1. Grief
The reaction to loss
21 Feb 2014
Kornkanok Jaruch, MD

2. Outline
0 Definition
0 Basic task of grief
0 Descriptions of the grief process
0 Psychological manifestations of grief
0 Social manifestations of grief
0 Physiological manifestations of grief
0 Abnormal grief reaction
0 Anticipatory grief

3. Grief
0 The process of psychological, social, and somatic
reaction to the perception of loss.
0 Based upon the unique, individualistic perception of loss
by the griever

4. Bereavement
0 The state of having suffered a loss
0 Resolved grief

5. Mourning
0 A wide array of intrapsychic processes, conscious and
unconscious, that are prompted by loss. (from
psychoanalytic theory)
0 The cultural response to grief

6. Loss
0 2 kinds
0 Physical (Tangible) loss
0 Losing a desired possession
0 Having a friend die
0 Symbolic (Psychosocial) loss
0 Getting a divorce
0 Losing status because of a job demotion
0 An argument with a colleague

7. The basic tasks of grief
Emancipation from bondage of the deceased
Readjustment to the environment in which the deceased
is missing
Formation of new relationships

8. Emancipation from
bondage of the deceased
0 “cathexis” when an individual cares about someone, he
emotionally invests part of himself in that person
0 To withdraw the emotional energy that was invested in
the person who is longer alive.
0 Movement along the continuum from a relationship of
presence to a relationship of memory.

9. Readjustment to the environment
in which the deceased is missing
0 To accommodate to the world without the presence of
the deceased
0 To adopt new roles and skills to compensate for those
functions that once were performed by the loved one.

10. Formation of new relationships
0 Based on the altered status of the loved one

11. Stage of grief
 Lindermann
 Shock and disbelief
 Inability to accept the loss and occasionally the absolute
denial that the loss has occurred.
 Acute mourning
 Acceptance of the loss, disinterest in daily affairs, weeping,
feelings of loneliness, insomnia, and loss of appetite.
 Resolutions of the grief process
 A gradual reentry into the activities of daily life and a
reduction in preoccupation with the image of the
deceased.

12. Stage of grief
 Bowlby, 1980
 Phase of numbness
 Phase of yearning and searching
 Phase of disorganization and despair
 Phase of reorganization

13. Stage of grief
 Kubler-Ross (1969)
Anger
Bargaining
Acceptance
Depression

14. Psychological manifestations of grief
0 The avoidance phase
0 Shock, confused, dazed, unable to comprehend what has
happened
0 Denial immediately crops up (therapeutic)
0 Emotional anesthesia
0 Disbelief and a need to know why the death occurred may
appear at this time
0 The loss is recognized -> intellectualized acceptance of the
death, followed by activities ex. Comforting of
others, making funeral arrangement

15. Psychological manifestations of grief
0 Caution !!
0 When the mourner is denying the death
0 Denying the emotions stimulated by the death

16. Psychological manifestations of grief
0 The confrontation phase
0 Grief is experience most intensely in this phase
0 Angry sadness
0 Panic or generalized anxiety disorder
0 It is critical to assure the mourner that his feelings are
normal and legitimate.
0 Anger to God, the doctors, the person who died, other who
have not sustained the loss, and the bereaved person
himself

17. Psychological manifestations of grief
0 The reestablishment phase
0 A gradual decline of grief and marks the beginning of the
emotional and social reentry back into the everyday world.
0 The loss is not forgotten but be the memory.

18. Social manifestations of grief
0 Loss of normal patterns of conduct
0 Restlessness and inability to sit still
0 A painful lack of ability to initiate and maintain organized
patterns of activities
0 Social withdrawal behavior that is antithetical to the
establishment of new relations and the alleviation of
stress

19. Physiological manifestations of grief
0 Anorexia and other gastrointestinal disturbances
0 Loss of weight
0 Inability to sleep
0 Crying
0 Tendency to sigh
0 Lack of strength
0 Physical exhaustion
0 Shortness of breath

20. Physiological manifestations of grief
0 Feelings of emptiness and heaviness
0 Feelings of “something stuck in the throat”
0 Palpitation
0 Nervousness and tension
0 Loss of sexual desire or hyper sexuality
0 Lack of energy and psychomotor retardation

21. Abnormal grief
0 4 type
0 Chronic grief reaction
0 Delayed grief reaction
0 Inhibited, suppressed
0 Postponed grief reaction
0 Exaggerated grief reaction
0 Masked grief reaction

22. Abnormal Grief Reaction
 Factors that relate to abnormal grief reaction
 High ambivalence relationship to the decease
 more anger and guilt
 highly narcissistic relationship : the decease as the
extension of oneself
 highly dependent relationship: helpless
 Circumstance:
 the death was not confirmed Ex. Soldier dead in the war
 The death of many people in family

23. Abnormal Grief Reaction
 Past history
 early parental loss
 insecure childhood attachments
 ambivalent toward mother – first love objects
 Personality
 Can’t resist to emotional stress
 Obstinate person
 Social
 loss of social support
 Suicide, criminal abortion
 uprooting

24. Prolonged grief disorder
0 DSM-V Criteria
0 experience 5 of 9 of these symptoms for 6 months or
longer after loss
0 yearning, disbelief, bitterness over the loss
0 confusion about one's identity
0 a sense of numbness
0 distrust of others
0 a feeling that life is meaningless since the loss
0 difficulty accepting the loss
0 feeling stunned by the loss

25. 0
0
0
0
0
0
psychomotor retardation)
(marked

26. To recovery from grief
0 3 tasks
0 Intellectual recognition and explanation of the loss
0 Develop an explanation of how the loss happened
0 Identified the inevitable cause of the death
0 Emotional acceptance of the loss
0 Finally reach a point where they no longer find the
reminders of the loss too painful to face

27. To recovery from grief
0 Assumption of a new identity
0 The process begins as mourners become uncomfortably
aware of the discrepancy between the world that is now
and the world that was
0 Inevitably painful and time consuming

28. Anticipatory grief
In dying patients and the families of the terminally ill
Depression
Heightened concern for the terminally ill person
Rehearsal of the death
Attempts to adjust to the consequences of the death

29. Anticipatory grief
Absorbing the reality of the loss gradually overtime
Finishing unfinished business with the dying person
 Ex. Expressing feelings, resolving past conflicts
Beginning to change assumptions about life and identity
Making plans for the future so that they will not be felt
as betrayals of the deceased after death

30. Anticipatory grief
The Lazarus syndrome
Occur when a patient is expected to die, the family
members’ potential losses are as resolved as possible
prior to death, and the patient goes into remission.
The family members may be frustration, anger ,and
resentment

32. Basic tasks of grief
 Emancipation from bondage of
the deceased
 Readjustment to the
environment in which the
deceased is missing
 Formation of new relationships
Stage of grief
-denial
-anger
-bargaining
-depression
-acceptance
Prolong grief disorder
experience 5 of 9 of these symptoms for >6 months
 yearning, disbelief, bitterness over the loss
 confusion about one's identity
 a sense of numbness
 distrust of others
 a feeling that life is meaningless since the loss
 difficulty accepting the loss
 feeling stunned by the loss
To recovery from grief
• Intellectual recognition and
explanation of the loss
• Emotional acceptance of the
loss
• Assumption of a new identity
JkPang

33. Pathological grief