Grief: Causes, Types, Stages, How to Cope With It, and When to Get Help Everyday Health MenuNewslettersSearch Grief

All About Grief What Causes It How to Cope With It and When to Get Help

By Markham HeidMedically Reviewed by Allison Young, MDReviewed: April 5, 2022Medically ReviewedMore so than most other species, we form intensely close bonds with family members and friends, and to a lesser extent also with neighbors, colleagues, and acquaintances. When loss breaks one of those bonds, it’s natural and normal to experience a strong emotional response. Grief is the name we’ve given to that emotional response. It encompasses the sadness, disorientation, and other intense and often sorrowful experiences we go through as we live with a loss. Grief can also cause a range physical symptoms and behavioral responses. While just about everyone has an idea of what it means to grieve, psychologists and therapists who study grief say that there is a lot more to the experience than most of us fully appreciate.

How Do Psychologists Define Grief

Grief, in a nutshell, is what we experience following loss. “Researchers, including myself, usually use the term grief to refer to our emotional reactions to the deaths of those we care about,” says Michael Cholbi, PhD, a professor of philosophy at the University of Edinburgh in Scotland. Dr. Cholbi’s research has focused on grief, much of which he details in his new book Grief: A Philosophical Guide. “In the wider culture, [grief] is increasingly used to refer to our emotional reactions to any significant loss, not just losses due to others’ deaths,” he says.more on Grief

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He mentions the loss of a job or a romantic breakup as examples. Others include the loss of a friend, of a dream, or of a way of life. Some experts have said that pandemic-related disruptions — to say nothing of lost lives — may also have initiated a form of collective grief, according to a report from the UCSF Department of Psychiatry and Behavioral Sciences.Grief is often described as a process rather than as a single state or emotion. And depending on the person and the source of loss, grief can take different forms or trigger a wide range of symptoms, according to a review article on the topic published in 2021 in StatPearls.

The Types of Grief

Some experts divide grief into numerous subtypes or categories. Many of those are debated — or downright contested — but a few have gained broad acceptance among doctors and academics.

Normal Versus Complicated or Prolonged Grief

At a high level, most experts recognize two types of grief. The first is sometimes termed “normal” or “healthy” grief, while the second goes by the name “complicated” or “prolonged” grief. “The difference between normal or healthy grief and prolonged grief is related to whether certain defensive responses — that are a normal part of early grief — become persistent and overly influential in mental functioning,” explains M. Katherine Shear, MD, the Marion E. Kenworthy Professor of Psychiatry at Columbia University in New York City, who studies grief and bereavement and is the founding director of Columbia’s Center for Complicated Grief. Dr. Shear says that some examples of such defensive responses include: disbelief that a loved one is really gone and never coming back; self-blame or anger related to the death; avoidance of things that trigger grief; or imagining alternative scenarios in which the source of one’s grief doesn’t happen or happens differently.The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) — the formal guide that psychiatrists use to identify and diagnose mental health problems — now recognizes “prolonged grief disorder” as a diagnosable mental health condition. ”It’s characterized by persistent pervasive yearning, longing, or preoccupation with the person who died, along with a range of other manifestations of intense grief that is interfering with the person’s life and is persisting at least six months and longer than the person’s social, cultural or religious group expects,” says Shear, whose work and input as an advisor helped shape the DSM-5’s inclusion of prolonged grief disorder. It’s important to highlight that, when a person is first grieving, almost all emotions or experiences are considered normal and not disordered. It’s only after a fair amount of time has passed — and again, the amount of time is going to depend on some cultural or subjective criteria — that some grief responses could potentially be considered a disorder. Learn More About Complicated Grief

Other Types of Grief

Apart from normal and prolonged grief, other subtypes that some experts recognize include:Anticipatory grief is a type of grief a person may begin to experience even before a loss. For example, anticipatory grief can happen when someone’s loved one is diagnosed with a terminal medical condition. Disenfranchised grief is a type of grief that people experience when they experience a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. An example is a doctor who cannot openly grieve for the loss of his or her patients, notes StatPearls. In an opinion article published in 2021 in the journal Frontiers in Psychology, psychologists posited that the COVID-19 pandemic has likely led to many people experiencing disenfranchised grief due to social distancing restrictions that made it impossible for people to be with loved ones leading up to and at the time of their deaths, or participate in typical bereavement rituals. RELATED: How Two Caregivers Are Coping With Losing a Loved One During the COVID-19 Pandemic

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Symptoms What Grief Feels Like and What It Does to the Body

Grief is an intensely personal experience. It can very look different from one person to the next.Sadness and yearning are often the primary emotions of grief. But grief can trigger a wide range of emotional, physical, and behavioral symptoms.

