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Bereavement, or grief, is a normal feeling of sadness that occurs following the loss of a loved one. Uncomplicated grief is believed to advance through a series of stages that, in many aspects, mimic the illness depression, raising questions as to
where normal bereavement ends and major depressive illness begins. The initial stage of grief occurs during the first few weeks after the loss and is experienced as feelings of disbelief and shock. It is commonly associated with bouts of crying, loss of appetite, loss of sexual drive, restless sleep or insomnia, lack of energy, and difficulty concentrating. In women, disturbances in the menstrual cycle are common.
The intermediate stage of grief takes place during the first year after the death of the loved one. During that phase, feelings of intense loneliness and sadness are accompanied by persistent thoughts about the death, the events leading up to the death, why it happened, and how it could have been prevented. Limited capacity for pleasure, lack of energy, sleep and appetite problems, and bouts of tearfulness persist to varying degrees.
The recovery phase of grief is the time when people begin to return to their social lives and "get on with life." That usually begins about the second year following the loss.
Little is known about the actual duration of normal grief. Studies of spouses and parents dealing with unexpected loss point to normal grief processes lasting up to seven years. Sudden death often causes bouts of grief that are more severe and longer lasting than the bereavement following an anticipated death.
Death of a spouse can have significant impact on the health of the surviving partner. Women tend to be at increased risk for health problems within the first three months after the loss. Men whose spouses die are particularly likely to develop emotional or physical problems during the first year after the loss and have an increased mortality rate. Bereaved men who remarry tend to have lower mortality rates than those who do not.
Death of a child is particularly likely to produce severe grief reactions regardless of the age of the parent and child. Bereaved parents experience high levels of psychological distress that are accompanied by changes in physical health, functional activities, and family cohesion, including an increased risk of divorce.
The distinction between "normal" grief and depression can be a difficult one to make. The two states share many similar
physical and emotional symptoms, and the duration of both can be prolonged. Grief can produce a preoccupation with guilt about actions taken or not taken surrounding the death of a loved one and thoughts that the survivor would be better off dead. Experiences of transiently hearing or seeing the deceased loved one can also be a part of the normal grief process, especiaUy in some cultures. Morbid rumination regarding other feelings of guilt, a sense of worthlessness, anticipated death of other loved ones, prolonged decrease in level of function, marked slowness of behavior or speech, reports of unusual beliefs, or persistent or recurring hallucinations should be considered outside the normal grief process and more indicative of a major depressive episode. When symptoms of severe grief extend more than two months beyond the death of a loved one, treatment with antidepressant medication may be needed in addition to supportive psychotherapy.
Grief in young children is most profound when it involves the death of a parent or a primary caretaker. It can produce such behaviors as crying, calling and searching for the deceased loved one, and refusing to be comforted. Emotional withdrawal often occurs and is associated with sad facial expressions, lethargy, and lack of interest in former activities. Eating and sleeping may be disrupted. Children may regress by losing some of their developmental milestones; i.e., toilet-trained toddlers may begin to soil themselves again. Bereaved young children may become detached and lack much facial expression. They often are very sensitive to any reminder of the lost loved one. Grief in young children is generally treated with supportive measures; use of antidepressant medication is usually not required.