Grief and Bereavement

1. Clinical Overview

Summary

Grief is the universal, multi-dimensional response to loss, encompassing emotional, cognitive, behavioural, somatic, and spiritual dimensions. While most individuals (approximately 90%) navigate the grieving process adaptively without professional intervention, a subset develops Prolonged Grief Disorder (PGD), characterized by persistent, intense yearning and significant functional impairment lasting beyond culturally expected norms (typically > 6-12 months). [1,2]

The inclusion of PGD in ICD-11 (2022) and DSM-5-TR (2022) represents a paradigm shift: recognizing that while grief is a normal human experience, pathological variants exist that require specific clinical attention and evidence-based intervention. Clinicians must distinguish normal grief (preserves self-esteem, comes in waves) from Major Depressive Disorder (MDD) and from PGD itself. [3,4]

Key Facts

• Universal experience: Bereavement affects 96% of adults by age 65; 78% actively grieving at any given time. [5]
• Prolonged Grief Disorder prevalence: Affects 7-10% of bereaved adults (pooled meta-analysis estimate: 9.8%). [6]
• Suicide risk: Significantly elevated in first week to 12 months post-loss, especially in elderly men losing spouses. [5]
• Takotsubo cardiomyopathy: Stress-induced cardiomyopathy triggered by acute bereavement, particularly in elderly women. [7]
• Normal hallucinations: Transient pseudo-hallucinations (seeing/hearing deceased) occur in 30-60% of acute grief and are not psychotic. [1]
• Dual Process Model: Contemporary framework describing oscillation between Loss-Oriented (grief work) and Restoration-Oriented (life changes) coping. [8]

Clinical Pearls

Grief vs Depression: In grief, self-esteem is usually preserved. The predominant affect is "emptiness" and "loss" which comes in waves ("pangs of grief") triggered by reminders. In MDD, self-esteem is low (guilt, worthlessness), mood is persistently depressed/flat, and anhedonia is pervasive. [9,10]

Do Not Medicalise Unnecessarily: Do not routinely prescribe antidepressants for normal grief. They may numb the adaptive grieving process and delay resolution. Reserve pharmacotherapy for comorbid Major Depression or Prolonged Grief Disorder with severe symptoms. [1,11]

Bereavement Exclusion Removed: DSM-5 (2013) removed the "bereavement exclusion" for Major Depression. You can diagnose MDD during bereavement if full criteria are met, particularly if severe symptoms include worthlessness, suicidal ideation, or psychotic features. [10]

"Broken Heart Syndrome" is Real: Takotsubo (stress-induced) cardiomyopathy presents with chest pain, ECG changes, and troponin rise in recently bereaved (especially elderly women). Angiography shows normal coronaries. Consider ECG/troponin in bereaved patients with chest symptoms. [7]

Anniversary Reactions: The first anniversary of death is a high-risk time for grief resurgence. Prepare patients for this predictable intensification. [1]

Cultural Competence: Grief expression, duration norms, and rituals vary widely across cultures. What appears "prolonged" in one culture may be normative in another. Always assess cultural context. [12]

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2. Epidemiology

Prevalence

Risk Factors for Prolonged Grief Disorder

High-Risk Bereavement Circumstances

• Nature of death: [6,14]
  • Sudden/unexpected death
  • Violent death (homicide, accident)
  • "Suicide (highest risk: stigma + trauma)"
  • Traumatic circumstances (witnessed death, mutilating injuries)
• Relationship: [6]
  • Loss of a child (parent-child bond strongest)
  • Loss of spouse in dependent relationship
  • Loss of primary attachment figure

Individual Vulnerability Factors

• Psychiatric history: [6]
  • Prior depression or anxiety disorders
  • Insecure or anxious attachment style
  • Previous unresolved losses (cumulative grief)
• Social factors: [5,6]
  • Lack of social support network
  • Social isolation
  • Financial hardship secondary to loss
• Personality: [6]
  • High neuroticism
  • Low resilience
  • Avoidant coping style

Demographic Patterns

• Gender: Women have higher PGD prevalence (OR 1.5-2.0), but men have higher suicide risk post-bereavement. [5,6]
• Age: Elderly spouses at highest risk for complicated grief and mortality ("widowhood effect"). [5,13]
• Cultural factors: Lower social support in individualistic cultures may increase PGD risk. [12]

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3. Theoretical Models of Grief

1. Stages of Grief (Kübler-Ross, 1969)

Classic but widely criticized for being overly linear and prescriptive.