What Are the Emotional Symptoms of Grief

Grief can trigger a wide range of emotions. Some of the most common emotions include:
SadnessYearningShockNumbnessDenialAngerHelplessnessGuiltIntense emotional pain Some people may cycle through many of these symptoms. Others may experience several at once.

Other Cognitive Symptoms of Grief

Grief can also trigger disbelief, confusion, poor concentration, or hallucinations. “One that people are often surprised by is a sense of disorientation or alienation — finding ordinary places, situations, or objects unfamiliar,” says Cholbi. Our lives can become so firmly anchored to our friends and loved ones that, when one of them is gone, everything feels changed and even foreign. “Some even feel like strangers in their own bodies,” he adds. “This aspect of grief seems to reflect how others’ deaths can upend our expectations for what is typical or normal in the world.”

Physical Symptoms of Grief

Grief doesn’t just affect your emotional health. It can also cause or contribute to some physical symptoms. These include: Tightness or heaviness in the chest or throatNausea or stomach discomfortDizzinessHeadachesNumbnessMuscle weaknessFatigueShortness of breathWeight loss or gainRemember, every person experiences grief in their own way, so there may be other physical symptoms or reactions to grief that show up for you. Some other common responses include insomnia, a loss of interest in daily activities, irritability, aggression, lethargy, or an overuse of alcohol or other substance.

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Complications How Grief Can Affect Our Long-Term Mental and Physical Health

The experience of grief, especially if it persists for long periods of time, is associated with an elevated risk for a number of mental and physical health conditions.

Anxiety Panic Disorders and Depression

Grief can increase risk of several mental health disorders, including anxiety, panic disorders, and depression. Depression in particular has been the subject of a lot of grief research. MORE ON DEPRESSION

8 Depression Symptoms You Shouldn t Ignore

Depression is a clinical mental health disorder recognized in the DSM-5. And there’s no doubt that grief is associated with depression-like symptoms. But according to an editorial in the journal American Family Physician, there’s an ongoing discussion among experts about whether the depression that people experience during grief should ever be categorized as “disordered.” In the past, the DSM has included a “bereavement exclusion,” which suggested depression linked to the death or loss of a loved one should not be considered disordered unless it lasted for more than two months and met other criteria. However, the latest version of the DSM dropped this bereavement exclusion. Instead, it draws many fine-grained distinctions between “normal bereavement” and a major depressive episode.For example, while normal bereavement is associated with “waves or pangs of grief associated with thoughts or reminders of the deceased that are likely to spread further apart over time,” a major depressive episode involves “negative emotions experienced continually over time.” To sum up, grief and depression often seem to go hand-in-hand. There’s no doubt that grief can be a risk factor for depression. But experts tend to treat clinical depression as separate from grief. RELATED: Detecting and Diagnosing Depression

Immune GI Pain and Sleep Problems

Grief and other extreme forms of emotional stress can stoke the immune system in ways that promote inflammation. This inflammation and other stress-related biological effects have been found to trigger or worsen symptoms related to pain disorders, GI problems, and other health conditions, according to a study March 2019 in the United European Gastroenterology Journal.
Grief can also cause insomnia, which itself is a risk factor or trigger for many different health problems. RELATED: How Does Stress Affect Digestion?

Heart Complications Related to Grief

In rare cases, grief can even cause heart trouble. Research in the journal Circulation identified an uncommon form of heart failure — known as takotsubo cardiomyopathy — that is associated with severe emotional stress, including grief events like the loss of a loved one. This form of heart failure is temporary, but it can be deadly. RELATED: How Stress Affects Your Body, From Your Brain to Your Digestive System

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The Stages of Grief

In the late 1960s, the psychiatrist Elisabeth Kübler-Ross identified the widely cited “five stages of grief.” Later, Kübler-Ross and her colleagues added several more stages to this list.Though widely cited and used by psychologists in clinical practice, many experts now dispute the idea that grief unfolds in tidy and predictable stages — or that these stages are valid at all. In a review published in March 2017 in the journal Omega, psychologists point out that the theory has little empirical evidence to back it up. One big issue is that the “stages of grief” model was developed to describe how people mourn their own impending death, not necessarily for people who are grieving, explains Heidi Horsley, PsyD, executive director and cofounder of the Open to Hope Foundation, a nonprofit organization that supports people experiencing grief and loss. The model can apply to people who are grieving, but it still shouldn’t be used to suggest that people process grief in a linear and rigid way, says Dr. Horsley, who also serves on the advisory council of the Elisabeth Kübler-Ross Foundation and is an adjunct assistant professor at Columbia University in New York City. “Everyone will go through some of the stages, but not necessarily all of the stages, and it won't necessarily be in a linear manner,” she says. “It is normal to move back and forth between the stages as you are going through the grief journey.”Briefly, Kübler-Ross’s stages of grief are: Shock A feeling of numbness or disbelief following a loss (one of the stages that was later added).Denial Failing to acknowledge or accept that a loss has occurred. Denial can also refer to a denial of one’s feelings or of the full significance of a loss.Anger This emotion may be directed at spouses, friends, family members, colleagues, a spiritual being, or even at the person or thing someone has lost.Bargaining This can involve asking a higher power to take the pain away in exchange for some personal sacrifice — such as: “I will never sin again if my loved one will be spared.” The bargaining stage can also involve what-if thoughts about how a loss occurred or may have been avoided.Depression This is thought to be a deeper level stage of grief that occurs once the early stages have passed, and a person recognizes that the situation is real. This stage is often defined by sadness and a withdrawal from daily life or normal activities.Testing A person seeks out new practices or ways of living with their grief (another stage that was later added).Acceptance A person more fully accepts that the loss is real and permanent. Sadness and other feelings still crop up. But a person has reorganized their life and relationships in ways that allow them to move forward, however changed they may be.

