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

Coming to Terms With Loss

Dr Pies: Can you say what helps the grieving person adapt and come to terms with the loss?

Dr Shear: Adaptation is largely a learning process. Bereaved people need to assimilate information about the finality and consequences of the loss into long-term memory and learn new ways to envision their own lives without the deceased person.

The process of adaptation to a death has been described by Bowlby[4] as one in which we must change a mental model, and he points out that such a change is always resisted. Bowlby asserts that our minds mercifully move toward and away from acknowledging the painful reality, providing bouts of grief interspersed with periods of respite. In other words, adaptation typically progresses in fits and starts, in which we oscillate between confronting and reflecting on painful information about the loss, and then setting it aside. Stroebe and Schut[5] point out that loss brings dual coping challenges related to dealing with the loss on the one hand, and restoring a meaningful life on the other.

Different feelings associated with acute grief can guide and motivate changes that help people adjust to the death. At the same time, preoccupation with the person who died helps weave into adaptation ways to stay connected to the person who died, and to feel their presence as the bereaved begin to engage in their own lives again.

For example, if there is a chore to be done, memory of how the deceased did this chore is likely to be easily accessible. This is useful for the bereaved person, who can then consider whether this would be a good way to do it or not. If not, it will help to see why not. If there is no idea how the person actually did the chore, easily accessible memories might still make it possible to recall what advice the deceased might have provided. Many people make it a habit to "talk" to a loved one who has died, especially when they are solving a problem or making an important decision.

Dr Pies: What about complicated grief, Kathy? What context does that occur in?

Dr Shear: Sometimes, maladaptive feelings, thoughts, or behaviors can get a foothold during grief. A person might become caught up in troubling thoughts about the circumstances or consequences of the death, or about aspects of their relationship with the deceased. Sometimes, reminders of the loss are so painful that the bereaved person goes to great length to avoid these, and thoughts about the death are so intensely painful that it is difficult to reflect on it and make peace with the loss. Or there may be an external situation: hostility or severe neglect by other people, devastating financial consequences, or other highly stressful changes in a bereaved person's situation.

Complicated grief occurs when something interferes with learning that is the core process of healing. The result is a situation in which the bereaved person seems "stuck" in acute grief, trying to deal with the complications that block acceptance and adaptation to the loss. Initially identified using a 19-item self-report questionnaire called the Inventory of Complicated Grief, complicated grief can be a disabling problem. Complicated grief is best understood as a severe form of grief, similar in many respects to the experience almost everyone has when a loved one dies.

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