Five stages (mnemonic: DABDA): [1]

1. Denial: "This isn't happening." Shock, numbness, disbelief.
2. Anger: "Why me?" Directed at self, others, doctors, God, or the deceased.
3. Bargaining: "If I do X, can I bring them back?"
4. Depression: Realization of loss. Withdrawal, sadness, existential despair.
5. Acceptance: Integration of loss. Re-engagement with life.

Limitations:

• Not empirically validated
• Not sequential (people oscillate, skip stages, or never reach "acceptance")
• Risk of prescriptive application ("You should be in acceptance by now")
• Originally developed for dying patients, not bereaved individuals

Clinical utility: Provides a general framework to normalize diverse grief reactions, but should not be applied rigidly. [1]

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2. Dual Process Model of Coping with Bereavement (Stroebe & Schut, 1999)

Current evidence-based gold standard model. [8]

Core concept: Grief involves dynamic oscillation between two orientations:

Oscillation: Healthy grief involves swinging between these two poles. The bereaved person:

• Cannot stay in loss-orientation continuously (exhausting)
• Cannot avoid loss-orientation entirely (grief remains unprocessed)

Pathology arises when:

• Stuck in loss-orientation: Chronic grieving, rumination → Prolonged Grief Disorder
• Stuck in restoration-orientation: Avoidance, denial, delayed grief reactions

Evidence base: Supported by longitudinal studies showing oscillation predicts better outcomes. [8]

Clinical application: [8]

• Encourage both grief work and engagement with life tasks
• Normalize oscillation: "It's okay to take breaks from grief"
• Identify if patient is stuck in one pole

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3. Tasks of Mourning (Worden, 2009)

Active, process-oriented model (more empowering than "stages"). [1]

Four tasks:

1. Accept the reality of the loss: Overcome denial. Cognitive acceptance ("They are dead") and emotional acceptance.
2. Work through the pain of grief: Feel and process emotions rather than avoid.
3. Adjust to an environment where the deceased is missing: Adapt to external (practical tasks), internal (identity), and spiritual (meaning) changes.
4. Find an enduring connection with the deceased while embarking on a new life: Maintain symbolic bonds (memories, values) without being immobilized.

Strengths:

• Active, non-linear framework
• Compatible with Dual Process Model
• Emphasizes agency

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4. Continuing Bonds Model (Klass, Silverman, Nickman, 1996)

Challenges old "grief work" hypothesis that resolution requires severing bonds. [1]

Core concept: Healthy grief often involves maintaining an ongoing symbolic relationship with the deceased (e.g., talking to them, feeling their presence, living by their values).

Evidence: Many bereaved individuals report comfort from continuing bonds, without functional impairment. [1]

Caveat: Becomes maladaptive if bonds prevent engagement with present life (e.g., "I can't remarry because of loyalty to my dead spouse").

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4. Clinical Presentation

Normal (Uncomplicated) Grief

Timecourse: Acute intense phase (weeks to 3 months) → Gradual integration (6-12 months) → Enduring low-level sadness (lifelong, but non-impairing). [1,5]

Manifestations:

Key features of normal grief:

• Self-esteem preserved: "I miss them" (not "I am worthless")
• Affect is reactive: Can experience joy/laughter when distracted
• Symptoms come in waves ("pangs of grief"), triggered by reminders
• Gradual improvement over months, even if not linear

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Prolonged Grief Disorder (ICD-11 6B42, DSM-5-TR)

Diagnostic criteria (harmonized ICD-11/DSM-5-TR): [2,3,4]

A. Duration:

• ICD-11: At least 6 months after death
• DSM-5-TR: At least 12 months after death (6 months for children)

B. Core symptoms (at least one):

1. Persistent, intense yearning or longing for the deceased
2. Preoccupation with thoughts or memories of the deceased

C. Additional symptoms (at least 3 from DSM-5-TR; ICD-11 similar):

1. Identity disruption: "Part of me died with them"
2. Disbelief about the death
3. Avoidance of reminders of the reality of the loss
4. Intense emotional pain (anger, bitterness, sorrow)
5. Difficulty with reintegration (social, occupational, other activities)
6. Emotional numbness (detachment)
7. Feeling that life is meaningless without the deceased
8. Intense loneliness or feeling alone

