Grieving Loss Can Be a Complicated Clinical Process
Maintaining Your Health on Mackinac
By Yvan Silva, M.D.

Looking as far back as 1961, grief has been the subject of many studies and efforts at understanding and managing the complex processes that result in emotional and physical responses to death of a loved one. The question, “Is grief a disease?” was posed then in a classic dissertation that described the typical characteristics of grief or bereavement – initial shock or disbelief resulting from an important loss of an individual, followed by the pain of sadness, hopelessness, emptiness, and loss of interest in activities of living.

Grief was described by a noted scientist as a normal, though painful, life experience that was a necessary, yet a time-limited psychological process of mourning. Grief is accompanied by a variety of emotions, including guilt, profound sadness and despair extending into a pathological state of melancholia, which can continue and may require therapy.

Beyond the usual death and dying among us in our society, the huge loss of life and human tragedy of 9/11 and the subsequent involvement of our people in international conflicts have brought grief into focus in our everyday living; daily news reports and images of natural worldwide disasters like the tsunami, violence and trauma of armed conflicts around the world, with great morbidities and mortality on daily television, are affecting large numbers of people in a variety of ways.

In the span of a lifetime, along with the joys of living and loving, comes the inevitable, the loss of the ones we love. Growing older comes with the statistical increase in the number of people we know or have been associated with, in one way or another, who will die, some suddenly, some after protracted illnesses filled with pain and suffering. Grief ensues as an inescapable reaction to the death of someone very close to us, related to us in any of many ways, or even an acquaintance whose interactions leave within us a void that yearns to be filled.

Grief is a painful state filled with emotional and physical challenges and reactions; a state that is usually temporary, but one that can last into a long period of adversity during which stress and emotional exhaustion can dominate our day to day lives. Indeed, in some instances, a chain of these reactions can lead to an early death. Individual reactions to grief are widely variable, unpredictable, and often, indescribable. We mourn singly or together in the initial stages of loss and then carry on into closure and return to a normal life. But for some, grief can become a severe burden and lead into an abnormal and prolonged disorder. Unexpected or violent death can set off a type of post-traumatic stress disorder. Abnormal grief, whatever the cause, requires appropriate analysis and, in some cases, appropriate medical treatment.

Complicated grief is a debilitating disorder with important negative consequences on an individual’s health, and current research into treatment strategies have shown that both interpersonal psychotherapy and tailored complicated grief treatments can be more effective after careful analysis to differentiate components of depression, anxiety, and post-traumatic stress disorder. A somewhat new type of therapy has evolved - a type of psychotherapy or “talk therapy” that is specially designed to treat people with complicated grief on a case oriented basis.

In the family setting, the death of a spouse is thought to be the most poignant and difficult loss. Next, and not necessarily comparable, is the loss of a child. The most common cause of intense personal grief remains the loss of a spouse.

There are about 12 million Americans who have been widowed and every year about 800,000 men and women become widowed. By the age of 65, 10 percent of men have been widowed at least once, while 50 percent of all married women over the age of 65 have lost at least one husband. Women live longer than men, and while losing a spouse is more common with women, the loss of a wife is more serious for a man.

In one study, over a 23-year period, 1,453 men and 3,294 women lost their spouses. These individuals were studied for the resultant psychological and socio-economic difficulties, as well as for their subsequent mortality rate. Thirty percent of men died, while 15 percent of the women died. The risk was highest from seven to 12 months following the spousal demise, and yet an increased death rate persisted for about two more years.

Healthy men who were seriously bereaved were 2.1 times more likely to succumb than healthy men who coped with their bereavement, after stratification for age, education, and other parameters relating to life span. Men with health problems were found to have an increase 1.6 times the rate of death.

In what might be termed normal grief, although each individual’s experiences is unique, the overall response moves toward recovery. Even though the loss was expected, the initial reaction is numbness and shock. A transitional period ensues, comprised of disbelief with a seemingly total focus on the thoughts and memories and life’s experiences with the lost one. In the immediate term, preparations for services and notification of the death to other logistics take precedence. The next stage may be encumbered with depression and anxiety, sleep disturbances, and loss of interest in social activities. Later, in the normal course of events, acceptance sets in and the mourner returns to normal, accepting the loss, enriched with the relationship that was and the process of rebuilding a new life. There are flashbacks; anniversaries and holidays can be difficult times, and then the intensity of grief gets progressively diminished.

Complicated grief may be evident when the emotional states are long-lasting and the inability to accept the death, persistent dwelling on the death, and ongoing preoccupation with thoughts of the lost one. Major depressive disorder should be considered when grief lasts more than two or three months, accompanied by expressions of guilt, preoccupation with death in general, loss of self-esteem, abnormal or diminished physical activity, and inability to cope with activities of daily living.

The absence of overt grief and the inability of the individual to express grief may be signs of abnormality. The inability to weep or be demonstrative in the early phases, and the continuation of depression, is usually associated with symptoms that are serious enough to preclude normal lifestyle and function. Strong relapses of severe emotion pertaining to the loss, strong longings for the deceased with fantasies of their presence, isolation and feelings of hopelessness may persist. Loss of social interests, avoidance of people previously associated with the deceased, sleep disturbances, and loss of health point to a condition that will require analysis and treatment.

When death occurs from violence or trauma, especially when witnessed by the patient, PTSD - post-traumatic stress disorder should be considered. Recurring and distressing images of the event, avoidance of people or places involved, insomnia, diminished attention spans, and outbursts of emotions like anger outbursts.

Relatives and friends can be most helpful in all the early stages of bereavement. In the uncommon instances, when grief becomes a pathological burden, the individual may be well served by referral to a specialist in psychiatry for a thorough evaluation. Psychotherapy with a psychiatrist (a medical doctor) or psychologist, a professional trained in non-medical treatment of mental disorders, provide opportunities for the individual to talk out feelings of loss and emotional difficulties and learn to cope with them. Support groups are helpful for some, who may find it helpful to share feelings and experiences with other individuals who are also affected. Medications may be prescribed; antidepressants may help to alleviate some symptoms, especially if major depression is diagnosed. Medications for sleep are helpful in coping with a daily cycle of living. What is important is that the grieving individual return to good physical and emotional health with the past in perspective and the loss embedded in a positive acceptance.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.