bereavement

Introduction

• Sadness, emotional suffering or grief experienced after the tragic loss of a loved one or priceless object.
• also see adjustment disorder

Epidemiology

• most common in elderly after loss of spouse

Clinical manifestations

• grief
• depressed mood
• insomnia
• anorexia
• weight loss
• waves of somatic distress
  • sighing & choking
  • empty feeling in the stomach
  • duration 20 minutes to 1 hour
  • precipitated by mention of the deceased or expressions of sympathy from relatives
• delusions generally do NOT occur
• self esteem is preserved
  • loss of self esteem is a symptom of depression rather than bereavement
    • persistent low mood, avoidance of family contact, feeling of no purpose, & sense of futility consistent with loss of self esteem
• acute period
  • exhaustion with the slightest activity
  • avoidance of social interaction
  • loss of appetite for food
• subacute period (days to weeks following loss)
  • preoccupation with the image of the deceased
  • feelings of guilt (appropriate) or anger
  • searching behaviors such as expecting to see the deceased
• mourning period of 6-12 months (working through loss)
  • after 6 months consider complicated grief

Complications

• increased medical complaints
• substance abuse
• anxiety
• insomnia
• prolonged depression (exceeding 1 year)
  • 20% of bereaved spouses show little resilience to bereavement
  • majority of patients without prior mental illness will return to former level of functioning
• increased risk of cardiovascular events
  • risk for myocardial infarction, stroke greatest within 30 days after death of loved one
  • risks for acute coronary syndrome & pulmonary embolism increased for 90 days
  • increased risk for atrial fibrillation (RR=1.9)

Differential diagnosis

• complicated/abnormal grief
• features suggesting major depression rather than bereavement*
  • suicidal ideation
  • pervasive guilt
  • morbid preoccupation with worthlessness
  • marked psychomotor retardation
  • prolonged disability
  • functional impairment
  • loss of self esteem (see Clinical manifestations above)

* DSM 5 does NOT consider bereavement an exclusion for the diagnosis of major depression

Management

• screen for depression with PHQ9 as indicated
• treat depression if in doubt of diagnosis
  • psychotherapy
  • cognitive behavioral therapy
  • SSRI if non-pharmaceutical measures inadequate
  • patients with severe grief who do not show improvement within 2 weeks or who have risk factors for complicated grief or depression (prolonged caregiving, social isolation) should be started or referred for psychotherapy or prescribed an antidepressant
• adjustment disorders usually resolve without medications with resolution of acute stressor
• bereavement support
  • a hand-written note from the physician
    • acknowledges the loss
    • provides support to the family
    • empahsizes personal strengths of family
  • attendance at funeral
• majority of patients without prior mental illness will return to former level of functioning

More general terms

• adjustment disorder

Additional terms

• abnormal grief; depressive grief; complicated grief; prolonged grief disorder
• grief
• mourning