D. Impairment: Significant distress or impairment in social, occupational, or other important areas.

E. Cultural norms: Duration and severity exceed cultural or religious norms.

Distinguishing features from normal grief: [2,3]

• Persistence beyond cultural norms (not improving over time)
• Intensity remains severe (not diminishing)
• Functional impairment (unable to work, care for self/dependents)
• "Stuck": Unable to oscillate between loss/restoration orientations

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Differential Diagnosis: Prolonged Grief Disorder vs Major Depressive Disorder

Comorbidity: PGD and MDD can coexist (30-50% comorbidity). Treat both. [9,10]

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Diagnosis of Major Depression During Bereavement

Historical context: DSM-IV (1994-2013) included a "bereavement exclusion": MDD could not be diagnosed in the first 2 months after loss unless severe features present. [10]

DSM-5 change (2013): Exclusion removed. MDD can be diagnosed at any point during bereavement if full criteria met. [10]

Features suggesting MDD (not normal grief): [9,10]

• Worthlessness or excessive guilt unrelated to actions/inactions around death
• Suicidal ideation (active, with plans)
• Psychotic features (delusions of guilt, somatic delusions)
• Psychomotor retardation
• Marked, prolonged functional impairment
• No improvement over weeks/months

Clinical approach: If uncertain, observe for 2-4 weeks. If symptoms worsen or plateau at severe level, consider MDD diagnosis and treatment. [9]

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Traumatic Grief and PTSD

When death is traumatic (sudden, violent, witnessed), bereaved may develop both PGD and PTSD: [14]

PTSD features in traumatic bereavement:

• Intrusive re-experiencing of traumatic death scene
• Avoidance of trauma reminders (not just grief reminders)
• Hyperarousal, hypervigilance
• Negative alterations in cognition/mood

Management: Treat PTSD (trauma-focused CBT, EMDR) concurrently with grief therapy. [14]

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5. Clinical Examination

Mental State Examination (MSE)

• "Empty"
• "Heartbroken" | "Depressed"
• "Worthless"
• "Hopeless" | | Affect (objective) | Depressed but reactive (can smile at fond memory) | Flat, non-reactive | | Thoughts | Preoccupation with deceased, themes of loss | Rumination, worthlessness, suicidal ideation | | Perception | Pseudo-hallucinations (retained insight: "I know they're not really there") | True hallucinations (psychotic depression) or none | | Cognition | Mild concentration difficulties | Marked impairment | | Insight | Preserved | May be impaired |

Critical assessment:

• Suicide risk: ASK explicitly (does not increase risk): "Are you thinking of harming yourself or ending your life?" [5]
  • "High-risk groups: Elderly men, recent loss of spouse, social isolation, substance use, prior depression"
• Capacity for self-care: Eating, hygiene, medication adherence
• Safeguarding: If children/dependents, assess ability to care for them

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6. Investigations

Screening Questionnaires

Physical Investigations

Not routinely indicated for grief itself, but consider if:

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7. Management

Management Algorithm

               BEREAVED PATIENT
           (Presenting with distress)
                      ↓
┌─────────────────────────────────────────────┐
│         IMMEDIATE RISK ASSESSMENT            │
│  - Suicide risk (ASK explicitly)             │
│  - Ability to care for self/dependents       │
│  - Substance misuse                          │
│  - Chest pain (Takotsubo if elderly)         │
└─────────────────────────────────────────────┘
                      ↓
        ┌─────────────┴─────────────┐
        ↓                           ↓
  NORMAL GRIEF                PROLONGED GRIEF / MDD
  (Waves of sadness,          (Persistent, severe, 
   functional capacity,        functional impairment,
   improving over time)        > 6-12 months)
        ↓                           ↓
  SUPPORTIVE CARE            SPECIALIST REFERRAL
  - Watchful waiting          - Complicated Grief Therapy (CGT)
  - Normalize symptoms        - Psychiatry if MDD/suicidality
  - Signpost support orgs     - Consider SSRI if comorbid MDD
  - DO NOT MEDICATE           - Trauma-focused therapy if PTSD
  - Follow-up 4-6 weeks

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Management of Normal Grief

Principles: "Watchful waiting" – monitor, support, normalize, but do not medicalize. [1,11]

1. Psychoeducation and Normalization

• Explain that grief is a normal, adaptive process (not a disorder)
• Normalize range of reactions: [1]
  • "Seeing or hearing them is very common and doesn't mean you're going crazy"
  • "Anger is a normal part of grief"
  • "Grief comes in waves – some days will be harder than others"
• Provide timeline expectations: "Most intense phase lasts weeks to months; gradual improvement over 6-12 months"

