Grief

Grief is the natural response by a person to the anticipated or actual loss of something or somebody that is important to that person. The person finds themselves going through a range of emotions such as shock, denial, outrage, sadness, guilt, numbness, confusion, etc.

Most people in their life experience grief at some point of time in their lives, typically over the loss of a loved one. How or when a person adjusts to their life after loss depends on several factors. In case a person is unable to adapt over a substantial period of time, they may require medical attention for overcoming grief and continue their daily activities.

A bereaved person (i.e., one going through a loss) experiences the following symptoms:

• Distress due to anxiety of separation
• Emotional numbness
• Sadness
• Shock, disbelief or denial
• Crying
• Insomnia
• Dreams or even hallucinations of the deceased
• Anger
• Fatigue
• Guilt
• Appetite or weight changes
• Decline in interest
• Unorganised routine

The person is also likely to experience highly intense periods of distress usually lasting for 20 to 30 minutes – also called grief waves, pangs or bursts. These occur because of any reminder of the deceased or even unexpectedly.

The above symptoms decline in intensity approximately six months post-loss. And over a period of one to two years, these symptoms largely get resolved.

The above symptoms are associated with common grief. In the case of complicated grief, these symptoms do not lessen in intensity even 6 to 12 months after a loss. Further, the following are also linked with complicated grief:

• Preoccupation with the deceased or circumstances of their death
• Longing or yearning for the deceased
• Desire to die with the deceased
• Intense sorrow and emotional pain
• Difficulty accepting death
• Bitterness or anger
• Disbelief or numbness
• Holding oneself guilty or blaming oneself
• Difficulty in trusting other people
• Feeling lonely or detached
• Lack of desire to live or find meaning in living – reduced interests
• Lack of motivation – disengagement from goals
• Low self-esteem

The above symptoms persist and occur frequently, resulting in significant impairment to the social, occupational and other areas of life. Further, these symptoms present excessively in comparison to the cultural or religious norms.

The following are some of the predisposing factors that may result in complicated grief:

• Lower socioeconomic status
• History of depression or ongoing depression
• Intense stressful life events
• Absence of identifiable social support
• Age less than 60 years
• Nature of relationship: distant or dependent, loving or ambivalent, secure or insecure attachment, parent or sibling or spouse or friend
• Men have been found to experience more negative experiences than women upon the loss of a spouse, resulting in higher chances of complicated grief for men
• Experience and manner of progression of terminal disease
• Mode of death: natural death typically results in common grief while accidental or sudden death might result in complicated grief
• Lack of meaningful communication with the deceased prior to their death
• Chronic medical illness

The type of grief one experiences also determines whether they require medical attention and in case required, what kind of treatment would best suit them:

• Anticipatory grief: This arises because of anticipation or expectation of an imminent loss and the term is typically used in relation to families of patients with a terminal illness, although the patient can also go through anticipatory grief. It presents as elevated distress, medical complications and pain.
• Common or normal grief: Also called uncomplicated grief, this occurs in more than 50% of the cases and is associated most often with the natural death of a loved one. Most people with common grief report a decline in the intensity of negative emotions and an increase in acceptance after around 6 months post-loss.
• Complicated grief: Reported to occur in 10% of the cases, this occurs when a person fails to reach the stage of acceptance because the negative indications are still strong in intensity. Generally, it is diagnosed in persons experiencing grief even after 6 to 12 months post-loss.

Each person experiences grief differently. Researchers have proposed theories to organise grief-related symptoms into phases or stages, in a bid to describe the sequence of those symptoms. The most famous is the Kübler-Ross model, which was initially developed for terminally ill patients, and has the following five stages:

• Denial: A common defence or coping mechanism, this is pretending that the loss did not occur. While it might provide a person with more time to come to grips with the situation, it just prolongs the onslaught of sorrow denied at this stage.
• Anger: Not everyone experiences this stage while for some it may last longer. Anger masks the pains and emotions and in turn may present itself as resentment. It occurs due to intense feelings and may even come up against other people or towards inanimate objects.
• Bargaining: While grieving, there is a sense of loss of control due to the loss that has occurred. Bargaining is again a defensive mechanism, to create ‘what-if’ and ‘if-only’ scenarios or attempt to strike a deal with higher power or God.
• Depression: This is a stage of loss of self-esteem. The person might question their reason for living and existence and hate themselves. In this state, the person may isolate themselves and may also require consultation with a mental health professional. 
• Acceptance: This does not imply restoration to the previous self (i.e., prior to a loss). Over a period of time, as the person goes through the stages of grief, the person learns to understand this as part of life and the meaning of the loss of their loved one – finding meaningful ways of carrying on their connection with the loved one.

The above stages are not linear or sequential and a person may go through the above as domains. While the Kübler-Ross model is one of the most popular ones that try to explain the process of grieving, there are other models as well such as one with the following indicators:

• Disbelief
• Yearning
• Anger
• Depression
• Acceptance

The occurrence of a depressive state is recognized as a consequence of the grieving process, especially during the first couple of months post-loss. It presents itself as insomnia, anxiety, desire for isolation, feeling empty, loss of appetite, fatigue, irritability, etc. However, this needs to be distinguished from major depression, as per the following:

• Grief also involves experiencing positive emotions as time passes. The waves of grief are related to internal or external reminders of the deceased. However, depression tends to have enduring negative moods.
• In grief, thoughts of suicide occur as a way to unite with the deceased or towards addressing feelings of guilt or failed relationship with the deceased. However, in depression, suicidal thoughts are directed at the self only.
• A prior history of severe major depression in the person or their family may trigger the same during grief.
• Depression involves loss of self-esteem, worthlessness and self-loathing, while grief usually does not.
• Depression also has biological symptoms including affecting the immune system and worsening pre-existing conditions such as diabetes, obesity, arthritis, etc.

Grieving is a natural outcome of an event of loss and cannot be prevented. In more than 50% of the cases, it resolves over a period of 1 to 2 years with a marked reduction in intensity and frequency of symptoms about 6 months post-loss.

However, complicated grief tends to last far longer and in case it is not treated, may even be life-threatening. Further, grief-related major depression needs proper medical attention and care. Treatment involves psychotherapy and if required, medications. In some cases, a residential treatment programme may also be recommended.

Psychotherapy treatment involves individual counselling, group counselling, cognitive behavioural therapy (CBT) or other approaches. During the therapy, the focus is on the person learning to identify unhealthy thought patterns, the external stimuli that might trigger those and how to deal with those.

Medications such as antidepressants could help manage symptoms such as insomnia and anxiety. However, in treating complicated grief, it is not necessary to resort to medicines if psychotherapy helps achieve the desired results. 

The bereaved person can take the following measures to recover:

• Socialising: taking the support of family and friends.
• Managing stress and lifestyle choices: through exercise, meditation, reduced or no intake of alcohol or recreational drugs.
• Support group: joining a support group and talking about one’s thoughts in an empathetic environment can be quite helpful.
• Following the treatment plan: regularly attending therapy sessions and completing the assigned tasks. If medications are prescribed, adhere to those.
• Planning for anniversaries, holidays: Discovering new ways of remembering the loved one.
• Learning new skills, cultivating new hobbies

Grief cannot be prevented. While some people are resilient to the passing away of their loved ones, most people experience grief for some months with varying intensity and frequency. The bereaved should not be afraid to rely on their family and friends for support. Common grief resolves in due course. However, complicated grief and grief-related major depressive order require the attention of healthcare professionals for effective treatment and guidance on management.