Grief and Bereavement
Bereavement
Refers to the objective situation of having lost someone significant through death.
Grief
Refers to the primarily emotional reaction to the loss of a loved one through death. It also incorporates diverse psychological and physical manifestations, including cognitive, social-behavioral, and physiological-somatic reactions (Stroebe, Hansson, Schut, & Stroebe, 2008). It is a natural and normal process that occurs when we experience a significant loss.
Common Grief Reactions
Bereaved individuals may experience a range of common grief reactions in different domains (Stroebe, Schut, & Stroebe,2007).
People may experience a range of intense emotions, including depression, anxiety, despair, sadness, anger, guilt, loneliness, yearning, longing, shock, and numbness. These emotions may be triggered by reminders of the person who has died, such as a song, a photograph, or a place.
Grief can affect the way people think and process information. Bereaved persons may experience preoccupation with thoughts of the deceased and intrusive thoughts or images related to the deceased. They may have difficulty concentrating, making decisions, or remembering things. Some people may cognitively deny the loss or have a sense of unreality. Lowered self-esteem and self-reproach are also common reactions toward loss.
People may change their behavior in response to grief. Crying is the most common reaction. Some people may withdraw from social activities, avoid reminders of the person who has died, or show overactivity and restlessness.
Grief can manifest in physical symptoms, such as fatigue, difficulty sleeping, loss of appetite, headaches, and endocrine changes. Some people may experience physical symptoms similar to the deceased.
It is important to note that grief is a highly individual experience, and everyone experiences it differently. The manifestation and degree of grief can vary greatly from person to person. As professionals, it is crucial that we understand and accept these differences, and conduct individualized assessments and support accordingly.
Prolonged Grief Disorder (PGD)
While grief is a natural response to bereavement, it can become problematic in certain circumstances. Prolonged grief disorder (PGD) has been recognized as a distinct disorder in both the International Classification of Diseases 11th revision (ICD-11) by the World Health Organization and in the Diagnosis and Statistical Manual for Mental Disorders, 5th Edition, text revision (DSM-5-TR) by the American Psychiatric Association.
ICD-11 described PGD as "a persistent and pervasive grief response characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain" (Prigerson, Kakarala et al., 2021), with examples of emotional pain provided for consideration. The diagnosis of PGD is based on the duration of the grief response, which should last for a prolonged period of time beyond social and cultural norms, with a minimum of 6 months. Additionally, the grief response should result in significant functional impairment in the bereaved person's personal life, family, work, or other important aspects.
In DSM-5-TR, PGD should only be considered after 12 months following the loss (6 months for children) (Prigerson, Boelen et al., 2021). As with ICD-11, persistent longing for and preoccupation with the deceased are the primary features of PGD. A specific standard of the number of additional symptoms (3 out of 8) is required for diagnosis. Similar to ICD-11, the duration of the grief response should exceed social and cultural norms, and significant functional impairment is necessary for the diagnosis of PGD.
Multi-dimensions of grief
Apart from grief reaction, bereavement may lead to multi-dimensional outcomes. The ADAPTS model (Chow, 2017), for bereavement assessment and intervention, includes six dimensions of bereavement outcomes.
Bereavement-related Dysfunctional cognition
Bereavement-related Adjustment challenges
Bereavement-related Physical responses
Bereavement-related Traumatic responses
Separation Distress
It is hence important that helping professionals should examine all the dimensions of bereavement outcome in order to make a comprehensive assessment of the bereaved clients.
Chow, A.Y. M. (2017, July 13). Multifacet of Grief, Multufacet of Coping: The ADAPTS Model. [Conference session]. The 11th International Conference on Grief and Bereavement in Contemporary Society, Lisbon, Portugal.
Prigerson, H. G., Kakarala, S., Gang, J., & Maciejewski, P. K. (2021). History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis. Annual Review of Clinical Psychology, 17, 109-126.
https://doi.org/10.1146/annurev-clinpsy-081219-093600
Prigerson, H. G., Boelen, P. A., Xu, J., Smith, K. V., & Maciejewski, P. K. (2021). Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry, 20(1), 96-106. https://doi.org/10.1002/wps.20823
Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370(9603), 1960-1973.
Stroebe, M. S., Hansson, R. O., Stroebe, W. E., & Schut, H. E. (2001). Handbook of bereavement research: Consequences, coping, and care. American Psychological Association.