2. Active Listening and "Witnessing"

• Being present is the most powerful intervention [1]
• Encourage storytelling about the deceased
• Avoid platitudes: ❌ "They're in a better place" ❌ "Time heals all wounds" ❌ "I know how you feel"
• ✅ Better responses: "I'm so sorry for your loss" / "Tell me about them"

3. Encourage Dual Process Coping

• Validate both:
  • Grief work: "It's important to feel your feelings"
  • Restoration work: "It's also okay to take breaks, see friends, enjoy moments"
• Discourage avoidance OR chronic rumination [8]

4. Social Support and Practical Help

• Mobilize existing support networks (family, friends, faith communities)
• Signpost bereavement support organizations: [1]
  • "UK: Cruse Bereavement Support, Sue Ryder"
  • "US: The Compassionate Friends, GriefShare"
  • "Online: What's Your Grief, Refuge in Grief"

5. Self-Care Advice

• Maintain routine (sleep, meals, exercise)
• Limit alcohol (tempting but impairs grief processing)
• Delay major decisions (moving house, changing jobs) for 6-12 months if possible

6. Avoid Pharmacotherapy

• Do NOT routinely prescribe: [1,11]
  • Antidepressants (may numb adaptive grief)
  • Benzodiazepines (interfere with grief processing, risk dependence)
• Exception: Short-term hypnotics (3-5 days max) for extreme insomnia if essential

7. Follow-Up

• Review at 4-6 weeks
• Red flags for referral: Worsening symptoms, suicidal thoughts, severe functional impairment

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Management of Prolonged Grief Disorder

First-line treatment: Specialized psychotherapy [15,16]

1. Complicated Grief Therapy (CGT)

Evidence: RCT by Shear et al. (2005, 2016) showed CGT superior to standard interpersonal psychotherapy (response rate 51% vs 28%). [15,16]

Structure: [15]

• 16 sessions over 4-6 months
• Individual therapy

Key components:

1. Revisiting the loss: Imaginal conversations with deceased
2. Exposure to avoided situations: Visiting grave, going through possessions
3. Restoration work: Goal-setting for re-engagement with life
4. Addressing complications: Guilt, anger, trauma

Mechanism: Facilitates both emotional processing (loss-orientation) and life re-engagement (restoration-orientation). [8,15]

Availability: Requires specialist training. Refer to bereavement services, psychiatry, or clinical psychology.

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2. Cognitive-Behavioral Therapy for Grief (CBT-Grief)

Evidence: Effective for PGD, particularly internet-delivered CBT. [17]

Components: [17]

• Psychoeducation
• Cognitive restructuring (maladaptive beliefs: "I should have prevented this")
• Exposure to grief-related cues
• Behavioral activation

Duration: 10-16 sessions

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3. Pharmacotherapy

Evidence: Weak as monotherapy; adjunctive role for comorbid MDD/anxiety. [16,18]

Indications:

• Comorbid Major Depressive Disorder
• Severe anxiety impairing engagement with therapy
• Patient preference

First-line medication: SSRIs [16,18]

• Citalopram 20-40 mg daily
• Sertraline 50-150 mg daily
• Escitalopram 10-20 mg daily

Evidence: Shear et al. (2016) RCT showed citalopram + CGT superior to placebo + CGT (response: 69% vs 56%), but citalopram alone insufficient. [16]

Avoid:

• Benzodiazepines: Risk of dependence, impair grief processing [1]
• Tricyclics (unless SSRIs contraindicated): Side effect burden

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4. When to Refer to Psychiatry

• Suicidal ideation/plans
• Psychotic features
• Comorbid severe MDD
• No response to first-line therapy
• Diagnostic uncertainty (PGD vs MDD vs PTSD)

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Management of Traumatic Grief (PGD + PTSD)

Approach: Treat both conditions concurrently or sequentially. [14]

1. Trauma-focused CBT (TF-CBT): Exposure to trauma memories
2. Eye Movement Desensitization and Reprocessing (EMDR): For trauma processing
3. Complicated Grief Therapy: For grief-specific symptoms

Sequencing: Some experts recommend stabilizing PTSD first (trauma memories may interfere with grief work); others integrate approaches. [14]

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Management in Special Populations

Children and Adolescents

Developmental considerations: [1]

• Young children (3-5 years): Concrete thinking ("Where is Daddy?" "Will I die too?"). "Puddle jumping" grief (in and out of sadness).
• School-age (6-12 years): Understand permanence; guilt ("I caused this"). Behavioral regression.
• Adolescents: Identity formation disrupted; peer support critical.

