Types of Grief Reactions
Many authors have proposed types of grief reactions.[1,2] Research has focused on normal and complicated grief while specifying types of complicated grief  and available empirical support  with a focus on the characteristics of different types of dysfunction. Controversy over whether it is most accurate to think of grief as progressing in sequential stages (i.e., stage theories) continues.[5,6] Most literature attempts to distinguish between normal grief and various forms of complicated grief such as chronic grief or absent/delayed/inhibited grief.[1,3,4]
Bereavement research has tried to identify these patterns by reviewing available empirical support  while also looking for evidence that these grief reactions are unique and not simply forms of major depression, anxiety, or post-traumatic stress.
The term anticipatory grief is most often used when discussing the families of dying persons, although dying individuals themselves can experience anticipatory grief. Anticipatory grief includes many of the same symptoms of grief after a loss. Anticipatory grief has been defined as “the total set of cognitive, affective, cultural, and social reactions to expected death felt by the patient and family.”
The following aspects of anticipatory grief have been identified among survivors:
- Heightened concern for the dying person.
- Rehearsal of the death.
- Attempts to adjust to the consequences of the death.
Anticipatory grief provides family members with time to gradually absorb the reality of the loss. Individuals are able to complete unfinished business with the dying person (e.g., saying “good-bye,” “I love you,” or “I forgive you”).
Anticipatory grief cannot be assumed to be present merely because a warning of a life-threatening illness has been given or because a sufficient length of time has elapsed from the onset of illness until actual death. A major misconception is that anticipatory grief is merely conventional (postdeath) grief begun earlier. Another fallacy is that there is a fixed volume of grief to be experienced, implying that the amount of grief experienced in anticipation of the loss will decrease the remaining grief that will need to be experienced after the death.
Several studies [11,12] have provided clinical data documenting that grief following an unanticipated death differs from anticipatory grief. Unanticipated loss overwhelms the adaptive capacities of the individual, seriously compromising his or her functioning to the point that uncomplicated recovery cannot be expected. Because the adaptive capacities are severely assaulted in unanticipated grief, mourners are often unable to grasp the full implications of their loss. Despite intellectual recognition of the death, there is difficulty in the psychologic and emotional acceptance of the loss, which may continue to seem inexplicable. The world seems to be without order, and like the loss, does not make sense.
Some researchers report that anticipatory grief rarely occurs. They support this observation by noting that the periods of acceptance and recovery usually observed early in the grieving process are rarely found before the patient’s actual death, no matter how early the forewarning. In addition, they note that grief implies that there has been a loss; to accept a loved one’s death while he or she is still alive can leave the bereaved vulnerable to self-accusation for having partially abandoned the dying patient. Finally, anticipation of loss frequently intensifies attachment to the person.
Although anticipatory grief may be therapeutic for families and other caregivers, there is concern that the dying person may experience too much grief, thus creating social withdrawal and detachment. Research indicates that widows usually remain involved with their dying husbands until the time of death. This suggests that it was dysfunctional for the widows to have begun grieving in advance of their husbands’ deaths. The widows could begin to mourn only after the actual death took place.
Normal or Common Grief
In general, normal or common grief reactions are marked by a gradual movement toward an acceptance of the loss and, although daily functioning can be very difficult, managing to continue with basic daily activities. Normal grief usually includes some common emotional reactions that include emotional numbness, shock, disbelief, and/or denial often occurring immediately after the death, particularly if the death is unexpected. Much emotional distress is focused on the anxiety of separation from the loved one, which often results in yearning, searching, preoccupation with the loved one, and frequent intrusive images of death.
Such distress can be accompanied by crying; sighing; having dreams, illusions, and even hallucinations of the deceased; and seeking out things or places associated with the deceased individual. Some bereaved people will experience anger, will protest the reality of the loss, and will have significant periods of sadness, despair, insomnia, anorexia, fatigue, guilt, loss of interest, and disorganization in daily routine.
Many bereaved persons will experience highly intense, time-limited periods (e.g., 20–30 minutes) of distress, variously called grief bursts or pangs. Sometimes these pangs are understandable reactions to reminders of the deceased person, and at other times they seem to occur unexpectedly.
Over time, most bereaved people will experience symptoms less frequently, with briefer duration, or with less intensity. Although there is no clear agreement on any specific time period needed for recovery, most bereaved persons experiencing normal grief will note a lessening of symptoms at anywhere from 6 months through 2 years postloss. Normal or common grief appears to occur in 50% to 85% of persons following a loss, is time-limited, begins soon after a loss, and largely resolves within the first year or two.
