Grief

Bereavement IN ELDERLY
By DR. SUNIL SUTHAR

INDEX
1. Definitions
2. Phenomenology, Phases and Types of grief
3. Age and bereavement
4. Complications
5. Diagnosis
6. Neurobiology
7. Differential diagnoses
8. Assessment
9. Management

Definitions
•Grief-Grief is the subjective feeling precipitated by the death
of a loved one.
•Mourning-mourning is the process by which grief is resolved;
it is the societal expression of post bereavement behavior and
practices.
•Bereavement-Bereavement literally means the state of being
deprived of someone by death and refers to being in the state
of mourning.

Phenomenology of Grief
• Bereavement reactions include intense feeling states, invoke a
variety of coping strategies, and lead to alterations in:-
1. interpersonal relationships
2. biopsychosocial functioning
3. self-esteem
4. world view
they can last indefinitely.

Cont…
• Manifestations of grief reflect the individual's:-
1. Personality
2. previous life experiences
3. past psychological history
4. the significance of the loss
5. the nature of the bereaved's relationship with the deceased
6. the existing social network
7. intercurrent life events
8. Health
9. Other resources.

• Despite individual variations in the bereavement process, investigators
have proposed grieving process models, which include at least three
partially overlapping phases or states:
1. initial shock, disbelief, and denial
2. an intermediate period of acute discomfort and social withdrawal
3. a culminating period of restitution and reorganization.

Normal Bereavement Reactions
• The first response to loss is protest.
• followed by a longer period of searching behavior.
• As hope to reestablish the attachment bond diminishes,
searching behaviors give way to despair and detachment
before bereaved individuals eventually reorganize themselves
around the recognition that the lost person will not return.
• Grief work allows the survivor to redefine his or her
relationship to the deceased and to form new but enduring
ties.

Duration of Grief
• The bereaved is expected to return to work or school in a few
weeks, to establish equilibrium within a few months, and to be
capable of pursuing new relationships within 6 months to 1
year.
• Ample evidence suggests that the bereavement process does
not end within a prescribed interval; certain aspects persist
indefinitely for many otherwise high-functioning, normal
individuals.
• The most lasting manifestation of grief, especially after spousal
bereavement, is loneliness.

• Usually, these reactions become increasingly short-lived over
time, dissipating within minutes, and become tinged with
positive and pleasant affects.
• Such bittersweet memories may last a lifetime.
• Thus, most grief does not fully resolve or permanently
disappear; rather, grief becomes circumscribed and submerged
only to reemerge in response to certain triggers.

• The stages are tools to help us frame and identify what we may be
feeling.
• Different for everyone.
• Doesn’t always happen in exact order, may revert before moving
forward.

Anticipatory Grief
• In anticipatory grief, grief reactions are brought on by the slow
dying process of a loved one through injury, illness, or high-risk
activity.
• Although anticipatory grief may soften the blow of the eventual
death, it can also lead to premature separation and withdrawal,
while not necessarily mitigating later bereavement.
• At times, the intensification of intimacy during this period may
heighten the actual sense of loss, even though it prepares the
survivor in other ways.

Anniversary Reactions
• When the trigger for an acute grief reaction is a special occasion,
such as a holiday or birthday, the rekindled grief is called an
anniversary reaction.
• It is not unusual for anniversary reactions to occur each year on
the same day the person died or, in some cases, when the
bereaved individual becomes the same age the deceased was at
the time of death.
• Although these anniversary reactions tend to become relatively
mild and brief over time, they can be experienced as the reliving
of one's original grief and prevail for hours or days.

Chronic Grief-
• The most common type of complicated grief is chronic grief.
• It is highlighted by bitterness and idealization of the dead.
• Chronic grief is most likely to occur when the relationship
between the bereaved and the deceased had been extremely
close, ambivalent, or dependent or when social supports are
lacking and friends and relatives are not available to share the
sorrow over the extended period of time needed for most
mourners.

Delayed Grief
• Absent or inhibited grief when one normally expects to find
overt signs and symptoms of acute mourning is referred to
as delayed grief.
• This pattern is marked by prolonged denial; anger and guilt
may complicate its course.

Hypertrophic Grief
• Most often seen after a sudden and unexpected death
• Bereavement reactions are extraordinarily intense in
hypertrophic grief.
• Customary coping strategies are ineffectual to mitigate anxiety,
and withdrawal is frequent.
• When one family member is experiencing a hypertrophic grief
reaction, disruption of family stability can occur.
• Hypertrophic grief frequently takes on a long-term course,
albeit one attenuated over time.