Management: [1]

• Honesty: Use clear language ("died," not "passed away" or "sleeping")
• Maintain routine: School, activities
• Allow participation: Funerals (if child wishes), remembrance rituals
• Refer if: Prolonged functional impairment, regression, suicidal ideation

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Elderly

Vulnerabilities: [5,13]

• Widowhood effect: Increased mortality in surviving spouse (especially first 6 months)
• Multiple losses: Cumulative grief
• Social isolation: Loss of primary social contact

Considerations:

• Assess physical health: Takotsubo risk, self-neglect
• Practical support: Meals, transport, finances
• Group interventions: Bereaved spouse support groups effective [13]

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Suicide Bereavement

Unique features: [14]

• Stigma: Shame, blame, isolation
• Trauma: PTSD from discovery/circumstances
• Unanswerable questions: "Why?"
• High PGD risk: 43-50% develop PGD [14]

Management: [14]

• Normalize ambivalence: Anger and love coexist
• Address guilt: "It's not your fault"
• Suicide-specific support groups: Survivors of Bereavement by Suicide (SOBS-UK), Alliance of Hope (US)
• Refer early: High complexity

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8. Complications of Grief

Psychiatric Complications

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Physical Complications

1. Takotsubo (Stress-Induced) Cardiomyopathy [7]

Pathophysiology: Catecholamine surge → transient LV dysfunction (apical ballooning)

Presentation:

• Chest pain + dyspnea in recently bereaved (hours to days post-loss)
• Predominantly elderly women (90%)
• Mimics acute coronary syndrome

Investigations:

• ECG: ST elevation (anterior leads), T wave inversion
• Troponin: Mildly elevated
• Echo: Apical ballooning, reduced EF (30-40%)
• Coronary angiography: Normal coronaries (distinguishes from MI)

Management: Supportive (ACE inhibitors, beta-blockers); resolves in weeks to months

Prognosis: Mortality 1-2% (can cause cardiogenic shock); recurrence rare

Clinical pearl: Always consider in bereaved elderly with chest pain. [7]

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2. Immune Dysregulation [1]

Evidence: Bereaved individuals show reduced lymphocyte function, increased cortisol.

Clinical implications: Increased infection risk (e.g., pneumonia in elderly widowers)

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3. Widowhood Effect (Excess Mortality)

Epidemiology: Surviving spouse has 50-90% increased mortality in first 6 months, especially from cardiovascular events. [5]

Mechanisms: Takotsubo, self-neglect, immune suppression, suicide

Prevention: Close monitoring, social support, physical health checks

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9. Prognosis and Outcomes

Natural History of Grief

Key point: "Recovery" does not mean forgetting or absence of sadness. It means adaptive integration – carrying the loss while re-engaging with life. [1,5]

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Prognostic Factors

Good prognosis: [5,6]

• Expected death (time to prepare)
• Strong social support
• Secure attachment style
• No prior psychiatric history
• Sense of meaning/purpose (religious/spiritual framework)

Poor prognosis (risk for PGD): [6]

• Sudden/traumatic death
• Loss of child
• Isolation
• Prior depression
• Multiple concurrent stressors

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Outcomes of Prolonged Grief Disorder

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10. Evidence and Guidelines

Key Guidelines

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Landmark Studies

1. Prigerson et al. (2009): PLoS Medicine [2]

Title: "Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-5 and ICD-11"

Design: Validation study, N=317 bereaved adults

Key findings:

• PGD is a distinct entity from depression and anxiety
• Core symptoms: Yearning, preoccupation, functional impairment
• 6-month threshold optimal for ICD-11; 12-month for DSM-5

Impact: Led to inclusion of PGD in ICD-11 (2022) and DSM-5-TR (2022)

DOI: 10.1371/journal.pmed.1000121

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2. Shear et al. (2005): JAMA [15]

Title: "Treatment of Complicated Grief: A Randomized Controlled Trial"

Design: RCT, N=95, Complicated Grief Therapy (CGT) vs Interpersonal Psychotherapy (IPT)

Results:

