Grief Reaction


Article Author:
Saba Mughal


Article Editor:
Waqas Siddiqui


Editors In Chief:
Andrew Sherman
Richard Kaplan


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/25/2019 12:02:49 AM

Introduction

Grief is a natural and universal response to the loss of a loved one. The grief experience is not a state but a process. Most individuals recover adequately within a year after the loss; however, some individuals experience an extension of the standard grieving process. This condition has been identified as complicated grief or prolonged grief disorder, and it results from failure to transition from acute to integrated grief. [1]Symptoms of acute grief include tearfulness, sadness and insomnia and typically require no treatment. Intense grief over the loss of a significant person may trigger the acute onset of myocardial infarction (MI). The impact may be higher with cardiovascular risk.[2] Complicated grief has prolonged symptoms of painful emotions and sorrow for more than one year. Patients show a preoccupation with the deceased and feel inner emptiness, no interest in life, and sleep poorly. There is a correlation between complicated grief and acute coronary syndrome (ACS).  There is now a new consensus that 7% to 10 % of bereaved individuals experience intense and chronic reactions called prolonged grief. 

The terms grief, mourning, and bereavement have slightly different meanings:

  • Grief is a person's emotional response to loss.
  • Mourning is an outward expression of that grief, including cultural and religious customs surrounding death. It is also the process of adapting to life after loss.
  • Bereavement is a period of grief and mourning after a loss.
  • Anticipatory Grief is a response to an expected loss. It affects both the person diagnosed with a terminal illness as well as their families. [3]
  • Takosubo Cardiomyopathy (Broken Heart Syndrome): is a weakening of left ventricle caused by severe emotional or physical stress such as loss of a loved one, sudden illness, a serious accident, or a natural disaster (e.g., earthquake). It almost exclusively occurs in women and resolves within a month.[4]

Etiology

Five Stages of Grief

  1. Denial and Isolation
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

Cardiac Outcomes of Grief

  • Heart Attack
  • Takosubo cardiomyopathy (broken heart syndrome): Occurs predominantly in postmenopausal women soon after exposure to sudden, unexpected physical and emotional stress.
  • Atrial Fibrillation: Heart rhythm disorders or arrhythmias, such as atrial fibrillation, caused by stress. Studies report stress and mental health issues worsening atrial fibrillation symptoms.

Factors Increasing Risk After Bereavement

Traumatic circumstances such as the death of a spouse or a child, the death of a parent in early childhood or adolescence, sudden, unexpected, and untimely deaths ( particularly if associated with horrific circumstances), multiple deaths (particularly disasters), deaths by murder or manslaughter.

Vulnerable people such as those with low self-esteem, low trust in others, previous psychiatric disorder, previous suicidal threats or attempts, and/or absent or unhelpful family are more likely to experience increased symptoms.

Specifically includes ambivalent attachment to deceased people, dependent or interdependent attachment to the deceased person, insecure attachment to parents in childhood (particularly learned fear or learned helplessness).[5]

Epidemiology

Gender

The loss of a spouse typically causes greater negative consequences in men than women. Mortality rates for both men and women who have lost a loved one are increased when compared to nonbereaved people, with the mortality rate higher for males as compared to females. Men experience greater depression and a higher overall health consequence than women.

Age

Younger bereaved persons have more consequences following a loss than older people, including more severe psychological and physical health consequences. These age-related symptoms may be because younger people often experience sudden and unexpected loss. Younger bereaved persons may have more difficulty in the initial period after a loss but may recover sooner because they have access to more social resources.

Pathophysiology

Grief related stress can lead to high blood pressure, tachycardia, and increased levels of cortisol. It can disrupt cholesterol-filled plaques that line coronary arteries and constrict blood vessels. These changes can increase the risk of myocardial infarction. Increased levels of stress lead to catecholamine surge which increases the platelet aggregation. If a plaque ruptures, platelets form a blood clot on top of the ruptured plaque obstruct blood supply.