How to Cope With Grief

First of all, it’s important to remember that grief is not a “problem” that must be handled or dealt with — especially not in the early weeks or months following a loss. “Grief is an emotionally rich event that allows us to appreciate what we’ve lost while also preparing us to adapt to that loss,” says Cholbi. “Even the most arduous grief episodes are healthy or fitting responses to the losses that cause them.” Other experts express similar sentiments. “Grief is all about time,” says George Bonanno, PhD, a professor of clinical psychology at Columbia University’s Teachers College and author of the book The Other Side of Sadness “When a couple of months go by and a person is still grieving, they may start to worry, but that’s still early.” Dr. Bonanno says that, speaking very generally, if after six months a person isn’t getting back into something that resembles their normal life — working, seeing friends, and other usual activities — than that may indicate the need to speak with a therapist or some other grief expert. “But some people take longer than others,” he adds. “If as time passes you’re able to do some elements of normal functioning, you’re probably going to get better.”However, if a lot of time has passed and a person seems to meet the qualifications of prolonged grief disorder, there is clinically validated research showing that therapy can help. according to a study published in July 2021 in the Australian and New Zealand Journal of Psychiatry. “We developed a therapy for prolonged grief disorder that is highly effective,” says Columbia’s Shear, citing some of her own research, published in October 2019 the journal Depression & Anxiety. This targeted psychotherapy is personalized to the individual and what they are going through, but that it also includes some standardized elements, Shear explains. “It consists of weekly sessions with and a set of activities to do at home,” she says. “It includes work on accepting grief, managing emotions, envisioning a positive future, strengthening relationships, narrating the story of the death, living with reminders, and connecting with memories.” Bonanno mentions Shears work, and says a key component of her therapy — and many other forms of treatment for people seeking help with grief — involves talking through the experience of grief and the events or loss that caused it. When you’re struggling to understand and accept a loss, you often only think about it in fragments, he says. This fragmented thinking can lead to “some really dysfunctional ideas,” he says. Talking through things with a professional can help to reveal the flaws in these ideas. “When people talk through things and put together the whole story, that can be really helpful,” he adds. Learn More About How to Cope With Grief

Editorial Sources and Fact-Checking

Trauma, Moral Injury, and Grief. UCSF Department of Psychiatry and Behavioral Sciences.Mughal S, Azhar Y. Grief Reaction. StatPearls. July 23, 2021.Boelen PA, Lenferink LI. Prolonged Grief Disorder in DSM-5-TR: Early Predictors and Longitudinal Measurement Invariance. Australia and New Zealand Journal of Psychiatry. July 7, 2021.Reynolds L, Botha D. Anticipatory Grief: Its Nature, Impact, and Reasons for Contradictory Findings. Counseling, Psychotherapy, and Health. July 2006.Kavan MG, Barone EJ. Grief and Major Depression — Controversy Over Changes in DSM-5 Diagnostic Criteria. American Family Physician. November 15, 2014.Clevers E, Törnblom H, Simrénet M, al. Relations Between Food Intake, Psychological Distress, and Gastrointestinal Symptoms: A Diary Study. United European Gastroenterology Journal. March 16, 2019.Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. December 16, 2008.Oates J, Maani-Fogelman P. Nursing Grief and Loss. StatPearls. August 11, 2021.Shear M, Bloom C. Complicated Grief Treatment: An Evidence-Based Approach to Grief Therapy. Journal of Rational and Emotional Cognitive Behavioral Therapy. May 24, 2016.Albuquerque S, Teixeira AM, Rocha JC. COVID-19 and Disenfranchised Grief. Frontiers in Psychology. February 12, 2021.Dr. Elisabeth Kübler-Ross And The Five Stages of Grief. Elisabeth Kübler-Ross Foundation.Stroebe M, Schut H, Boerner K. Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief. Omega. March 2017.Show LessNEWSLETTERS

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