• CGT response rate: 51%
• IPT response rate: 28%
• NNT = 4.3

Conclusion: Specialized grief-focused therapy superior to standard psychotherapy

DOI: 10.1001/jama.293.21.2601

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3. Shear et al. (2016): JAMA Psychiatry [16]

Title: "Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial"

Design: Placebo-controlled RCT, N=395, CGT + citalopram vs CGT + placebo vs placebo alone

Results:

• CGT + citalopram: 69% response
• CGT + placebo: 56% response
• Citalopram alone: Insufficient

Conclusion: CGT is essential; citalopram provides modest additional benefit

DOI: 10.1001/jamapsychiatry.2016.0892

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4. Lundorff et al. (2017): Meta-Analysis [6]

Title: "Prevalence of Prolonged Grief Disorder in Adult Bereavement"

Design: Systematic review + meta-analysis, 14 studies, N=3,089

Results:

• Pooled prevalence: 9.8% (95% CI: 7.0-13.0%)
• Higher in violent death (up to 50%), loss of child (up to 20%)

DOI: 10.1016/j.jad.2017.01.030

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5. Stroebe & Schut (1999): Death Studies [8]

Title: "The Dual Process Model of Coping with Bereavement: Rationale and Description"

Contribution: Introduced oscillation model (loss-orientation ↔ restoration-orientation)

Impact: Replaced stage models as dominant theoretical framework

DOI: 10.1080/074811899201046

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6. Kendler et al. (2008): American Journal of Psychiatry [10]

Title: "Does Bereavement-Related Major Depression Differ From Major Depression Associated With Other Stressful Life Events?"

Design: Longitudinal twin study, N=7,765

Results: Bereavement-related MDD is clinically indistinguishable from MDD triggered by other stressors

Impact: Contributed to removal of bereavement exclusion from DSM-5

DOI: 10.1176/appi.ajp.2008.07111757

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7. Campos et al. (2018): Takotsubo and Bereavement [7]

Title: "Mourning and Takotsubo Cardiomyopathy: Neuroendocrine Implications"

Key findings: Acute bereavement is a major trigger for Takotsubo (especially in elderly women)

Mechanism: Catecholamine surge → myocardial stunning

DOI: 10.1590/1806-9282.64.10.952

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11. Examination Focus

High-Yield Exam Scenarios

Scenario 1: Psychiatry OSCE – Grief vs Depression

Stem: "A 68-year-old widow presents 8 weeks after her husband's death. She cries daily, feels 'empty,' can't believe he's gone. She still enjoys seeing her grandchildren. How do you distinguish grief from MDD?"

Model answer:

• Grief: Self-esteem preserved, affect reactive (can smile with grandchildren), content focused on loss, waves of sadness
• MDD: Worthlessness, anhedonia (no pleasure even with grandchildren), persistent low mood, guilt/hopelessness
• Assessment: PHQ-9, assess suicidal ideation
• Management: Normalize grief; watchful waiting; review 4 weeks. Refer if worsening or suicidal. [9,10]

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Scenario 2: General Practice – Normal Hallucinations

Stem: "A 72-year-old man reports hearing his deceased wife's voice and seeing her in the kitchen 2 weeks after her death. He is distressed, fearing he is 'going mad.' Management?"

Model answer:

• Reassurance: This is a normal phenomenon in grief (30-60% of bereaved) [1]
• Pseudo-hallucinations: Retained insight ("I know she's not really there")
• Differentiate from psychosis: No delusions, no disorganization, insight intact
• NO antipsychotics
• Follow-up: Should resolve in weeks; if persists > 3 months or accompanied by other psychotic features, reconsider diagnosis

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Scenario 3: Cardiology – Takotsubo

Stem: "A 70-year-old woman presents with crushing chest pain 3 days after her husband's funeral. ECG shows ST elevation. Troponin 0.3 ng/mL. Coronary angiography shows normal arteries. Diagnosis?"

Model answer:

• Takotsubo (stress-induced) cardiomyopathy [7]
• Pathophysiology: Catecholamine surge → apical ballooning
• Diagnosis: Echo (reduced EF, apical ballooning), normal coronaries
• Management: Supportive (ACE inhibitors, beta-blockers), resolves in weeks
• Prognosis: Good (mortality 1-2%); recurrence rare

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Scenario 4: Psychiatry Viva – Dual Process Model

Question: "Describe the Dual Process Model of grief."

