Grief, Loss and Mood Disorders

by Paulette G. Lane

Dr. Robert Fernandez, a psychiatrist teaching at the University of South Florida School of Medicine and a private practice physician in the Tampa Bay area, spoke to the Depression and Bipolar Alliance in Tampa Bay, Florida, on May 13, 2003, on the subject of Grief, Loss and Mood Disorders.

Grief is normal and necessary. It is a reaction to the loss of a significant person or thing in one’s life. Such a loss can include death, divorce or estrangement, loss of a job, disability (loss of mental or physical function), relocation of self, friends or family, loss of status, youth, appearance, a body part, independence, a relationship, ideals or country. Grief is inevitable. If you want love in life, you must risk loss.

Grief is a wavelike phenomenon, with unsteady progress usually lasting about six months. Uncomplicated grief is minimally disruptive to one’s life. The first stage of uncomplicated grief is marked by shock and disbelief lasting from a few hours to a few weeks. Shock is followed by tearfulness and restlessness alternating with numbness, blunt affect, and withdrawal.

The second stage of the grieving process begins with a full realization of loss. Survivors may begin to experience somatic distress: tightness in the chest, choking with shortness of breath, sighing, an empty feeling in the abdomen, lack of muscle strength (weakness), or intense tension or mental pain. Other symptoms in the grief process include anger and irritability, perhaps rage, guilt, and attempts to focus blame or responsibility on others or on the self. There may also be an intense preoccupation with the deceased. This is the only time that psychiatrists consider hallucinations to be normal. These hallucinations, different from those of manic-depressive psychosis, may include hearing the deceased or, at times, having a sensation that the deceased is actually there.

The final stage brings resolution to the grieving process. One begins to review memories and discusses them in great detail when stimulated by inquiries. One gradually becomes interested in the outside world and becomes able to invest in new relationships. In this state, the loved one moves from being inside of us to a memory.

Anticipatory grief, in which one can start grieving before a loss occurs, as in grieving a spouse dying with cancer, can help a person cope with loss. However, there is a danger in anticipatory grief, as it could lead to premature withdrawal of loved ones from the dying patients.

People with uncomplicated grief rarely seek professional help. Dr. Fernandez stressed that very few people can grieve by themselves. Most need a good social network, if not professional help. Local hospices can offer some of the best support. They are professionals who help those grieving.

Societal expectations can contribute to the unresolved grief in our lives. Social factors contributing to the inability to grieve include the social negation of loss, as in society’s denial of loss in miscarriage and abortion; the socially unspeakable loss, as in AIDS and suicide; social isolation and social adulation of the strong, such as military men, doctors, nurses, counselors, and ministers. In addition, a loss of someone missing from military action (MIA) or someone with Alzheimer’s Disease can precipitate a reluctance to grieve due to the uncertainty of when to grieve.

Psychological factors can also complicate the grief process. Those whose attachments to family members or friends go beyond the normal and those who were never able to fully separate from their parents have particularly difficult times in grieving for their loved ones. They may suffer guilt. They may suffer the loss as an extension of the self (narcissistic loss). Or, their loss may reawaken an old loss (grief begets grief). Most of us have to grieve chronologically, according to Dr. Fernandez, and a disruption of that process complicates the grieving process. One needs to deal with an old loss before dealing with a new one. A grieving person may also be overwhelmed by multiple losses. One’s ego may be inadequately developed, compromising one’s ability to form relationships, and thus making it difficult to “let go.” For example, an abused, traumatized person needs to grieve his or her loss of potential, as the loss of a normal childhood leads to developmental problems. Dr. Fernandez noted that the only relationships we get over easily are the really good ones. Love-hate relationships are the most difficult to grieve.

There may be other idiosyncratic resistance to mourning. One might fear a loss of control, avoiding grief to avoid crying. A very religious person might think one must accept a loss and be happy for the person who has gone to heaven, or he or she might be angry with God. Unresolved grief can precipitate depression and can compromise one’s response to treatment for depression.

It is important to distinguish between grief and depression. We all associate grief with sadness. Anger and guilt are a normal part of grieving, but anger, guilt and sadness can also be part of mood disorder. A diagnosis of major depression is in order if symptoms persist after loss. Depression is characterized by certain symptoms not characteristic of a normal grief reaction. These include guilt about other actions, thoughts of death other than the survivor feeling better off dead, a morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged and marked functional impairment and hallucinations other than hearing the voice of the deceased.

How can we help someone who is grieving? Dr. Fernandez pointed out that it is not helpful to be direct with a loved one going through the grief process. However, it might be helpful to point out changes in lifestyle you see in the grief-stricken person. Telling the person about available resources or giving a book on the subject might also be helpful. Two good books are Harold Kushner’s When Bad Things Happen to Good People and Elizabeth Kubler-Ross’s On Death and Dying. An intervention by group of friends and family might also be necessary. Above all, says Dr. Fernandez, be patient with those going through the grieving process.

This article was reprinted with permission from the DBSA (Depression and Bipolar Support Alliance) Tampa Bay [Florida] Newsletter, August-September 2003.