Bereavement in adult life

British Medical Journal, March 14, 1998 by Colin Murray Parkes

All appetites are diminished, weight is lost, concentration and short term memory are diminished, and the bereaved person often becomes irritable and depressed. This eventually gives place to the third phase of grieving, disorganisation and despair. Many find themselves going over the events which led up to the loss again and again as if, even now, they could find out what went wrong and put it right. The memory of the dead person is never far away and about a half of widows report hypnagogic hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead person near at hand. These hallucinations are distinguished from the hallucinations of psychosis by the circumstances in which they arise and by their transience--they disappear as soon as the bereaved arouse themselves. A sense of the dead person near at hand is also common and may persist.

As time passes the intensity and frequency of the pangs of grief tend to diminish, although they often return with renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind. Consequently the phases of grief should not be regarded as a rigid sequence that is passed through only once. The bereaved person must pass back and forth between pining and despair many times before coming to the final phase of reorganisation.

After a major loss such as the death of a loved spouse or partner, the appetite for food is often the first appetite to return. By the third or fourth month of bereavement the weight that was lost initially has usually returned, and by the sixth month many people have put on too much weight. It may be many more months before people begin to care about their appearance, and for sexual and social appetites to return. Most people will recognise that they are recovering at some time in the course of the second year.

Assessing the risk

Much research, in recent years, has enabled us to identify people at special risk after bereavement either because the circumstances of the bereavement are unusually traumatic or because they are themselves already vulnerable (box). These risk factors can give rise to complicated forms of grief that can culminate in mental illness. A clear understanding of these factors will often enable us to prevent psychiatric disorder in bereaved patients.

Complicated grief

Bereavement has physiological as well as emotional effects (lower box). It also affects physical health: after bereavement, the immune response system is temporarily impaired[7 8] and there are endocrine changes such as increased adrenocortical activity and increases in serum prolactin and growth hormone,[2] as in other situations that evoke depression and distress.

A variety of psychiatric disorders can also be caused by bereavement, the commonest being clinical depression, anxiety states, panic syndromes, and post-traumatic stress disorder. These often coexist and overlap with each other, as they do with the more specific morbid grief reactions. These last disorders are of special interest for the light that they shed on why some people come through bereavement unscathed or strengthened by the experience while others "break down."