Model answer:

• Stroebe & Schut (1999): Oscillation between loss-oriented and restoration-oriented coping [8]
• Loss-oriented: Grief work (crying, yearning, intrusion of grief)
• Restoration-oriented: Life changes (new roles, tasks, distraction)
• Healthy grief: Dynamic oscillation between both
• Pathology: Stuck in loss-orientation → PGD; stuck in restoration-orientation → avoidance, delayed grief

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Scenario 5: Pharmacology – Role of Antidepressants

Question: "What is the role of antidepressants in grief?"

Model answer:

• Normal grief: Do NOT prescribe routinely (may numb adaptive process) [1,11]
• Prolonged Grief Disorder: Consider SSRIs adjunct to psychotherapy (CGT) [16]
  • "Shear et al. (2016): CGT + citalopram (69% response) vs CGT alone (56%)"
• Comorbid MDD: Yes, treat depression with SSRIs + psychotherapy [9]
• Avoid benzodiazepines: Interfere with grief processing, risk dependence [1]

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Viva Talking Points

"Tell me about the stages of grief."

• Kübler-Ross (DABDA): Denial, Anger, Bargaining, Depression, Acceptance [1]
• Limitations: Not linear, not empirical, originally for dying (not bereaved)
• Current practice: Dual Process Model (Stroebe & Schut) preferred [8]

"What is the bereavement exclusion?"

• DSM-IV (1994-2013): MDD could not be diagnosed in first 2 months post-loss (unless severe)
• Removed in DSM-5 (2013): Can now diagnose MDD during bereavement if criteria met [10]
• Rationale: Kendler et al. (2008) showed bereavement-related MDD is clinically identical to other MDD [10]

"When do you refer to psychiatry?"

• Suicidal ideation/plans
• Prolonged Grief Disorder (needs CGT)
• Psychotic features
• Comorbid severe MDD
• Diagnostic uncertainty
• No improvement with supportive care

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12. Cultural and Ethical Considerations

Cultural Variations in Grief [12]

Duration norms:

• Western cultures: Expectation of "moving on" by 6-12 months
• Many Asian, African, Indigenous cultures: Extended mourning periods (> 1 year) normative
• Implication: PGD diagnosis requires cultural context. ICD-11 explicitly includes this criterion. [2,12]

Expression:

• Stoic cultures (e.g., British, Nordic): Restrained public grief
• Expressive cultures (e.g., Mediterranean, Middle Eastern): Overt wailing, public mourning
• Neither is pathological

Rituals:

• Funeral timing (immediate vs delayed)
• Viewing body (encouraged vs forbidden)
• Continuing bonds (encouraged vs discouraged)

Clinical approach:

• ASK: "In your family/culture, what is the usual way of grieving?"
• Collaborate: "How can I support you in a way that fits your beliefs?"
• Avoid assumptions: Don't impose Western timelines or norms

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Spiritual and Religious Dimensions

Protective factors: [1]

• Belief in afterlife (reduces existential despair)
• Ritual structure (provides meaning, community)
• Faith community support

Risk factors: [1]

• Religious guilt ("This is punishment")
• Anger at God (spiritual crisis)

Clinical approach:

• Assess: "Do you have spiritual or religious beliefs that help you make sense of this?"
• Refer: Chaplaincy, faith leaders (if patient wishes)

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13. Patient and Layperson Explanation

What is Grief?

Grief is the normal reaction to losing someone or something you love. It is not a disease or a sign of weakness. It's how humans process loss.

Grief is not just sadness – it can include:

• Emotions: Sadness, anger, guilt, relief, numbness, anxiety
• Physical feelings: Tiredness, chest heaviness, trouble sleeping, no appetite
• Thoughts: "This isn't real," "I should have done more," preoccupation with memories
• Unusual experiences: Seeing or hearing the person (this happens to many people and is normal)

How Long Does Grief Last?

There is no set timetable. Most people find the most intense pain lasts weeks to a few months, and then gradually gets easier over 6-12 months. But everyone is different.

You might feel:

• Waves of grief: Sudden intense sadness triggered by a song, place, or memory
• Good days and bad days: Some days you can laugh; other days you can't stop crying. Both are okay.
• "Anniversary reactions": The first anniversary of the death is often very hard.

