Summary

Grief is the natural, multi-faceted response to loss, encompassing emotional, cognitive, behavioural, and physical reactions. While the majority of individuals navigate the "normal" grieving process without professional intervention, a subset develops Prolonged Grief Disorder (PGD), characterised by intense, disabling yearning and inability to function that persists beyond social norms (typically >6-12 months). Clinicians must distinguish normal grief (which includes waves of sadness but preserved self-esteem) from Major Depressive Disorder (MDD) and PGD. Management of normal grief is supportive; PGD may require specialised psychotherapy (CBT-Grief). [1,2]

Key Facts

• Kubler-Ross Stages: Denial, Anger, Bargaining, Depression, Acceptance (DABDA) - widely cited but not strictly linear.
• Dual Process Model: A more modern framework describing oscillation between "Loss-Oriented" (grief work) and "Restoration-Oriented" (attending to life changes) stressors.
• Prolonged Grief Disorder (PGD): New diagnosis in ICD-11 and DSM-5-TR. Prevalence ~10% of bereaved.
• Normal Hallucinations: "Pseudo-hallucinations" (seeing/hearing the deceased) are common (30-60%) in acute grief and are not psychotic.

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"). In depression, self-esteem is often low (guilt/worthlessness), and the mood is persistently low/flat.

Do Not Medicalise: Generally, do not prescribe antidepressants for normal grief. They numb the process and may delay resolution. Reserve them for co-morbid Major Depression.

"Broken Heart Syndrome": Takotsubo Cardiomyopathy is a real risk in the acute bereavement period, especially in elderly spouses. Chest pain in a bereaved person warrants ECG/Troponin.

The First Anniversary: Often a triggering time ("Anniversary Reaction"). Prepare patients for this.

1. Stages of Grief (Kubler-Ross)

Classic but criticised for being too rigid.

1. Denial: "This isn't happening." Shock/numbness.
2. Anger: "Why me?" Directed at self, doctors, God, or the deceased.
3. Bargaining: "If I do X, let them live."
4. Depression: Realisation of loss. Withdrawal.
5. Acceptance: Reintegration.

2. Dual Process Model (Stroebe & Schut)

Current gold standard model.

• Grief involves oscillation between:
  • Loss-Oriented: Crying, yearning, looking at photos, feeling the pain.
  • Restoration-Oriented: Paying bills, learning new skills (cooking/finances), socialising, distraction.
• Health is the ability to swing between these two. Getting "stuck" in either leads to pathology.

3. Worden's Tasks of Mourning

1. Accept the reality of the loss.
2. Work through the pain of grief.
3. Adjust to an environment where the deceased is missing.
4. Find an enduring connection with the deceased while embarking on a new life.

Mental State Examination (MSE)

• Appearance: Neglect of self-care? Weight loss?
• Behaviour: Tearful, agitated or retarded.
• Speech: Normal rate, or slow/monosyllabic.
• Mood: "Sad", "Empty".
• Affect: Depressed but often reactive (can smile at a fond memory).
• Perception: Check for pseudo-hallucinations (normal) vs psychotic hallucinations (abnormal).
• Thoughts: Themes of loss. Assess Suicide Risk.
• Insight: Usually preserved.

Timeline

• Acute Grief: Weeks to months.
• Integration: Most people adapt significantly by 6-12 months.
• Enduring Grief: A low level of sadness/remembrance often persists lifelong but does not impair function.

Outcome

• 90% resolve without medical intervention.
• 10% develop Prolonged Grief Disorder.

Key Guidelines

Landmark Studies

1. Prigerson et al. (2009) [4]

• Contribution: Defined criteria for Prolonged Grief Disorder distinct from Depression.
• Result: Validated PGD as a distinct nosological entity.
• Impact: Included in ICD-11.

2. Shear et al. (2005)

• Question: Psychotherapy for Complicated Grief.
• Result: Specific Complicated Grief Therapy (CGT) superior to standard Interpersonal Therapy (IPT).
• Impact: Need for specialised therapy protocols.

What is Grief?

Grief is the normal reaction to losing someone or something you love. It is not just sadness - it can include anger, guilt, numbness, exhaustion, and physical pain.

Symptoms you might not expect

• Physical pain: Heaviness in the chest, stomach aches.
• Hearing them: It is very common to think you see the person or hear their voice in the first few weeks. This does not mean you are going crazy.
• Memory loss: Brain fog and forgetfulness are common.

The Phases

There is no set "timetable", but most people experience:

1. Shock: Numbness, "autopilot".
2. Pain: The reality hits. This is the hardest part.
3. Adjustment: You start to build a life around the loss.

When to Seek Help

• If you feel you cannot function (wash, eat, work) after several months.
• If you feel life is not worth living.
• If you are using alcohol or drugs to cope.
• If the grief is getting worse rather than easier after 6 months.

How to Help Someone Grieving

• Don't avoid them.
• Say "I am sorry for your loss" (Don't say "I know how you feel").
• Listen more than you talk.
• Offer practical help (cooking, shopping) rather than "Let me know if you need anything."

Common Exam Questions

1. Psychiatry: "Distinguish Major Depression from Normal Grief."
   • Answer: Grief = Self-esteem preserved, sadness in waves, reactive mood. Depression = Worthlessness/guilt, persistent low mood, anhedonia.
2. General Practice: "A widow hears her husband's voice 2 weeks after death. Management?"
   • Answer: Reassurance. This is a normal distinct perceptual disturbance of grief (pseudo-hallucination). No antipsychotics.
3. Cardiology: "Widow presents with crushing chest pain 3 days after husband's funeral. Troponin elevated. Angio normal."
   • Answer: Takotsubo Cardiomyopathy.
4. Pharmacology: "Role of Benzos in grief?"
   • Answer: Avoid. They blunt the grieving process and risk dependence.

Viva Points

• Stages of Grief: Mention Kubler-Ross but acknowledge it's not linear. Prefer Dual Process Model.
• Suicide Risk: Highest in first week, especially elderly males. Always ask.
• Traumatic Grief: If PTSD features present (flashbacks), treat PTSD first/concurrently.

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.