Stage Models of Normal Grief
A number of theoretically derived stage models of normal grief have been proposed.[14-17] Most models hypothesize a normal grief process differentiated from various types of complicated grief. Some models have organized the variety of grief-related symptoms into phases or stages, suggesting that grief is a process marked by a series of phases, with each phase consisting of predominant characteristics. One well-known stage model, focusing on the responses of terminally ill patients to awareness of their own deaths, identified the stages of denial, anger, bargaining, depression, and acceptance. Although widely used, this model has received little empirical support.
A more recent stage model of normal grief  organizes psychological responses into four stages: numbness-disbelief, separation distress, depression-mourning, and recovery. Although presented as a stage model, this model explains "it is important to emphasize that the idea that grief unfolds inexorably in regular phases is an oversimplification of the highly complex personal waxing and waning of the emotional process." Bereavement researchers have found empirical support for this four-stage model, although other researchers have questioned these findings.[19,20]
Patterns of Complicated Grief
Since the time of Sigmund Freud, many authors have proposed various patterns of pathologic or complicated grief.[1,2] Some proposed patterns come from extensive clinical observation  supported by various theories (e.g., psychodynamic defense mechanisms and personality traits associated with patterns of attachment).
These patterns are described in comparison to normal grief and highlight variations from the normal pattern. They include descriptive labels such as the following:
- Inhibited or absent grief: A pattern in which persons show little evidence of the expected separation distress, seeking, yearning, or other characteristics of normal grief.
- Delayed grief: A pattern in which symptoms of distress, seeking, yearning, etc., occur at a much later time than is typical.
- Chronic grief: A pattern emphasizing prolonged duration of grief symptoms.
- Distorted grief: A pattern characterized by extremely intense or atypical symptoms.
Empirical reviews have not found evidence of inhibited, absent, or delayed grief and instead emphasize the possibility that these patterns are better explained as forms of human resilience and strength. Evidence supports the existence of a minimal grief reaction—a pattern in which persons experience no, or only a few, signs of overt distress or disruption in functioning. This minimal reaction is thought to occur in 15% to 50% of persons during the first year or two after a loss.
Empirical support also exists for chronic grief, a pattern of responding in which persons experience symptoms of common grief but do so for a much longer time than the typical year or two. Chronic grief is thought to occur in about 15% of bereaved persons. It may look very much like major depression, generalized anxiety, and possibly post-traumatic stress.
In addition to these theoretical and empirically supported patterns of grief reactions, much emphasis has been placed on distinguishing normal grief from complicated grief. Most clinicians will be focused on understanding the differences between normal and complicated grief reactions: What is the difference? Under what circumstances should I refer a patient/family member for grief therapy?
Prolonged or Complicated Grief as a Mental Disorder
The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) includes bereavement as a diagnosable code to be used when bereavement is a focus of clinical attention following the death of a loved one. In current form it does not consist of formal diagnostic criteria and is generally considered a normal reaction to loss via death. In an attempt to clearly distinguish between normal grief and complicated grief, a consensus conference  has developed diagnostic criteria for a mental disorder referred to as prolonged grief disorder, proposing that it be included in the next revision of the DSM.
Following are the proposed diagnostic criteria for complicated grief:
- Criterion A: Person has experienced the death of a significant other, and response involves three of the four following symptoms, experienced at least daily or to a marked degree:
- Intrusive thoughts about the deceased.
- Yearning for the deceased.
- Searching for the deceased.
- Excessive loneliness since the death.
- Criterion B: In response to the death, four of the eight following symptoms are experienced at least daily or to a marked degree:
- Purposelessness or feelings of futility about the future.
- Subjective sense of numbness, detachment, or absence of emotional responsiveness.
- Difficulty acknowledging the death (e.g., disbelief).
- Feeling that life is empty or meaningless.
- Feeling that part of oneself has died.
- Shattered worldview (e.g., lost sense of security, trust, control).
- Assumption of symptoms or harmful behaviors of, or related to, the deceased person.
- Excessive irritability, bitterness, or anger related to the death.
- Criterion C: The disturbance (symptoms listed) must endure for at least 6 months.
- Criterion D: The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
These criteria have not been formally adopted, and thus there is no formal diagnostic category for prolonged grief disorders in the DSM. However, these criteria help in specifying symptoms, the severity of symptoms, and how to distinguish complicated grief from normal grief.
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- Jacobs S: Pathologic Grief: Maladaptation to Loss. Washington, DC: American Psychiatric Press, Inc., 1993.
- Stroebe MS, Hansson RO, Schut H, et al., eds.: Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association, 2008.
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- Bonanno GA: Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 59 (1): 20-8, 2004. [PUBMED Abstract]
- Bonanno GA, Neria Y, Mancini A, et al.: Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. J Abnorm Psychol 116 (2): 342-51, 2007. [PUBMED Abstract]
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