Grief, Bereavement, and Adjustment Disorders

Definition

Grief may be defined as the physical and emotional pain precipitated by a significant loss. The loss may be of a person or pet, but it can also be of a meaningful place, job, or object. A term closely related to grief is bereavement, which literally means to be robbed by death. While complicated grief was not defined as a disorder in the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition (DSM-IV), many clinicians observed a need for criteria identifying pathological grief-related conditions. In response, the DSM-5 has removed the so-called “bereavement exclusion” from the criteria for major depressive disorder (MDD) so that even grief of only 2 weeks' duration may be diagnosed as MDD if the patient's symptoms meet criteria. The DSM-5 also defines persistent complex bereavement disorder (PCBD) in its “Conditions for Further Study.”

Epidemiology and Risk Factors

Death and loss are part of the human condition; therefore, everyone is at risk for the experience of grief. As death is universally feared, societies and cultures have developed rituals to help deal with the experience of loss and have provided support for survivors. In today's Western society, however, individuals are often distanced from their families or cultures of origin, leaving them to deal with death on their own.

Researchers have found that about 20% of bereaved persons meet criteria for a major depressive episode, with a course and treatment response similar to MDD in non-bereaved individuals. Those with pre-existing psychiatric disorders appear to be at increased risk for complications secondary to grief.

The prevalence of PCBD is approximately 2.5%–5%, and is seen in more females than males.

Clinical Findings and Differential Diagnosis

While grief may be universal, each individual's experience of bereavement is unique. When confronted with a grieving person, the physician is often challenged to determine whether the person's grief is proceeding normally, or requires clinical intervention. This determination is often complicated by the fact that grief is shaped by socio-cultural influences, and it does not necessarily develop smoothly from one phase to another.

Many investigators have described the stages of adaptive bereavement. One useful guideline proposes three overlapping phases: (1) shock, denial, and disbelief; followed by, (2) a stage of mourning that involves physical as well as emotional symptoms and social isolation; eventually arriving at, (3) a reorganization of a life that acknowledges, but is not defined by, the loss of the loved one.

Adaptive bereavement can lead to many symptoms reminiscent of depression: decreased appetite, difficulty with concentration, sleep disturbances, self-reproach, and even hallucinations of the deceased's image or voice (though reality testing remains intact in normal grief). In contrast to depression, however, the sadness of adaptive grief tends to wax and wane, and gradually diminish over time. Qualitatively, the symptoms of normal grief tend to pertain to the deceased, or events surrounding the death. Assessment of various dimensions of the mourner's experience can provide a more complete diagnostic picture ( Table 38-1 ).

The DSM-5 states that in the aftermath of loss, the diagnosis of MDD should not be delayed if the patient's symptoms meet criteria for MDD, are persistent and pervasive, and extend beyond the context of the loss (e.g., feelings of worthlessness not related to the relationship with the deceased). This new designation is supported by research documenting a lack of significant difference between depression related to bereavement and depression associated with other life stressors.

Adding to the difficulty in assessing grief is the lack of consensus regarding a normal duration of bereavement. Manifestations of normal grief (e.g., anniversary reactions) may continue indefinitely, even in otherwise well-functioning individuals. In the acknowledgment of ongoing efforts to better understand ongoing grief, the DSM-5 lists persistent complex bereavement disorder as a “condition for further study.” The proposed criteria are listed in Box 38-1 .