false, are also psy-chic objects and as such are not easily givenup. And only time and much work willestablish whose cherished ideas are the falseones.

I close with a quotation ascribed to Al-bert Szent-Gyorgyi: "Research is to see whateverybody else has seen and think whatnobody else has thought." To this I wouldonly add that Szent-Gyorgyi wisely refrainedfrom claiming that this necessarily impliedthat the "new" thought is correct—at least,not until tested. And that is my challenge!

References1. ENGEL, G. L. "Homeostasis, Behavioral Adjust-

ment and the Concept of Health and Disease."In GRINKF.R, R. Mid-Century Psychiatry, Thomas,Springfield, 111., 1953, pp. 33-59.

2. ENGEL, G. L. Selection of clinical material inpsychosomatic medicine: The Need for a Newphysiology. Psychosom. Med. 76:368, 1954.

3. ENGEL, G. L. A unified concept of health anddisease, Perspectives in Biology and Medicine.3 No. 4, 1960.

4. FREUD, S. "Mourning and Melancholia" (1917).Standard Edition, Complete Works, London, Vol.XIV, 237, 1957.

5. LINDEMANN, E. Symptomatology and manage-ment of acute grief. Am. J. Psychiat. 707.14,

- 1944.(&J SCHMALE, A. H. Relationship of separation and

depression to Disease. Psychosom. Med. 20:259,1958.

7. JASPER, H. H., Ed. Reticular Formation of theBrain, Little, Boston, U)58.

8. ENGEL, G. L., REICHSMAN, F., and SEGAL, H. L.A study of an infant with a gastric fistula. I.Behavior and the rate of total HC1 secretion,Psychosom. Med. 7S.374, 1956.

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