Bereavement

What is a normal, or uncomplicated, response to losing a loved one? Due to the stressful nature of the event and the broad spectrum of grief manifestations that can result, there is no single, simple answer to this question. As outlined by Selby Jacobs, the array of common symptoms includes yearning for the lost person, preoccupation with the deceased, sighing, crying, dreams or illusions involving the deceased, searching for the lost loved one, anger, protesting the death, anxiety, sadness, despair, insomnia, fatigue, lethargy, loss of interest in previously enjoyable activities, loss of a sense of meaning, emotional numbness, nightmares, and being unable to accept the loss. Normal grief generally involves some subset of these features, with symptom intensities varying widely between individuals and over time.

In the form of a simple list, this collection of symptoms is somewhat bewildering. How are these emotional and behavioral responses related to one another? Are there sets of associated symptoms that tend to be exhibited as groups? Theorists have attempted to construct frameworks that draw connections between these manifestations in order to deepen understanding of the grieving process.

Stephen Shuchter and Sidney Zisook postulated that normal grief generally follows three stages. First, according to their model, there is a period of shock and disbelief, during which the bereaved person cannot accept that the loss has occurred. This gives way to an intermediate stage of acute mourning in which the individual is forced to confront the reality of the loss, resulting in increasing physical and emotional discomfort and social withdrawal. Ultimately, the person is able to assimilate the loss into the greater context of his or her life, and gradually returns to normal levels of functioning.

While this model is appealing for its simplicity, it is somewhat restrictive. By invoking uniform, sequential stages of grief progression, this framework cannot accurately describe a large percentage of the varied bereavement responses. Another approach, taken by Jacobs, is to look at the bereavement process as made up of multiple dimensions, or sets of symptoms, each of which can be present simultaneously, to varying degrees. As time passes, one dimension may replace another as the predominant grief manifestation, thus creating the appearance of stages but maintaining greater flexibility in the overall model.

Separation anxiety. Taking this approach, the question becomes What are the primary dimensions of grief? One of the most fundamental components seems to be a group of symptoms that have been labeled "separation distress" or "separation anxiety." This includes what Erich Lindemann has called the pang of grief— episodes of intense longing and yearning for the deceased, characterized by preoccupation with thoughts of the lost person, sighing, crying, and, in some cases, dreams, illusions, or even hallucinations involving the deceased. Behaviorally, this is manifested as searching for the lost person by seeking out places and things identified with that person, as if hoping to bring the deceased back to life. This searching behavior, often done unconsciously, ultimately meets with frustration, commonly resulting in another pang of grief.

The reason for such a reaction becomes more clear when we consider the concept of separation anxiety in the framework of attachment theory, which was initially developed by John Bowlby to explain how and why babies and children form bonds with their parents. Bowlby observed that young children exhibit pronounced "attachment behaviors," such as crying, touching, following, and calling, that serve to keep them in close contact with their parents or other protective individuals, known as "attachment objects." Bowlby hypothesized that these attachment behaviors came about, and were perpetuated in humans through evolution, because of the selective advantage such behaviors confer. Children who maintain relationships with parents and membership in social groups will be provided protection from predators, easier access to food, and improved ability to contend with competitors, all of which improve their chances of surviving to the age of reproduction. Thus, ingrained through evolutionary processes, attachment behavior is thought to be a "primary drive," hardwired into the neural circuits of the brain.

With this perspective, it becomes understandable why isolation from an attachment figure is a threatening situation that results in feelings of alarm, anxiety, anger, loneliness, and insecurity. This separation distress, which is defined as the reaction to the danger of losing an attachment object, is readily observable in infants and young children upon separation from a parent. While adults do not usually exhibit this behavior as frequently and explicitly as children do, the loss of a close relationship does result in the separation distress that makes up a component of normal grief, and in excessive reactions, or dysfunctional grief (described later).

Traumatic distress. Mardi Horowitz outlined two components of a traumatic stress response. The first involves intrusive symptoms aroused by a fear that the event will recur: frightening perceptions (such as illusions, nightmares), hypervigilance (always being "on the lookout"), startle reactions, feelings of helplessness, and insecurity. The second component, partly in reaction to the intrusive symptoms, consists of strategies for psychologically avoiding thoughts of the traumatic event: denial that the death occurred, dissociation (becoming detached from one's environment), emotional numbing, and avoidance of any place or thing that would result in painful memories of the event. Often, bereavement occurs in conjunction with an objectively traumatic event (e.g., natural disaster, war, accident). In such cases, the bereaved person may be traumatized by the event as well as by the impact of losing a loved one(s).

Depressive symptoms. It is generally acknowledged that some depressive symptoms are common in normal grief (e.g., sadness, despair, loss of interest in activities, significant weight loss or gain without dieting, insomnia, and fatigue). Full depressive episodes also occur secondary to a major interpersonal loss.