Takosubo cardiomyopathy is caused by grief or fear that leads to stimulation of adrenal glands and progresses to elevated levels of adrenaline which creates reduced blood flow to the heart.

History and Physical

Common grief reactions: Reactions to loss are called grief reactions and vary from person to person and within the same person over time.  Grief reactions lead to complex somatic and psychological symptoms.

Feelings: The person who experiences a loss may have a range of feelings, including shock, numbness, sadness, denial, anger, guilt, helplessness, depression, and yearning. A person may cry for no reason.

Thoughts: Grief can cause feelings of disbelief, confusion, difficulty concentrating, preoccupation, and hallucinations.

Physical sensations: Grief can cause physical sensations like tightness and heaviness in the chest or throat, nausea or stomach upset, dizziness, headaches, numbness, muscle weakness, tension, or fatigue. It will make the person vulnerable to illness.

Behaviors: Difficulty sleeping, loss of interest in daily activities, and becoming more aggressive or irritable. 

Somatic symptoms: Chest tightness and choking, shortness of breath, abdominal distress, decreased muscle power, and lethargy.

Psychological symptoms: Guilt, anger, hostility, restlessness, inability to concentrate, lack of capacity to initiate and maintain an organized pattern of activities.

Takosubo cardiomyopathy: chest pain and shortness of breath after severe stress (emotional or physical), ECG changes that mimic heart attack with no coronary artery occlusion, movement abnormalities of left ventricle and ballooning of left ventricle.

Evaluation

The grief evaluation measure (GEM) is a screening tool designed to measure the development of complicated grief symptoms in a mourning adult. It assesses both qualitative and quantitative risk factors including mourner's loss and medical history, financial resources both before and after the loss, and circumstances surrounding the death. It provides in-depth information on bereaved the individuals' subjective grief symptoms and associated experience.[6]

There are some screening tools designed to predict complicated grief in the spouses of cancer patients. These two scales Family Adaptability and Cohesion Evaluation Scale (FACES III), and Brief Symptom Inventory (BSI) assess family functioning, psychological functioning and grief reaction. 

Patients having "complicated grief" symptoms may have interpersonal psychotherapy and cognitive- behavioral therapy to reduce the severity of complicated grief symptoms. [7]

In the majority of the patients with Takosubo cardiomyopathy, a coronary angiogram may be inconspicuous. Cardiac imaging plays an important role and shows left ventricular dysfunction.

Treatment / Management

Normal Grief: Most bereaved persons adapt over six months to 2 years. Patients experiencing complicated grief may require psychological treatment in the form of cognitive behavioral therapy (CBT) and pharmacological bereavement-related depression.[8]

Takosubo cardiomyopathy (TCM): Patients with TCM will require inpatient cardiology service. Treatment options are empiric and supportive; however, beta blockers can be helpful when hemodynamics permit. Serial imaging studies may be necessary. These patients should follow-up with a cardiologist within one week of diagnosis to resolve cardiomyopathy with echocardiograms.

Complications

Physical Complications

  • Impairment of immune response system
  • Increased adrenocortical activity
  • Increased serum prolactin and increased serum growth hormone. 
  • Increased mortality from heart disease (especially in elderly widowers)

Psychosomatic disorders 

Psychiatric (nonspecific) 

  • Depression (with or without suicidal risk)
  • Anxiety 
  • Panic disorders
  • Other psychiatric disorders

Psychiatric (specific)

  • Post-traumatic stress disorders
  • Chronic grief
  • Delayed or inhibited grief

Deterrence and Patient Education

Deterrence and Patient Education

It is important to consider the following before disclosing bad news: [9]

  • It is essential to have social support and place where to meet (setting). 
  • Try to establish a relationship of mutual trust and respect. 
  • Provide information at a speed and language that is easily understood.
  • Try to discover what facts are already known by the patient and family.
  • Encourage questions and monitor what is been understood. It takes time to hear and understand bad news. 
  • Give verbal and nonverbal assurance regarding the normality of their reactions.
  • It is important to give some time to the patient and family to react emotionally. 
  • Stay with the patient and the family until they are ready to leave and offer further opportunities for clarification, information, or support.[10]