Traumatic Bereavement
• CHRONIC + HYPERTROPHIC = TRAUMATIC BEREAVEMENT
• It is characterized by recurrent, intense pangs of grief with
persistent yearning, pining, and longing for the deceased;
recurrent intrusive images of the death; and a distressing
admixture of avoidance and preoccupation with reminders of
the loss.
• Positive memories are often blocked or excessively sad, or they
are experienced in prolonged states of reverie that interfere
with daily activities.
• A history of psychiatric illness appears to be common in this
condition, as is a very close, identity-defining relationship with
the deceased.

Bereavement during Adulthood
• Although the death of a spouse is often ranked as the most
stressful life event.
• The death of a child is a special sorrow, a lifelong loss for
surviving family members.
• A child's death is a life-altering experience.

• Grief appears most intense for the mother in late perinatal
losses.
• Sudden infant death syndrome is particularly problematic in
that the death is sudden and unexpected.
• Parents may experience extra guilt or blame each other, often
resulting in subsequent marital difficulties.

Next, we’ll look specifically how grief
and loss impact older adults…

The Grief Process: Older Adults
• Older adults express their grief in the same ways as younger and
middle-aged adults. However, because of their age and other life
circumstances, older adults may:
1. Experience several losses within a short period of time.
• Older adults are more likely than other adults to lose more
than one friend or family member within a short period of
time.
• This can cause them to grieve the losses at the same time
or grieve over a long period of time. It may also cause them
to feel overwhelmed, numb, or have more difficulty
expressing their grief.
2. Not be aware that they are grieving. They may feel sad and
experience other signs of grieving without realizing that they
are grieving.

3. Older adults also experience losses related to the aging process
itself:
• They may need to give up roles within their family.
• They may lose physical strength and stamina and lose
independence in areas that they previously mastered - the
lose of the ability to drive a car is especially difficult.
4. Be unwilling to tell other people that they are grieving. They
may also be unwilling to tell other people how sad they feel
when they see or care for older loved ones who are ill or aging.
5. Have long-term illnesses, including physical and mental
disabilities, that interfere with their ability to grieve.

6. Lack the support system they once had.
• Older adults who depended on their spouses or other
family members for social contact may lack a support
system after their spouses die or other family members
move away or die.
• These older adults may feel lonely and think that they have
no one to confide in.
7. Older adults are more likely to become physically ill after
experiencing a major loss.
• They may already have long-term physical illnesses or other
conditions that interfere with their ability to grieve.
• The symptoms of these illnesses may become worse when
they are grieving.

• Because of the special grieving challenges older adults experience,
elders are more at risk to develop unresolved grief or
complications associated with grieving.
• This may occur more often in older adults because, as noted
previously, they are more likely to experience:
1. Many major losses within a short period of time.
2. The death of their friends, including their spouses.
• Older adults who lose their spouses may suffer many losses,
including financial security, their best friend, and their social
contacts.

3. Losses that occur as a part of the natural aging process, such
as loss of societal standards of beauty and physical strength.
4. The loss of their independence or the development of illness
and other conditions that are common in older adults.
5. Anticipation of losing someone or something special to them
due to aging or chronic illness.
6. In addition, some older adults need more time than younger
people to adjust to change. As such, adjusting to change may
be more difficult and contribute to added emotional stress.
7. Older adults may seem to overreact to a minor loss. What is
considered a minor loss may bring memories and feelings
about a previous greater loss.

Men may have different coping styles than
women
• To remain silent.
• To engage in solitary mourning or secret grief.
• To take physical or legal action.
• To become immersed in activity.
• To exhibit addictive behaviour.

COMPLICATION OF GRIEF/BEREAVEMENT

Medical Illnesses Associated with Bereavement
• Medical complications include exacerbations of existing diseases
and vulnerability to new ones; fear for one's health and more trips
to the doctor; and an increased mortality rate, especially in men.
• The highest relative mortality risk is found immediately after
bereavement, particularly from ischemic heart disease.
• The greatest effect of bereavement on mortality is for men younger
than 65 years.
• Higher mortality rates in bereaved men than in bereaved women
are due to increases in the relative risk of death by suicide,
accident, cardiovascular disease, and some infectious diseases.

Psychiatric complications of bereavement
• Adjustment disorders
• Major depressive disorder, prolonged anxiety, panic, and a
posttraumatic stress like syndrome
• Acute and transient psychotic disorders
• Dysthymia
• Acute stress reaction
• Dissociative amnesia
• Overeating associated with other psychological disturbances
• Enduring personality change after bereavement
• Sexual Dysfunctions
• increased alcohol, drug, and cigarette consumption; and risk of
suicide.

