COMMENTARY

Distinguishing Grief, Complicated Grief, and Depression

Ronald W. Pies, MD; M. Katherine Shear, MD; Sidney Zisook, MD

Disclosures

December 26, 2014

In This Article

Treatments and Terminology

Dr Pies: And yet, as bad as the illness is, we have effective treatments for major depression; wouldn't you agree, Sid?

Dr Zisook: Although treatments are imperfect—and there is ample room for better, more rapidly acting, safer, and more sustainable therapies—there is strong evidence that both antidepressant medications and depression-focused psychotherapies work. They reduce symptoms, enhance functioning, improve well-being, reduce suicide risk, and can reduce relapse and recurrence. For many individuals with major depression, combining antidepressants with psychotherapy is more effective than either alone.

There also is a role for exercise, light, good nutrition, and a host of other health-promoting behaviors, but these may become feasible only after the darkest periods begin to lift.

For those who have dwelt in depression's dark wood...their return from the abyss is not unlike the ascent of the poet, trudging upward and upward out of hell's black depths and at last emerging into what he saw as "the shining world."

—William Styron, Darkness Visible

Dr Shear: Terminology is used inconsistently, so I will start by defining how we use key terms.

"Bereavement" is the situation of having experienced the death of someone close, not the response to the loss. "Grief" is the response to loss, not simply an emotion. The word "grief" is a simple shorthand for a complex, multifaceted experience that changes over time and varies from loss to loss. Grief is an automatic reaction, presumably guided by brain circuitry activated in response to a world suddenly, profoundly, and irrevocably altered by a loved one's death.

At any given time, grief symptoms are a manifestation of ongoing psychobiological processes as modified by an evolving process of adaptation. Adapting to an important loss often entails reevaluation of one's self-concept, and revising expectations and predictions of self and others, especially the deceased. Adaptation entails understanding the meaning of the finality and consequences of the loss and re-envisioning life goals and plans. As adaptation progresses, the frequency and intensity of grief symptoms attenuate.

Death is permanent, and so too is the response to the loss, though the manifestations of grief usually evolve and change over time. Grief can be considered as the form love takes when someone we lose someone we love. Like other forms of love, grief can be an avenue for personal change and growth.

Dr Pies: Kathy, what about the notion that people can and should "get over" grief?

Dr Shear: As Wortman and Silver[2] have argued, return to a prior state after a significant loss does not occur.They suggest that the idea of resolving grief is one of a number of common misconceptions not supported in survey studies of bereaved people. Another is the idea that successful adaptation means "letting go" or "saying goodbye" in order to "move on."

Another misconception is the belief that experiencing and expressing strong emotions is the key to successful adaptation and that those who do not experience and express their emotions right after someone dies will pay later, or the corollaries of this—that the more intense a person's emotions, the more effectively she or he is grieving and that once you have grieved effectively, you never have to grieve again.

Many clinicians believe that problems with grief are seen primarily in people who have an ambivalent relationship to the person who died. However, complicated grief is seen primarily in people who have enjoyed a very rewarding and loving relationship with the deceased.

Acute grief is the initial response to a painful loss that usually entails painful emotions; a sense of disbelief about the finality of the loss; preoccupation with thoughts, images, and memories of the deceased; and an inclination to social withdrawal. Longing, yearning, and sorrow are the most prominent emotions, often accompanied by a sense of disbelief even though the bereaved person knows that their loved one has died.

As time passes, the disbelief wanes; acute grief is reshaped, and its dominance subsides. As the finality and consequences of the loss are understood, grief is integrated into memory systems, emotional reactivity (both positive and negative) to reminders of the deceased is extinguished, and ways are discovered to use this relationship to foster continued psychological growth. Though grief is more than a feeling state, emotions form an important component of the response to bereavement.

Dr Pies: What, then, characterizes the person's emotions in grief?

Dr Shear: Grief is not a single emotion, but rather contains a compendium of emotions, both negative and positive. Yearning and sorrow are the emotions that define grief. In addition, almost everyone experiences some anxiety, guilt, anger, or shame in response to a significant loss.

Most grieving people are anxious about the meaning of the loss, the experience of grief, or the shape of the future without their deceased loved one. Some people are afraid that they will never stop feeling wrenching pain, anxious about whether they can ever be happy again, or whether they can ever feel comfortable with themselves without the person they lost.

Many bereaved people experience some remorse or guilt about how they treated their loved one. Many feel some survivor guilt because they get to live and enjoy life when the person they loved can no longer do this.

Anger is also common. It is easy to feel cheated, to think it is unfair that the person died, or that someone failed in caring for the person who died. Sometimes anger is directed toward the person who died.

Grief creates feelings of extreme vulnerability, and people who pride themselves on being strong and capable can feel ashamed of the weakness that accompanies grief. People who value emotional control might be ashamed of uncontainable anguish.

Sometimes people also feel guilt or shame about having positive emotions. However, grief usually contains positive feelings interspersed with the negative ones, even in the early period of bereavement. Susan Folkman and her colleagues[3] found that bereaved people reported positive emotions as frequently as negative ones as early as 1 month after the death of someone very close. It feels good to recall happy memories, tell funny anecdotes, feel pride in honoring the person who died, or feel warmth in recollecting closeness to a loved one.

If the person who died was ill and burdensome, it is very natural to feel relief when they die. People might feel relief after the death of a person who was difficult to live with.

In addition to evoking strong emotions, bereavement presents major cognitive and behavioral challenges. Bereaved people need to change the ways in which they think about themselves, other people, and the world at large. Behavioral changes may be needed to achieve new roles or to form new relationships

Overall, many complex and varying emotional, cognitive, and behavioral changes are entailed in making the adaptation needed to come to terms with the loss and to re-envision the future after bereavement.

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