Preparedness for End-of-Life Care

It is important to mentally prepare spouses of terminally ill patients. Preparedness for death and coping with bereavement play a very important role in complicated grief.[11]

Enhancing Healthcare Team Outcomes

Management of the grieving patient is best done with a multidisciplinary team that includes a mental health nurse, palliative care team, psychiatrist, primary care provider, social worker, and other support teams. Even temporary grieving can affect patients both physically and mentally, and it is best to have a mental health nurse involved in the care early on. For most patients, time will help heal the grieving process but some patients may benefit from counseling or temporary use of pharmacotherapy.


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Grief Reaction - Questions

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A 78-year-old man, whose wife passed away four weeks ago after a long illness, is admitted to the hospital for worsening chest pain. During the hospital stay, it is observed that he is tearful, depressed, and claims to hear his wife's voice intermittently. He blames himself for not looking after her well. Which of the following is the most appropriate diagnosis?



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Which of the following is not a stage of grief as per Kubler Ross?



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Which of the following is typical of grief?



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What is the first stage of grief according to the Kubler-Ross model?



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Which one of the following is sign of abnormal bereavement?



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Which of the following is not a risk factor for abnormal bereavement?



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What is incorrect about childhood bereavement?



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A patient is diagnosed with a disabling condition. Which of the following adaptive responses is most likely to resolve without intervention?



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Which of the following is not a characteristic of grieving?



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Which of the following is not associated with normal bereavement?



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Which of the following is true of anticipatory grief?



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Which of the following does not cause Takotsubo cardiomyopathy?



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Which of the following is not a common symptom in people going through grief reaction?



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Grief Reaction - References

References

Meeting the needs of carers of people at the end of life., Hardy B,, Nursing standard (Royal College of Nursing (Great Britain) : 1987), 2018 Apr 28     [PubMed]
[Influential Factors of Complicated Grief of Bereaved Spouses from Cancer Patient]., Kim SM,Kown SH,, Journal of Korean Academy of Nursing, 2018 Feb     [PubMed]
Primary Care for the Elderly Bereaved: Recommendations for Medical Education., Morris S,Schaefer K,Rosowsky E,, Journal of clinical psychology in medical settings, 2018 Mar 2     [PubMed]
Emotional triggers in myocardial infarction: do they matter?, Edmondson D,Newman JD,Whang W,Davidson KW,, European heart journal, 2013 Jan     [PubMed]
Depression, Hopelessness, and Complicated Grief in Survivors of Suicide., Bellini S,Erbuto D,Andriessen K,Milelli M,Innamorati M,Lester D,Sampogna G,Fiorillo A,Pompili M,, Frontiers in psychology, 2018     [PubMed]
Anticipatory Grief, Proactive Coping, Social Support, and Growth: Exploring Positive Experiences of Preparing for Loss., Rogalla KB,, Omega, 2018 Jan 1     [PubMed]
Guilt in bereavement: Its relationship with complicated grief and depression., Li J,Tendeiro JN,Stroebe M,, International journal of psychology : Journal international de psychologie, 2018 Mar 5     [PubMed]
When a broken heart is real: Takotsubo cardiomyopathy., Pore N,Burley M,, The Nurse practitioner, 2012 Oct 10     [PubMed]
Treating complicated grief: effects on sleep quality., Germain A,Shear K,Monk TH,Houck PR,Reynolds CF,Frank E,Buysse DJ,, Behavioral sleep medicine, 2006     [PubMed]
The grief evaluation measure (GEM): an initial validation study., Jordan JR,Baker J,Matteis M,Rosenthal S,Ware ES,, Death studies, 2005 May     [PubMed]
Screening to predict complicated grief in spouses of cancer patients., BrintzenhofeSzoc KM,Smith ED,Zabora JR,, Cancer practice, 1999 Sep-Oct     [PubMed]

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