Grief, loss and bereavement

Question 1

Why is grief distressing?
Link to bowlby

Answer 1

The distress and emotional response to breaking bonds of attachment to the ‘lost person’

Question 2

What is the relationship between the terms loss, grief, bereavement and mourning?

Answer 2

Loss - no longer have something
Grief - the emotional and psychological reaction to loss, what we feel when bereaved
Bereavement - the period of time that occurs after death when individuals learn to cope with the loss
Mourning - the expression of grief, outwardly.

Question 3

What are some of the physical signs of grief?

Answer 3

Nausea
Low-level infections
Sleep disturbance
Lethargy
Reduced appetite
Headaches
Psychosomatic illness.

Question 4

What are some common cognitive processes during grief?

Answer 4

Disbelief
Sense of unreality
Short term memory loss
Hopeless
Reduced sense of purpose
Poor concentration
Obsessive thoughts.

Question 5

What emotions often accompany grief?

Answer 5

Anxiety
Anger
Injustice
Sadness
Regret
Relief
Helplessness
Shock
Guilt
Numb.

Question 6

What are some behavioural responses to grief?

Answer 6

Social withdrawl
Over active
Aggressive
Sleep
Change in habits
Planning radical changes.

Question 7

What are the four domains within grief?

Answer 7

Feelings
Behaviour
Physical signs
Thoughts/

Question 8

What is the historical social perspective on grief?

Answer 8

As a society we an unprepared for death
Very taboo subject, no often talked about due to negative or grim connotations.
Death is often viewed as a medical failure.

Question 9

What are the different types of grief?

Answer 9

Normal/uncomplicated
Anticipatory
Inhibited
Delayed
Absent grief
Disenfranchised
Prolonged

Question 10

What is normal/uncomplicated grief?

Answer 10

Uncomplicated grief lasting 6-12 months before persons starts to resolve to normal.
Day to day life and activities may be difficult
Numbness, shock, crying and pain
Dream of dead and waves of emotions.
Is expressed openly and allows person to go through social ceremonies and person process of bereavement.
May follow a series of stages to adapt.
Symptoms gradually fade over time

Question 11

What is anticipatory grief?

Answer 11

An impeding loss (terminal diagnosis), grieve and have emotional response before loss/death
Can be equally intense mentally and physically as other types of grief

Question 12

What is inhibited grief?

Answer 12

When grief is for a valid topic but person feels socially unable to express their grief.
Persons feels all the emotions of grief but does not express them, expression would be socially unacceptable. Can manifest physically and inwardly.
E.g male grief

Question 13

What is delayed grief?

Answer 13

When unable to grieve initially for example too young to understand or trauma response to war/natural disater meant needed to continue at high functioning
Person grieves later, time after loss.

Question 14

What is absent grief?

Answer 14

When a person feels no grief after a death/loss
This may be when a person is in denial or a result of anticipatory grief.

Question 15

What is disenfranchised grief?

Answer 15

Grief that the topic is not socially acceptable for example over a pet or abortion
Would be considered weird to grieve over this but person still expresses this grief socially.

Question 16

What is prolonged grief?

Answer 16

Pathological grief - experience by 7% of people
Are overwhelmed by feelings of fried, become obsessive, irrational and catastrophisising.
Often need counselling.
Intense and persistent - interferes with daily life and functioning.

Question 17

What are some risk factors affecting how likely a person is to suffer from complicated/pathological grief?

Answer 17

Personal vulnerability - internal coping abilities
Relationship with deceased person - strength of attachment that has been lost
Events and circumstances leading up to death - expected death, anticipatory grief etc??
Amount of social support.

Question 18

How does the way we cope and express grief affect the amount of support we need?

Answer 18

How we cope determines the type of support we need - for example maladaptive coping require more intervention, some people may need to be left alone to come to terms with feelings others may need lots of social support
Internal and external resources available to use and how we apprais them will affect how we cope

Question 19

What is the attachment theorist view of how we express grief?

Answer 19

The expression of grief as mourning has a survival benefit.
Supported by the evidence that animals grieve, expression is a evolutionary perspective necessary for survival
Aims to increase social support, come to terms with emotions, prevent long term maladaptive health behaviours.

Question 20

How does societal beliefs and cultural differences alter the grief process?

Answer 20

Affects how we display (mourn) and what we feel during grief
Spirituality and belief in afterlife tend to resolve grief faster
Some cultures prepare bodies and follow certain rituals with burying and mourning.
These ritualis offer stability and security during loss improving coping.
Culture impacts our meaning on death and life and what happens after it.

Question 21

What is the mourning process?

Answer 21

A series of phases that must be passed through before grief can be resolved.
IN overview, initial numbenss becoming searching for replacement for loss, then despair when realise loss is inevitable, finally moves to recovery and reorganisation as adjusts to new way of life.

Question 22

What are Parkes stages of normal bereavement?

Answer 22

Alarm - high stress and high physiological arousal
Numbness - disconnected often protection against acute loss of pain
Pining - constantly reminded and missing the grieved may have hallucinations or dreams of dead one
Depression and despair - depressed or irritated, loss of pleasure, insomnia, impaired concentration and short term memory loss.
Recovery and reorganisation - accept loss and return to normal social and psychology behaviour, grief may still return at periods associated with loved one.

Question 23

What is the dyer model of grief?