• Contacts with medical and psychiatric
services because of normal bereavement
reactions, appropriate to the culture of the
individual concerned and not usually
exceeding 6 months in duration, should not
be recorded by means of the codes in this
book (ICD-10) but by a code from Chapter
XXI of ICD-10 such as Z63.4 (disappearance
or death of family member) plus for
example Z71.9 (counselling) or Z73.3 (stress
not elsewhere classified).
• Grief reactions of any duration, considered to be abnormal because
of their form or content, should be coded as F43.22, F43.23, F43.24
or F43.25, and those that are still intense and last longer than 6
months as F43.21 (prolonged depressive reaction).

DSM-5
• V62.82 (Z63.4) Uncomplicated
Bereavement
• Exclusion criteria for adjustment disorder-
The symptoms should not represent
normal bereavement.
• Other Specified Trauma- and Stressor-
Related Disorder = Other reactions to
severe stress (ICD-10)

Persistent Complex Bereavement Disorder:
diagnostic criteria
A. The individual experienced the death of someone with
whom he or she had a close relationship.
B. Since the death, at least one of the following symptoms is
experienced on more days than not and to a clinically
significant degree and has persisted for at least 12 months
after the death in the case of bereaved adults and 6 months
for bereaved children:
1. Persistent yearning/longing for the deceased. In young children,
yearning may be expressed in play and behavior, including behaviors that
reflect being separated from, and also reuniting with, a caregiver or
other attachment figure.

2. Intense sorrow and emotional pain in response to the death.
3. Preoccupation with the deceased.
4. Preoccupation with the circumstances of the death. In children,
this preoccupation with the deceased may be expressed through
the themes of play and behavior and may extend to
preoccupation with possible death of others close to them.
C. Since the death, at least six (additional symptoms are
required) of the following symptoms are experienced on
more days than not and to a clinically significant degree, and
have persisted for at least 12 months after the death in the
case of bereaved adults and 6 months for bereaved children:

• Reactive distress to the death
1. Marked difficulty accepting the death. In children, this is
dependent on the child’s capacity to comprehend the meaning
and permanence of death.
2. Experiencing disbelief or emotional numbness over the loss.
3. Difficulty with positive reminiscing about the deceased.
4. Bitterness or anger related to the loss.
5. Maladaptive appraisals about oneself in relation to the deceased
or the death (e.g., self-blame).
6. Excessive avoidance of reminders of the loss (e.g., avoidance of
individuals, places, or situations associated with the deceased; in
children, this may include avoidance of thoughts and feelings
regarding the deceased).

• Social/identity disruption
7. A desire to die in order to be with the deceased.
8. Difficulty trusting other individuals since the death.
9. Feeling alone or detached from other individuals since the death.
10. Feeling that life is meaningless or empty without the deceased,
or the belief that one cannot function without the deceased.
11. Confusion about one’s role in life, or a diminished sense of one’s
identity (e.g., feeling that a part of oneself died with the
deceased).
12. Difficulty or reluctance to pursue interests since the loss or to
plan for the future (e.g., friendships, activities).
D. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.

E. The bereavement reaction is out of proportion to or
inconsistent with cultural, religious, or age-appropriate norms.
• Specify if: With traumatic bereavement: Bereavement due to
homicide or suicide with persistent distressing preoccupations
regarding the traumatic nature of the death (often in response
to loss reminders), including the deceased’s last moments,
degree of suffering and mutilating injury, or the malicious or
intentional nature of the death.

• Prevalence- it is approximately 2.4%–4.8% (females>males)
• Development and Course-
It can occur at any age, beginning after the age of 1 year.
Symptoms usually begin within the initial months after the death,
although there may be a delay of months, or even years, before the
full syndrome appears.
Although grief responses commonly appear immediately following
bereavement, these reactions are not diagnosed as persistent
complex bereavement disorder unless the symptoms persist
beyond 12 months (6 months for children).

Biological Perspectives
• Grief is both a physiological and an emotional response.
• During acute grief persons may suffer disruption of biological
rhythms.
• Grief is also accompanied by impaired immune functioning:
decreased lymphocyte proliferation and impaired functioning of
natural killer cells.
• Whether the immune changes are clinically significant has not
been established, but the mortality rate for widows and widowers
following the death of a spouse is higher than that in the general
population.
• Widowers appear to be at risk longer than widows.