When to Seek Help

Normal grief does not require treatment. But see your GP if:

• You can't function (can't wash, eat, work) after several months
• You feel life is not worth living or think about harming yourself
• You are using alcohol or drugs to cope
• Your grief is getting worse (not better) after 6 months
• You feel completely stuck (can't accept the death, avoid all reminders)

How to Help Someone Grieving

DO:

• Be present: You don't need to "fix" them. Just listen.
• Say: "I'm so sorry" / "Tell me about them" / "I'm here for you"
• Offer practical help: Cook a meal, walk their dog, help with paperwork
• Remember: Mention the person's name – the bereaved want to talk about them
• Be patient: Don't expect them to "get over it" quickly

DON'T:

• Avoid them (common mistake – people fear "saying the wrong thing")
• Say: "They're in a better place" / "Time heals" / "At least they're not suffering" / "I know how you feel"
• Pressure them: To remove photos, clear out belongings, "move on"
• Judge: However they grieve (crying vs not crying, talking vs silence)

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14. Summary for Rapid Revision

Key Distinguishing Features

Red Flags (Immediate Referral)

1. Suicidal ideation with plan/intent
2. Psychotic features (true hallucinations, delusions)
3. Severe self-neglect (not eating, hygiene)
4. Chest pain in elderly bereaved (Takotsubo)

Treatment Hierarchy

1. Normal grief: Supportive, normalize, no medication
2. Prolonged Grief Disorder: Complicated Grief Therapy (CGT) ± SSRI
3. Comorbid MDD: SSRI + psychotherapy
4. Traumatic grief + PTSD: Trauma-focused CBT/EMDR + grief therapy

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15. References

Primary Sources

1. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8(2):67-74. PMID: 19516922

2. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-5 and ICD-11. PLoS Med. 2009;6(8):e1000121. doi:10.1371/journal.pmed.1000121

3. Prigerson HG, Boelen PA, Xu J, Smith KV, Maciejewski PK. Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry. 2021;20(1):96-106. PMID: 33432758

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing; 2022.

5. Wilson DM, Cohen J, MacLeod R, Houttekier D. Bereavement grief: A population-based foundational evidence study. Death Stud. 2018;42(7):463-469. PMID: 28985143

6. Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I, O'Connor M. Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. J Affect Disord. 2017;212:138-149. PMID: 28167398

7. Campos MTFS, Valente FMQ, Araújo RMA, Bressan J. Mourning and Takotsubo cardiomyopathy: neuroendocrine implications and nutritional management. Rev Assoc Med Bras (1992). 2018;64(10):952-959. PMID: 30517244

8. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Stud. 1999;23(3):197-224. PMID: 10848151

9. Bağcaz A, Kılıç C. Differential correlates of prolonged grief and depression after bereavement in a population-based sample. J Trauma Stress. 2024;37(2):231-242. PMID: 38129914

10. Kendler KS, Myers J, Zisook S. Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry. 2008;165(11):1449-1455. PMID: 18708488

11. National Institute for Health and Care Excellence. Mental Health Problems in Adults (NG222). NICE; 2023. Available at: https://www.nice.org.uk/guidance/ng222

12. Smid GE, Groen S, de la Rie SM, Kooper S, Boelen PA. Toward Cultural Assessment of Grief and Grief-Related Psychopathology. Psychiatr Serv. 2018;69(10):1050-1052. PMID: 30041592

13. Thiemann P, Street AN, Heath SE, Quince T, Kuhn I, Barclay S. Prolonged grief disorder prevalence in adults 65 years and over: a systematic review. BMJ Support Palliat Care. 2023;13(e1):e30-e42. PMID: 33707297

14. Tal Young I, Iglewicz A, Glorioso D, et al. Suicide bereavement and complicated grief. Dialogues Clin Neurosci. 2012;14(2):177-186. PMID: 22754290

15. Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA. 2005;293(21):2601-2608. PMID: 15928281

16. Shear MK, Reynolds CF 3rd, Simon NM, et al. Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial. JAMA Psychiatry. 2016;73(7):685-694. PMID: 27276373

17. Eisma MC, Boelen PA, van den Bout J, et al. Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial. Behav Ther. 2015;46(6):729-748. PMID: 26520217

18. Szuhany KL, Malgaroli M, Miron CD, Simon NM. Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Focus (Am Psychiatr Publ). 2021;19(2):161-172. PMID: 34690579

19. Stroebe M, Schut H. The dual process model of coping with bereavement: a decade on. Omega (Westport). 2010;61(4):273-289. PMID: 21058610

20. Eisma MC. Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Aust N Z J Psychiatry. 2023;57(7):944-951. PMID: 36748103

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