Answer 23

Creates six dimensions to grief
Physical - palpitations, fatigue, nausea, SOB
Emotional - helpless, numbness, panic, anger
Occupational - restlessness, disorganization, short temper, impaired work
Social - avoid others, low self esteem, relationship problems
Intellectual - forgetful, poor concentration, denial
Spiritual - doubting faith, angry or bargaining with god.

Question 24

What are the Kubler-Ross stages of grief?

Answer 24

Denial
Anger
Bargaining
Depression
Acceptance.

Question 25

What are the drawbacks ofthe Kubler-Ross stages of grief?

Answer 25

Stages - denial, anger, bargaining, depression and acceptance
+ helps understand complexity of grief

Problem - reductionist outlook, does not provide explanation for why stages may be prolonged or delayed
Not everyone passes through all these stages, not always a linear process.
People who don’t follow these processes can be seen as abnormal grief
There are societal pressures to feel all these stages, thought of as necessary in order to have greeved completely.

Question 26

What are the different experiential models of grief?

Answer 26

Dual Process model
Growing around grief model

Question 27

What is the dual process model of grief?

Answer 27

Suggests that bereaved people move between confronting grief (loss-orientated behaviour) such as denial, depression, yearning.
To avoiding grief (restoration-orientated behaviour) such as doing new things and creating new relationships, sense of moving forward without loved one.

Question 28

What is the growing around grief theory?

Answer 28

Describes what happens from inside out rather than the outside in
Grief always remains the same so that person, will likely always be felt but we continue to develop around that - gain new life experiences and new way of living, that in comparison makes grief seem smaller and more manageable, despite grief never actually going away there will always be a bond to grief, person can not return to same as before.
Idea of heals with time.

Question 29

When does grief become determental?

Answer 29

Can have poor physical and mental health
Increase levels of mortality and morbidity.
Grief increases risk of death from heart disease, suicide, anxiety and depression.
Pervasive symptoms such as loss of enjoyment can significantly impair functioning.
Broken heart syndrome - high strain on heart from intensity of grief. causes severe stress and weakening of heart muscles.

Question 30

Who is detrimental grief more common in?

Answer 30

Females - more socially acceptable, tend to focus on loss whilst males focus on recovery from
Older individuals - suffer commutative grief as lost of people around them die, cumulative stress and loss of social support, more difficult to cope each time.

Question 31

What is an adjustment disorder?

Answer 31

Excessive reaction to stress that involves strong negative emotions, negative thoughts and changes in behaviour.

Question 32

What is pathological (abnormal) - prolonged grief disorder?

Answer 32

Adjustment disorder - may be excessive or prolonged grief or absent grieving with abnormal denial.
Usually stuck in grief with insomnia, dreams of dead one, anger at doctors or person for dying, may feel guilt,
Are unable to say good bye to loved ones as unable to deal with effect of grief.
Unable to work through grief despite the passage of time.

Question 33

What clinical diagnosis may a person suffering from grief be qualified for?

Answer 33

Meet criteria for depressive episode but is normal during grief not pathological so should not make diagnosis.
Bereaved people should be assessed and treated for depression as normal.
But patients who have grieved are now at higher risk of severe depressive illness.
Classification is starting to avoid normal or abnormal grief definitions, starting to describe extremely prolonged or intense grief as a disorder (suicideal, negative health outcomes).

Question 34

What differential diagnosis are important to consider when talking to a grieving person?

Answer 34

Prolonged grief disorder - consider the process, duration, intensity and functional impact of symptoms
Major depressive episode or disorder - may be triggered by grief - this would be more persistent or wide-ranging sadness (not just focused on loss of loved one)
Acute stress disorder or PTSD - can be co-occurence with grief, more fear orientated and hyperarousal. Can share avoidance and intrusion with PGD. Main difference is PTSD is fearful of trauma/death reminders rather than sadness and seeks no proximity to reminders of loved one.

Question 35

What preceeding factors are determinants of grief?

Answer 35

Childhood experience - ACE’s maladaptive coping
A previous life crisis - primed and chronic stress response
Mental illness
Nature or relationship with deceased
Mutliple prio-bereavements

Question 36

What present circumstances are determinants of grief?

Answer 36

Age
Gender
religion
Personaility (low self esteem)
Cultural background.
If death was unexpected, sudden, of a young person, death was stigmatised (AIDS) or traumatic/violent in nature

Question 37

What circumstances after death are determinants of grief? (influence how (well) we greeve)

Answer 37

Amount of support - e,g having young children
Time and availability to grieve - for example during conflict.
Stress from other life crisis

Question 38

What different treatments can be offered for grief?

Answer 38

Guided mourning - use cognitive and behavioural techniques to allow the relative to stop grieving and move on in life

Psychoeducation about grief - help process loss and their feelings, focus on positive reminiscing, reinstory function and purposeful engagement in life, focus on overcoming challenging thoughts that worsen negative feelings,

CBT focused on prolonged grief - exposure to death situations helps reduce symptoms.

Question 39

What is the use of medication in treating grief?

Answer 39

Antidepressants are not effective for prolonged grief symptoms
However anti-depressants alongside psychotherapy may improve treatment success and reduce co-occuring depressive symptoms.

Question 40

What help do people want when they are suffering from grief?

Answer 40

Clear and consie communication
Acknowledgement and empathy
Community and normlisation
Support to find their own way.

Question 41

As a health professional how should we prepare to help a grieving patient?

Answer 41

Recognise converstations will not be easy and prepare yourself for them
Recognise your thoughts, fears and situations and how this influences your view. Be honest with yourself and patient
Remember we can not change a persons loss - is not treatable.