Neurobiology Cont….
• The experience of grief tends to activate both specific brain
areas linked to the aspect of grief that’s primary in the
moment, and a more general network of structures and
processes.
• These brain areas are involved
1. Parasympathetic nervous system
2. Frontal lobes
3. Cingulate gyrus
4. Insula
5. Amygdala

PNS
• This wing of the autonomic nervous system:
1. Handles maintenance functions: “rest and digest”
2. Balances the “sympathetic”wing: “fight or flight”
3. Is primary; unlike SNS, is necessary for life
• Activate and strengthen it by:
1. Breathing
2. Relaxation
3. Improving heart rate variability
4. Yawning
5. Positive emotion
6. Fiddling the lips

Frontal Lobes
• Grieving-related functions:
1. Finding meaning
2. Planning responses to loss
3. Bringing verbal thought to emotional and somatic processes
4. Controlling problematic expressions of feelings and desires
1. Have conscious reasons for self-care; be for oneself
2. Deliberately exercise the will
3. Make intentions conscious, multi-modal, and vivid; call to
mind a strong sense of the desired state
4. Give instructions to oneself
5. Re-intend at short intervals

Cingulate Gyrus
1. Retrieving autobiographical memories (i.e., with the person)
2. Integrating emotion and memory, and thinking and feeling
3. Controlling attention
4. Interest in other people
1. Activities which call for monitoring performance (e.g., careful
crafts, precision sports)
2. Deliberately linking emotion and memory (e.g., scrapbooks)
3. Linking thinking and feeling (e.g., speaking one’s experience or
reflecting about it in present time, therapy)

Insula
1. Sensing internal bodily (especially visceral) states
2. Involved in the sense of weight, heaviness, even loss of some
literal part of the self
1. Internal sensing activities (e.g., yoga)
2. Abiding in physical pleasure

Amygdala
1. Interprets stimuli (internal and external) as unpleasant, and
sends instructions to avoid or resist them
2. Active in nightmares
3. Major role in any traumatic components to grieving
• Incline the amygdala more positively:
1. Shift memories in a positive direction:
2. Memories are not recalled, but reconstructed.
3. Infuse the reconstruction with positive qualities:
Compassion, encouragement,Forgiveness practices

Bereavement v/s Depression DSM-5
1. In grief the predominant affect is feelings of emptiness and
loss while in MDE it is persistent depressed mood and the
inability to anticipate happiness or pleasure.
2. The dysphoria in grief is likely to decrease in intensity over
days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or
reminders of the deceased.The depressed mood of a MDE is
more persistent and not tied to specific thoughts or
preoccupations.

3. The pain of grief may be accompanied by positive emotions
and humor that are uncharacteristic of the pervasive
unhappiness and misery characteristic of a major depressive
episode.
4. The thought content associated with grief generally features
a preoccupation with thoughts and memories of the
deceased, rather than the self-critical or pessimistic
ruminations seen in a MDE.
5. In grief, self-esteem is generally preserved, whereas in a
MDE, feelings of worthlessness and self loathing are
common.

6. If self-derogatory ideation is present in grief, it typically involves
perceived failings vis-à-vis the deceased (e.g., not visiting
frequently enough, not telling the deceased how much he or she
was loved).
7. If a bereaved individual thinks about death and dying, such
thoughts are generally focused on the deceased and possibly
about “joining” the deceased, whereas in a major depressive
episode such thoughts are focused on ending one’s own life
because of feeling worthless, undeserving of life, or unable to
cope with the pain of depression.

Bereavement v/s PTSD
1.Unnatural and violent deaths, such as homicide, suicide, or death
in the context of terrorism, are much more likely to precipitate
PTSD in surviving loved ones than are natural deaths.
2.In such circumstances, themes of violence, victimization, and
volition (i.e., the choice of death over life, as in the case of suicide)
are intermixed with other aspects of grief, and traumatic distress
marked by fear, horror, vulnerability, and disintegration of
cognitive assumptions ensues.
3.Disbelief, despair, anxiety symptoms, preoccupation with the
deceased and the circumstances of the death, withdrawal,
hyperarousal, and dysphoria are more intense and more
prolonged than they are under nontraumatic circumstances, and
an increased risk may exist for other complications.

Bereavement v/s Separation anxiety disorder
1. Intense yearning or longing for the deceased, intense sorrow
and emotional pain, and preoccupation with the deceased or
the circumstances of the death are expected responses
occurring in bereavement.
2. whereas fear of separation from other attachment figures is
central in separation anxiety disorder.

Grief Assessment
What was the relationship
The age of the deceased
Nature of the Attachment
Mode of Death
Historical Antecedents
Personality Variables
history of psychiatric problems
Social Variables

Grief Therapy
• Persons in normal grief seldom seek psychiatric help because
they accept their reactions and behavior as appropriate.
• Accordingly, a bereaved person should not routinely see a
psychiatrist unless a markedly divergent reaction to the loss is
noted.
• For example, under usual circumstances a bereaved person
does not make a suicide attempt
• If someone seriously contemplates suicide, psychiatric
intervention is indicated.

Specific Ways to Help Others Cope with Loss
• Ask if they want to talk about their loss.
• Just sit with them, you don’t have to say anything to comfort
others
• Allow them to cry and be sad
• Don’t minimize their feelings
• Show you care by words AND actions
• Help with practical needs

• When professional assistance is sought, it usually involves a
request for sleeping medication from a family physician.
• A mild sedative to induce sleep may be useful in some situations,
but antidepressant medication or antianxiety agents are rarely
indicated in normal grief.
• Bereaved persons may have to go through the mourning process,
however painful it is, for successful resolution to occur.

• Because grief reactions can develop into a depressive disorder or
pathological mourning, specific counseling sessions for those
bereaved are often valuable.
• In regularly scheduled sessions, grieving persons are encouraged
to talk about feelings of loss and about the person who has died.
• Many bereaved persons have difficulty recognizing and expressing
angry or ambivalent feelings toward a deceased person, and they
must be reassured that these feelings are normal.

• Grief therapy need not be conducted only on a one-to-one basis;
group counseling is also effective.
• Self-help groups offer companionship, social contacts, and
emotional support; they eventually enable their members to
reenter society in a meaningful way.
• Bereavement care and grief therapy have been most effective with
widows and widowers.
• The necessity for this therapy stems, in part, from the contraction
of the family unit; extended family members are no longer
available to provide the needed emotional support and guidance
during the mourning period.

the components of grief counseling - key areas of
focus in helping persons process grief.

Grief Counseling
• Grief counseling is short term and focuses on helping people
work through the grieving process related to a major loss.
• Grief counseling is also called bereavement counseling, but
the term "bereavement" usually is used only when referring
to the loss of a person through death.

Grief Counseling
• Grief counseling typically has four components:
1. Learning about grief and what to expect when grieving.
• In grief counseling, people are taught the normal grieving process,
including expected feelings and thoughts.
• They are also taught how to tell the difference between normal grieving
and other conditions, such as depression, that can develop from
grieving.
2. Expressing feelings.
• People are encouraged in grief counseling to express all their feelings,
whatever they may be.
• Sometimes people who are having trouble expressing their feelings are
encouraged to talk about their loss or to use other means of expressing
themselves.
§ For example, they may be asked to speak with the lost person as
though he or she were there.

Grief Counseling
• Other techniques that help people express their feelings
include:
§ Writing letters about their loss or writing to the lost person.
§ Looking at photos and remembering the lost loved one or
object, or visiting the grave of a loved one who has died.
3. Building new relationships.
• This component of grief counseling helps people develop a
new relationship with the lost person or object.
• Since memories usually linger for years and can sometimes be
troubling, emphasis is placed on learning how to incorporate
memories of the past into the present.

Grief Counseling
4. Developing a new identity.
• During grief counseling, people are taught how to develop a
new sense of self after a loss.
• For example:
§ A top corporate executive who retires strengthens his or her
self-perception as a grandparent and spouse instead of as a
corporate leader.
§ A widow who has lost her husband of 68 years begins
meeting with other women in her building for tea every
morning.

References
• Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry, 10th Edition
• Harald Gündel, M.D.; Mary-Frances O’Connor, Ph.D.; Lindsey Littrell,
B.A.; Carolyn Fort, B.S.; Richard D. Lane, M.D., Ph.D. Am J Psychiatry
2003;160:19461953.doi:10.1176/appi.ajp.160.11.1946
• Implications of Neuroscience and Contemplative Wisdom Rick Hanson,
Ph.D.
• Coping with Grief and Loss:Lou Ann Hamilton,MSW, LCSW, Counselor
Office of the Dean of Students Schleman Hall Purdue University
• http://www.kidshealth.org/teen/your_mind/emotions/someone_died.h
tml 1995-2007 The Nemours Foundation.
• Understanding Grief: Assessment and Treatment Planning:Karen Horinek,
L.C.P.C. Bereavement Coordinator/Counselor And Terra Solove, M.S.W.
Bereavement Counselor
• Ian Anderson Continuing Education Program in End-of-Life Care

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